Читать книгу Emergency Incident Management Systems - Mark Warnick S., Louis N. Molino Sr - Страница 51

On 20 March 1995, members of the Aum Shinrikyo doomsday cult discharged a deadly nerve agent (sarin gas) in the world's busiest subway system; the Tokyo subway. The gas was developed by the cult at their compound, and the delivery system utilized was human delivery by members of the cult. The attack was timed to happen simultaneously on three different trains, using five devices. The group planned the attack so that they materialized as the trains converged on the main hub of the Tokyo subway system. This incident caused 12 confirmed deaths and 50 injuries specifically from the attack itself. Another 6252 injuries resulted from the subsequent panic, fear, confusion, and secondary contamination, with the secondary contamination making up the majority of the injuries (Murakami, 2000).

Preparedness is a key factor that is often overlooked in incident management, and in 1995, Tokyo officials and the federal government somewhat overlooked preparedness. While there were some disaster plans in place, those plans primarily covered what should be done when resources are overwhelmed in only the response phase. It did not take into consideration what to do in a Weapons of Mass Destruction (WMD) scenario. Nobody knew what to do on a Weapons of Mass Destruction (WMD) incident except for the federal government (Pangi, 2002). Additionally, The Cycle of Preparedness was not part of the Japanese disaster management methodology at the time of the attack.

As you will learn later in this chapter, preparedness is comprised of a continuous cycle of planning, organizing, training, equipping, exercising, evaluating, and taking corrective action. This is referred to as the Cycle of Preparedness (explained later in this Chapter 5). This cycle helps to work out any issues (or gaps) prior to an incident so that there will be active and effective coordination during a real incident response.

After reviewing extensive research, it appears as if the country of Japan and the local government entities in Tokyo undertook very few disaster preparedness efforts prior to the attack. This caused complications in the overall response because these entities did not integrate, cooperate, coordinate, or collaborate with each other before, or during, the incident. This in effect caused a substantial amount of problems and caused stove‐piping (or the silo effect) of information sharing.

Stove‐piping is when information is closely controlled (and sometimes choked down) in a horizontal fashion. Information can be shared up the chain of command within an organization, but cross‐organizational or multijurisdictional sharing is not free‐flowing. In most instances, this stove‐piping is caused by failing to share information. While varying agencies might have critical information or intelligence, this information is kept for only that agency and is not shared with similar agencies who might be working on the same issue or issues. Because these agencies typically work on some level to keep some information secret, a stovepipe occurs. These stovepipes prevent all agencies from being on the same page with the same intelligence and situational awareness. Because many of the Japanese public safety agencies worked in their own circle, stove‐piping existed. Prior to the attack, there were no preparedness efforts, and there was a serious deficit in interorganizational cooperation. This included being able to identify that the incident was an organized attack.

The initial signs of the attack were unclear. Initial first responders identified that attack as extremely chaotic and confusing, and what was causing the physical symptoms to people riding the trains was not known for several hours. Had there been information sharing in place, then the identification of a Weapons of Mass Destruction (WMD) incident most likely would have been discovered much sooner. This is based on the premise that a 360° view from multiple response agencies would have given an Incident Commander ([IC] if there were one) or a primary agency enough intelligence to determine that it was an organized attack. Considering that many passengers who had been on the subway were displaying the physical characteristics of choking, vomiting, and some even were even suffering blindness, should have been a quick indicator of a larger attack rather than assuming it was an isolated incident. Additionally, the report of individuals making their way from the subway station to the street only to collapse on the sidewalk should have been another quick indicator of something other than normal (Pangi, 2002).

As the local government and the various agencies began to respond to the incident, they were overwhelmed by chaos, confusion, and uncertainty. In the initial reports, the National Police Agency received information of several incidents at numerous stations and did not understand that they were all from a single organized attack. For quite some time, they had no idea that it was actually a Mass Casualty Incident (MCI). They were initially unaware of the magnitude, so they assumed that these reports were multiple smaller incidents rather than being interconnected. Had all agencies worked together, and reported suspicions to a centralized agency, the extent of this incident likely would have been realized substantially quicker; possibly within minutes (Pangi, 2002).

