This is the third installment in our examination of the Aum Shinrikyo sarin attacks on the Tokyo subway system. In this post, we'll look at one of the most vexing of issues in CBRN: the problem of worried well. This is a problem bigger than most CBRN professionals think it is, and one few jurisdictions and organizations are fully prepared to deal with. Worried well issues present significant problems for responders, medical care givers, emergency management, policy makers, and public officials. The problem of worried well is most acutely felt in the immediate aftermath of a major CBRN event and then tends to linger, for days, weeks, or even years depending on how local, state, and federal government choose to address the issue.
This post focuses exclusively on the Aum Shinrikyo case study and offers some ideas about how to address the problem where it has the greatest and most immediate impact - in emergency rooms, hospitals, and other urgent care centers. In future posts at CBRNPro.net we will examine some of the other issues and cases associated with the worried well problem and other means of dealing with the issue in its many manifestations.
While this particular post looks at the response in a civilian setting, it should be noted that most military CBRN plans do not include significant plans to deal with worried well problems, placing too much faith in military discipline. Many of the techniques described in this post have application to military settings. The worried well problem, as noted in previous posts in this series, dates back to the FIrst World War, when medical officers estimated that as many as 30% of their "chemical casualties" were "malingering" (i.e. worried well or shirkers). That was during a period (1917-1918) during which chemical attacks were frequent and many soldiers had gotten used to them. Imagine the response among troops today when encountering a CBRN attack for the first time!
It was this very issue that led to major fears among leaders and planners in the early stages of Desert Shield in 1991. It dominated their plans for war in Kuwait, and the defense of Saudi Arabia, which in the early stages was down to the 82nd Airborne, alone. If the Iraqis unleashed their chemical arsenal on Coalition forces (and that arsenal was significant in 1991) it would effectively halt operations by the coalition ground forces in the short term and seriously disrupt their ability to defend Saudi Arabia, let alone retake Kuwait.
The worried well problem and the issues associated with responding to a chemical attack by untested troops and equipment and operating in contaminated environments, led to a threat by the US and the UK delivered via Tariq Aziz to Saddam - that if Iraq used chemical weapons, the United States and the UK would consider the use of nuclear weapons. Israel issued a similar threat in response to the SCUD attacks on its cities launched by the Iraqis, when "unofficial" news was circulated that they had nuclear armed aircraft on standby.
If you are a CBRN professional and you think the worried well problem doesn't affect you, think about that nuclear threat. It is that big of a problem. But I digress, let's get on with the show...
While there are plans, whether adequate or not, for decontamination at medical facilities, the aforementioned survey of such plans (in a previous post in this series) did not note whether they included plans for dealing with large numbers of worried well. In numerous reviews conducted by the author of many jurisdictions Emergency Operations Plan, it is similarly absent, and is generally not a planning criteria emphasized by states, the Department of Homeland Security, or the Federal Emergency Management Agency. Hospitals and jurisdictions that only focus on decontamination and incident response miss the larger, long-term strain on their system presented by the worried well. Likewise, many of the drills examined in the 2008 survey noted those plans involved outside agencies. As previously discussed, that is a problem. Those hospitals that depend on outside agencies like police, fire, and EMS in a CBRN incident may struggle to get that support if the incident overwhelms those systems, as happened in Tokyo. Hospitals must be able to act independently, much as St. Luke’s had to in Tokyo.
CBRN attacks typically generate large numbers of worried well. The Goiania, Brazil release of radioactive Cesium-137 saw 120,000 individuals show up for radiation screening encouraged by government information. The Anthrax letters incidents in 2001 following the attacks of 9-11 led to the administration of antibiotics to a large number of those associated with mail handling and the attack sites while other individuals attempted to hoard and stockpile antibiotics around the country. While the anthrax attacks did not generate significant medical system effects, it did generate widespread “white powder” calls throughout the 911 system in the United States. These resulted in numerous police, fire, and hazardous materials responses throughout the nation for a period of several weeks until jurisdictions implemented screening scripts for 911 operators to eliminate the large number of “worried” callers with no actual evidence of anthrax in their mail.
