An Exercise in Terror

On Monday April 4, 2005, terrorists released aerosolized pneumonic plague in a New Jersey city. Ambulances were stolen, tainted blood was found, and the body count began to climb. The Governor's office and the Commissioner of Health held conference calls with local health departments. At the same time, the state health department and the FBI sent out information on the use of personal protection equipment, infection in the animal population, and how and where to obtain prophylactic antibiotics.

The New Jersey Department of Health and Senior Services flooded computers throughout the state with emails detailing the imaginary events as they unfolded under the direction of 80 game planners huddled in a hotel ballroom.

Imaginary? Game planners? Ballroom?

It was just an exercise. In fact, the "bioterror attack" of April 2005 was the third such exercise. In 1999, the US Congress mandated that periodic exercises should be held to test the coordination of emergency events in major cities, and the capacity of emergency and public health services to handle them. These exercises are known by the acronym TOPOFF (for "Top Officials"), and two had already been held, one in May 2000 and one in May 2003.

The April 2005 exercise was the largest and most complex preparedness drill ever held in the United States. Terrorist attack scenarios were staged in New Jersey (the aerosolized pneumonic plague) and Connecticut (a chemical incident), with related exercises occurring in Canada ("TRIPLE PLAY") and the United Kingdom ("ATLANTIC BLUE").

Public Health Front and Center

I was involved in the exercise because I work as a public health nurse in a small community health department in New Jersey. It could be considered a sleepy job, except that my county in New Jersey holds more than 800,000 people, has major state and interstate highways, and is within sight of Manhattan, which has already witnessed several terrorist attacks.

Indeed, the recognition that bioterrorism is a viable threat to the public has brought the once thankless job of public health into the spotlight. Agencies responsible for emergency readiness have been reorganized, and public health has emerged as the entity that would best be able to handle large-scale health emergencies. Why? Because public health already has in place the protocols for epidemiology, disease surveillance, mass screenings, and inoculations. All that remains is to effectively coordinate these activities with those of law enforcement and emergency response.

Responding to TOPOFF's Terror

So while every email that came in from government departments read "This is an Exercise," the scenario was vivid and frightening. Within two days, the terror level had been elevated to red. The roads and borders of the state were closed to traffic. Schools were commandeered for health purposes. Hospitals ran out of masks and gloves, and their switchboards were unable to handle the volume of calls from the "worried well."

Each new problem sparked immediate lengthy discussions and another round of decision-making. On the third day, New Jersey's Commissioner of Health ordered each county to open a place for dispensing antibiotics (known as a "POD") from the Strategic National Stockpile.

We established a POD at a local high school on Thursday, April 7, for four hours, between 4–8 pm. In reality, PODs would be established throughout the state and expected to be open 12 to 18 hours each day. A crowd of about 400 gathered, including nurses, doctors, pharmacists, and mental health workers. Emergency management and law enforcement personnel, students, and the media were recruited to put the play into action. Trying to staff and run just one POD highlighted the potential problems and enabled game planners to evaluate the success of existing emergency plans.

Adding the Human Factor …

I was a role-player, and I was given eight different characters to play over the four-hour period in which our POD was in operation. My first role was as a blind man wondering where they were taking me. Next I was a deaf woman, unable to read lips through speakers' surgical masks. In one scenario I spoke only Spanish, and had to wait for a translator. Following this, I was a father with a child who took seizure medication and was allergic to the drug being prescribed. Waiting in line for medication for my children I grew impatient and threw what amounted to quite a temper tantrum, so mental health workers quickly hauled me out of sight. Five times my fever and coughing caused me to be removed from the line and sent to the hospital. But along with other plague victims, I had to wait for non-existent transportation.

The play-acting demonstrated to everyone how difficult it is to manage a crowd of this size. Even though the protocol designers hoped that nearly everyone would fit a profile that would allow for quickly dispensing medication to cover the entire population, it was not the case. Many people had underlying chronic conditions, emotional issues, or disabilities that took up precious time. While Emergency Operations expected to be able to process 500 people an hour, the process took much longer, leaving us to wonder how effectively we could serve nearly a million people.

Over the next day, the imaginary death count continued to mount into the tens of thousands, the dead filled the morgues, and the sick overwhelmed the hospitals. Stable patients had to be transferred by airplane and ship to facilities in other states in order to make room for the acutely ill. As their staff became ill or stayed home to care for their own families, healthcare facilities operated with only half their workforce. A temporary hospital for 10,000 needed to be quickly constructed in a massive outdoor arena, and it was to be staffed with healthcare workers imported from other states, who also needed to be housed and fed.

Aftermath

The week-long TOPOFF 3 exercise is over. During the exercise, representatives from 13 counties and Congress, as well as other high-ranking agency officials made note of each success or failure. Now, the officials have returned to their offices to grade the exercise. Protocols will be examined and suggestions made.

One suggestion might be that the local nursing schools could consider adding acting classes to their curriculum. First, I doubt that my gray-haired portrayal of a pregnant Hispanic teenager really fooled anyone. But on a more serious note, if I were ever to face a real disaster of this type and size, with the fear, urgency, confusion, and uncertainty, I'm certain that I'd need help to act confident before the patients I'd encounter, such as those eight characters I played.

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