The use of incident management was significantly delayed. Pangi (2002) suggests that there were two problems that led to the postponement of using an IMS method; the first was the delay in identifying that it was an organized attack, and second, because of a lack of interagency interconnections. The agencies involved with this incident operated at the same time, but they had no centralized management to put forth a unified effort. Such an effort likely would have led to identifying additional resources that could have been utilized and integrated into the response, which would have likely reduced the pain, suffering, and the death toll.

Approximately 45 minutes after the first report, and 15 minutes after realizing that this was a singular attack, the National Police Agency requested assistance from the Self‐Defense Force (SDF). The National Police Agency failed to shut down the subway system for at least one‐half hour after asking for, and waiting on, assistance from the Self Defense Force. The total shutdown of subway system was not complete until one and a half hours after the incident began. For that hour and a half, bystanders could freely come and go through these contaminated areas, unrestricted. Most of the trains continued to run their normal schedule, while being contaminated from individuals that came from other trains. One train that suffered direct contamination from the attack was even allowed to run its entire route before it was stopped and isolated (Pangi, 2002).

This failure to act caused secondary contamination throughout the subway system and the city as well. Prior to this attack, there was no record found of government agencies nor subway personnel having discussed a Weapons of Mass Destruction (WMD) attack, nor had any of the entities prepared for one. Only the Japanese military had made plans of how to respond to a Weapons of Mass Destruction (WMD) attack, so even if those responding to the incident were able to miraculously identify what caused the incident, there were no plans in place to help direct them in the best way to handle such an incident (Pangi, 2002).

Whenever a Weapons of Mass Destruction (WMD) incident occurs, it is important that the response includes a multilevel, multidisciplined, and multiagency response. It will take a coordinated response to bring the incident to a quick and successful completion (Creamer, 2005). This was not the case during the sarin attack in Tokyo. Prior to knowing that the incident was a coordinated attack, response agencies worked in isolation from each other, and each agency made their own independent decisions. When it was realized that this was a coordinated attack, these same agencies still worked independently from other agencies. There was little to no coordinated response until the Self Defense Force arrived on scene; this was nearly two hours after the initial report. Even after they arrived, the cooperation, collaboration, and the use of an integrated response were only promoted between the Self Defense Force and the National Police Agency; other first responders were still managing the incident they responded to independently of any other public safety agency.

The Self Defense Force identified the agent used as sarin gas shortly after arriving on scene. First responders and other agencies were not notified of what the substance was for at least another hour. In looking at this detail, this equates to emergency personnel being on scene and unknowingly contaminated for a total of three hours before they were notified of what the chemical agent was. The primary reason for the delay was because there was no coordination between agencies and no overarching IMS method in place. Perhaps even more disturbing than the agencies and first responders suffering a long delay is that the hospitals never received official notification from a government agency. St. Luke's Hospital initially learned that the substance was sarin from television news reports around 11:00 a.m. (Pangi, 2002).

From the onset of the first call, the response to the incident was confusing, chaotic, and uncertain, not to mention extremely disorganized (Murakami, 2000; Pangi, 2002). Local and state governments were totally unprepared on multiple levels. The agencies involved had never practiced a multiagency response, and they had no IMS method in place to help integrate resources. This made the response haphazard at best. There was no overall guidance for the incident, and no singular or unified command. Those arriving on scene created their own strategies and decisions, which were usually based on what they saw, or based on what their agency thought was most viable way to proceed. Rather than having an overall strategy developed by a group of individuals who saw the whole picture, decisions were made viewing one small piece of the overall incident with the goals of only their agency in mind.

This lack of cooperation, collaboration, and communication also led to hospitals being overwhelmed. While some hospitals were overwhelmed from being inundated with a multitude of patients, other nearby hospitals had no patient, or only few patients. There was a haphazard approach in accounting for patient's destination, and the ability of the hospital to treat patients. As an example, St. Luke's Hospital was flooded with 150 patients that were transported by ground ambulance to this hospital in just the first hour and a half. This does not even take into consideration the walk‐ins and the private citizen transports to the hospital. In all, St. Luke's Hospital had 641 patients show up at the emergency room on the day of the incident. It clearly overwhelmed this one hospital.

