Myth
Hospital personnel, particularly professional staff, are all trained in recognition and treatment of CBRNE related casualties. Our doctors and nurses are already trained to treat mass casualties of all types. They are too busy to participate in CBRNE education and training exercises; when the time comes, they will know what to do.

Reality
Post 9/11 CBRNE emergency management exercises and their after-action/lessons learned revealed that the lack of a CBRNE working knowledge base among health professionals (recognition and treatment of CBRNE casualties) was and is a significant weakness in the system.  The need for health professional involvement in all-hazards planning and their active participation in realistic CBRNE exercises are essential to meet future threats.

Myth
Hospital personnel, at all levels, are willing to actively participate in a real CBRNE hostile environment. Our hospital personnel are willing to place themselves in harm’s way in the event of an actual CBRNE threat environment.

Reality
Recent experience with the SARS threat brings into question the validity of this general statement.  Incidents of refusal to work in such an environment were not unusual. One state survey revealed that half of physicians and nurses answered NO to a question about their willingness to participate in a real CBRNE event in a non-hospital setting. This signifies that in a high percentage of real CBRNE events the hospital is on lock-down. There is no substitute for strong leadership, effective training, and understanding in the use of protective equipment and confidence in personal survival in a CBRNE environment.

Myth
The healthcare system has been tested by the Oklahoma City bombing and the 9/11 attacks on New York and the Pentagon.  We have sustained terrorist attacks and we understand a lot more about how to deal with them.

Reality
We have gained some insight from those experiences, however, they were largely mortuary management events. One significant lesson learned was that healthcare facilities were ill prepared to deal with huge crowds looking for friends and family members. An accompanying biological or chemical attack would have resulted in the immediate contamination of area healthcare resources.

Myth
CBRNE responses are not that different from ones used to deal with natural hazards and the occasional hazmat events.  We have been able to deal with multiple catastrophic events--most recently, four major, destructive hurricanes in one season.

Reality
Managing CBRNE risks requires an understanding of significant differences between Natural and Manmade terrorist events. To identify a few:

• Predictability
• Casualty production
• Ratio between property loss and loss of life
• Post event recovery time
• Economic impact
• Public acceptance of protracted loss of personal freedom
• "Terror factor" psychological impact

Natural hazards are, for the most part, predictable and bounded by geography, for instance, hurricanes. Citizens in Nebraska feel little anxiety over a Florida hurricane. Terrorist attacks anywhere in the nation create a psychological trauma response in most inhabitants.

Myth
Our long experience with natural hazards has allowed us to incrementally improve on mitigation, preparation, response and recovery giving us a degree of comfort in our ability to deal with future events. We have, through trial and error, been able to deal with all-hazards.

Reality
Expected new strategies from the terrorist community will test our creativity and resolve.  New terror tactics include:

• CBRNE attacks to coincide with predictable natural hazard events, hurricanes as they make landfall, peak flood levels, immediately following earthquakes or coinciding with aftershocks
• Introduction of different biological agents at peak known endemic or pandemic events
• Introduction of chemical agents to co-mingle with smoke from forest fires, etc.

Myth
Making the decision to "protect in place or evacuate" in a CBRNE terrorist event is about the same as preparing for a category three hurricane, which we do that every year.

Reality
In the case of the hurricane you have the advantage of knowing hour by hour the location, velocity and direction of the hazard. There are essentially two elements to deal with, wind and water.  

Conversely, when dealing with an unanticipated chemical agent attack, the decision window time is short, and there are multiple elements to consider:

• agent identification and knowledge of it characteristics,
• wind speed and direction,
• concentration of agent,
• structural integrity of building,
• efficiency of exit routes, etc.

If the decision is made to "protect in place," depending on the agent, there are multiple variables to consider as well, such as:

Should we go to the top floor or to the basement?

Who receives the limited amount of protective equipment?

If the decision is made to "to evacuate," the considerations are no less complex.

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