Public information plays a significant role in worried well. During the Tokyo attack, television crews were present amidst the chaos at St. Luke’s – in the Emergency Department. Likewise, there were numerous news helicopters hovering over the scene of the attacks at the various stations downtown. In addition to sensational coverage, the media also provided more information than official channels, which were completely overwhelmed and uncoordinated.
This problem is a documented issue in producing worried well. Disjointed or overly reassuring officials that lack or lose credibility lead the public to seek alternative information sources via the media, as in Tokyo, or social media as observed more recently in Boston, Paris, and Brussels. Credibility and honesty are essential components of any communications plan, and communications plans should adhere to the basic principles learned from events like Tokyo. For a full discussion of these issues, the literature addressing the communications problems of the Centers for Disease Control and other government agencies during the Anthrax attacks outlines the issues and recommends solutions.
The announcement by the police, three hours into the incident, that the substance was sarin, observed on television at St. Luke’s, acted as confirmation of their own developing diagnosis. This was the first official announcement regarding an identification of the cause and contradicted an early, erroneous report that the substance was acetonitrile from the Tokyo Metropolitan Fire Department. St. Luke’s ignored this false report, as it was inconsistent with the information they had on hand and the symptoms they were seeing. These information problems only added to the confusion. Once the announcement of a positive identification occurred, signs and symptoms of Sarin poisoning appeared on television, radio, and print throughout Japan via the media. These contributed to an increased number of worried well. A headache was just a headache until the television said it might be sarin poisoning. Likewise, acute stress and panic attacks mirror the effects of mild nerve agent poisoning. These complicated differentiating the worried well from the mildly affected.
The worried well problem extends beyond the incident as well, as evidenced by the continued arrival of individuals in the medical system in the weeks following the attacks. Incidents of PTSD and other stress disorders following the attack led many to seek long-term treatment and care, citing symptoms that mirrored some of those who known to have been exposed.
Key to developing response plans that deal with the worried well problem is to keep people who do not need urgent or immediate care away from health care facilities that are critical to the response. One potential solution, first outlined by Fred P. Stone in 2007, is the implementation of a three tier pre-triage process he terms the “Low Risk Patient Response Plan.” At its core, this plan seeks to encourage worried well to stay home or go to an alternate facility for assistance during high demand periods on health care facilities in a CBRN event. The first tier of this process is encouraging worried well to stay home or seek care at a designated facility. Information strategies, including the use of prepared messages distributed through emergency warning systems, provide information and encourage worried well to stay home.
Stone suggests worried well-designated facilities should be shelters or community centers, mainly serving to reassure worried well and provide information, encouraging them to return to their homes after receiving “reassurances” with instructions to seek medical checks with their personal physician, preferably after the high demand period has subsided. This proposal fails to account for the role that mental health professionals and support can play in staffing these facilities and intervening in psychological casualty cases (see further discussion below). Likewise, other strategies can provide reassurance. One process used during the Goiania incident was to screen 120,000 self-reporting individuals at soccer stadiums with hastily trained radiation monitors sweeping individuals with radiation detectors. Monitors trained in chemical and radiological monitoring can be volunteers and need not be hazmat professionals. The important factor is the “screening” occurring at the worried well facility, which by its very nature can provide enough reassurance to get worried well to return to their homes. Another possibility is to use these sites as recruiting sites for disaster volunteers, suggesting these sites would make an excellent Community Emergency Response Team (CERT) responsibility. By assigning tasks to help out, worried well feel control and purpose, which alleviates the fear and lack of control that is their motivation.
The second tier of Stone’s response plan addresses those worried well who fail to respond to public communication or are unwilling to report to designated facilities. This tier is to stop worried well at the door or perimeter of the medical facility or campus. See the detailed discussion above regarding site control in decontamination. The complicating factor of such screening is that facilities must make near immediate decisions as to the status of these individuals. While there is risk in doing so, it is low, and the use of questioning tactics can quickly identify these individuals. This is “triage at the gate,” applicable to psychological casualties, worried well, the curious, and scheduled patients (who were in issue in Tokyo). Gateway screening uses a series of questions, for example:
1. Do you have a scheduled appointment at (medical facility)?
2. Were you at (incident site), or where you in (impact zone), between (start of incident) and (end of incident)?
3. Have you been in close contact with anyone who was?
Individuals answering yes to question one can be immediately redirected, possibly with an information sheet offering rescheduling information or alternate care sites. Direct all those answering no to such questions to the aforementioned “worried well” designated facility. It is important screeners vary the questions and separate those being questioned from any large group of individuals. Once “worried well” figure out trigger words and answers to get screened they will adapt and start false reporting – this was evident in the wake of the October 2001 anthrax attacks as worried well learned ways obtain CIPRO prescriptions. Sending these screened individuals them to a worried well holding area designated on a facility campus is another potential venue, but it should be separate from and out of sight of any decontamination area. By sending individuals to an alternate site like this, then busing them from that site to a designated worry well center can also limit any adaptations by individuals to bypass worried well screening. Those answering yes to either question two or three (or similar questions) are escorted to designated decontamination points. Injured and ill from sources other than the CBRN incident must also redirect, preferably to alternate medical facilities, but at a minimum to an alternate controlled entrance for such (as previously discussed). EMS should plan for and notify the public, police, fire, EOCs, and ICS command of designated hospitals or reception stations for non-incident casualties.
Other worried well issues of concern to planners are the questions of liability and security in a CBRN event. Securing and controlling large numbers of individuals at health care and other facilities and ensuring contaminated casualties do not make it into those facilities without passing through decontamination lines is essential to the operation. This may require the use of force, should things get out of hand. This is a primary role for law enforcement, and in a longer-term or larger event, National Guard forces. Planners should incorporate such security planning into their response plans.
The issue of liability is important. Triage involves the allocation of scare medical resources. This runs legal liability risks especially for private health care facilities and medical centers as well as health care professionals. Laws need to be in place to protect these facilities and workers in such events, and planners at all levels, local, state, and federal, need to address issues of legal liability and insure those facilities are aware of their legal standing.
Levels of fear, anxiety, and stress all rise in the general public following CBRN and terrorist attacks including among those not directly affected. After the events of 9-11 in New York, patients presented at hospitals and medical facilities with psychological complaints who had witnessed the attack from some distance. Because individuals like these mix with the worried well and other casualties, there is a potential that worried well may have higher incidences of psychological impairment and a simple redirection may not be sufficient.
While information strategies prove useful in reducing the number of worried well arriving at hospitals and other critical medical facilities, psychological casualties are less likely to avoid treatment. Redirection of psychological cases to other facilities prepared to handle them is one possible alternative accomplished via media messages and other means of public information. Another is to allocate locations and mental health resources to deal with psychological casualties at “worried well” designated sites, as previously mentioned.
More problematic are those psychological casualties whose symptoms mimic CBRN related symptoms. A similar problem exists in distinguishing bio agent casualties from ordinary flu and cold patients. The best solution is to recognize this possibility and do as St. Luke’s did and presumptively treat these individuals as exposed until further testing confirms or denies it. Further, most of these cases will present symptoms consistent with mild exposure and will triage out on a lower priority. Including mental health staff in plans to circulate through this area of triage and talk and console individuals in this group might also act as a screening tool.
Fortunately, most psychological effects from disaster are transient and temporary with supportive care. PTSD is a common long-term problem in physical casualties, and evidence suggests it may also be a problem even in those not directly affected though that is an unsettled issue in the literature. Likewise, psychological support for victim families is essential to avoiding long-term psychological problems. Stress and PTSD are also problems for responders and hospital staff. Planners should allocate mental health resources to provide supportive care for first responders and hospital staff, following an event, and may look to provide care during an incident, especially if the incident stretches into multiple shifts.
Medical Capacity and Response
As occurred at St. Luke’s in Tokyo, one of the first needs in medical facility CRBN response is to expand patient capacity quickly. St. Luke’s cancelled routine procedures and outpatient services. This is possible if procedures exist to notify those affected before they show up at the hospital to avoid the complications encountered in Tokyo. In order to expand treatment space at St. Luke’s they used their chapel, previously outfitted for that purpose. Likewise, hallways, cafeterias, sheltered parking, and other locations to include adjacent buildings and public shelters can be used. Early discharge of in-patients and other “deck clearing” actions can also prove productive, as occurred in Virginia during the 2001 attack on the Pentagon.