Communication with all hospitals, and between hospitals, was clearly lacking as well. In one eyewitness account, a television news van rushed several patients to a secondary hospital (not the closest hospital). They arrived an hour after the initial attack, only to find out that the hospital had no idea that an attack had taken place. The treatment of the patients that the news crew transported was delayed. They were initially denied help by a nurse because there was no doctor on duty. The news crew essentially begged for help, and eventually a doctor was brought in to treat those patients (Murakami, 2000, pp. 27–29).

In another eyewitness account, the secretary for the head of the School of Medicine at Shinshu University received a call approximately 30 minutes after the attack. It was a reporter asking if Dr. Nobuo Yanagisawa wanted to make a comment on what might have been used in the attack. Because he was unaware of the attack at this time, he turned on the television to gather more information. Having investigated a similar event of sarin gas that happened almost a year earlier in Matsumoto, Japan (on 27 June 1994), Dr. Yanagisawa was very familiar with the symptoms, and he thought that he knew what the substance, and what antidote should be used.

He immediately called in two doctors to assist him in getting the word out to the hospitals and the EMS providers. They also attempted to communicate with the fire department, so they could spread the word on the suspected type of attack, and the antidote. Unfortunately, contact was never made with the fire department. Initially, the three doctors began faxing the Matsumoto Report to the hospitals nearest to the incident and other nearby hospitals. The report was quite long, so it took a long time to send it by fax. Before the information was sent to all emergency rooms, they began getting requests for the information from hospitals not yet reached. In all, over 100 different hospital accepted patients (Murakami, 2000, pp. 220–223).

Even when this team of doctors led by Dr. Yanagisawa did send the report to the various emergency rooms, the lack of communication within the hospital itself led to delays. A prime example of this was St. Luke's Hospital. Dr. Yanagisawa called the hospital and requested to speak to the doctor in charge of the emergency room. While technically he should have gone through the person in charge of the hospital, he felt that time was of the essence, so he called direct. He had a brief discussion with the person he thought was in charge of the emergency department and told the person he would send the information via fax as soon as possible. He would later find out that several doctors were combing through the library, looking for what the substance might be until 11:00 a.m., and they found out the answer from news coverage of the incident (Murakami, 2000, p. 221).

While most of the other 100 hospitals were available and willing to assist, most received relatively few patients. A lack of communication, collaboration, and coordination, as well as a breakdown of the communication (hardware) system, led to the closest hospital to the incident being overwhelmed. With over 100 hospitals in close proximity, most saw less than 10 patients, while St. Luke's hospital saw over 600 patients.

The lack of preplanning, coordination, cooperation, and a lack of integration of resources led to more human suffering, and it caused the incident to last longer. It also placed emergency personnel at greater risk, and it allowed contamination to be spread citywide. Subsequently, more people (including first responders) needed to be seen as patients. Nurses, doctors, EMS, and many that had contact with any of the initial patients needed treatment, which overwhelmed the medical system for weeks.

Allocation of resources in this incident was disorganized as well. Because agencies had rarely worked together, there was an issue of trust. The culture among these response agencies was been described as isolationist (Pangi, 2002). This led to no information sharing and even more disorganization. Information in this incident only went from pier to pier, rather than going to a higher command, or in all directions so that all personnel were on the same page.

Another key factor that negatively affected the response was governmental bureaucracy. This bureaucracy not only added layers of approvals and direction but also compartmentalized agencies from each other. According to a study by Pangi (2002), this compartmentalization not only caused responding agencies to respond as separate units, it caused them to be in competition with each other. This competition caused information and expertise to not be shared. Rather than helping each other, these agencies made every effort to ensure that their agency knew more than the competing agencies; the same agencies they should have been working with and cooperating with.

As if these issues did not cause enough disorganization, then they added the failure of not using an IMS method to manage the response and recovery. It is easy to see that the Tokyo sarin attack lasted substantially longer than it needed to. Additionally, the chaos, confusion, and uncertainty increased because the responding agencies worked against each other rather than with each other. When one agency would employ a mitigation strategy, another agency might unintentionally do something that made that strategy less effective. Had there been coordination and collaboration, everyone likely would have been on the same page rather than being at odds with each other.