For planning purposes, hospitals should calculate their expansion capacity according to minimum standards of care. The hospital should also exercise any mutual aid agreements, coordinate with area hospitals and EMS systems, and look to expand personnel on duty. The expansion of personnel was one measure implemented by St. Luke’s when they utilized their adjacent Nursing School to provide additional staff. In addition, hospitals need to be prepared to extend shift hours, call back off-duty personnel, and utilize non-medical staff to assist medical staff in non-medical activities.
The use of non-medical staff in particular, is one area where hospitals can “plus up” their medical staff by relieving them of tasks that are non-medical in nature. Just-in-time training and other expedient measures can work in such circumstances. Clerical and support staff can provide assistance in triage with tagging and documentation, operate decontamination lines, and perform numerous other tasks in the event of a CBRN disaster. Such actions free up medical staff to focus on their assigned duties. In particular, non-medical staff plays an important role in reducing and containing the worried well problem. From assisting in controlling access to the facility, to directing worried well away from critical areas, non-medical staff can provide valuable assistance.
One of the most important elements for non-medical staff in this regard is in establishing and supporting hospital emergency operations, especially in the role of information dissemination and public affairs. It is critical hospitals communicate not only among staff, but also with patients, outside agencies, and the public. Regular updates and providing accurate information in a timely matter to press and media outlets can alleviate much of the worried well problem. During the Tokyo event informal communications networks between hospitals allowed the medical response to be coordinated and information about the incident disseminated between medical facilities. Such communications between medical and non-medical staff also assisted in resource management and leveraged expert power when needed. Knowing whom to call and having an established relationship is one of the most critical elements of emergency management. Hospitals should develop emergency communications channels that mirror some of their normal everyday communications networks.
In our next post on Aum Shinrikyo, the last of this series, we'll offer our conclusions and talk about the future of medical system resilience.
 International Atomic Energy Agency, “Dosimetrics and the Medical Aspects of the Radiological Accident of Accident in Goiania in 1987,” (Vienna: IAEA, 1998), 88. http://www-pub.iaea.org/MTCD/publications/PDF/te_1009_prn.pdf (accessed April 24, 2013).
 Nkuchia M’ikantha, M., Kathleen G. Julian, Allen R. Kunselman, Robert C. Aber, James T. Rankin, and Ebbing Lautenbach. “Patients’ request for and emergency physicians’ prescription of antimicrobial prophylaxis for anthrax during the 2001 bioterrorism-related outbreak,” BMC Public Health, January 5, 2005, http://www.biomedcentral.com/1471-2458/5/2 (November 22, 2013).
 Fred P. Sloan, “The ‘Worried Well’ Response to CBRN Events: Analysis and Solutions” The Counterproliferation Papers, Future Warfare Series No. 40. (Maxwell AFB, AL: USAF Counterproliferation Center, Air University, 2007). Sloan discounts some of the reporting of the worried well in this and other cases. He fails to note the significant increase in calls to emergency services for “mail checks” and other anthrax hoaxes, which still fulfill the definition used for this paper, as their primary purpose was to assuage fear. For a comprehensive, non-academic account of the anthrax attacks see Laurie Garrett, I Heard the Sirens Scream: How Americans Responded to the 9/11 and Anthrax Attacks (Seattle: Amazon Digital Services, 2011).
 Okumura, et al, “Part 2: Hospital Response,” 620.
 Kaplan and Marshall, 247.
 The best of these include Lee Clarke and Caron Chess, “Elites and Panic: More to Fear than Fear Itself,” Social Forces 87 (December 2008): 993-1014; Lee Clarke, Caron Chess, Rachel Holmes, and Karen M. O’Neill, “Speaking with One Voice: Risk Communication Lessons from the US Anthrax Attacks,” Journal of Contingencies and Crisis Management 14 (2006): 160-169.
 Okumura, et al., “Part 2: Hospital Response,” 621. Okumura discusses the information problems at length. St. Luke’s hospital had already concluded sarin poisoning when the President of the Shinshu University Hospital, that had treated the patients of an earlier Aum Sarin attack in Matsumoto city, contacted the hospital. A doctor from the Japanese Ground Self Defense Forces Hospital also arrived at St. Luke’s and suggested sarin. An informal, inter-hospital network also formed between the hospitals receiving casualties. The police did not communicate their announcement of Sarin and information about the prior attack through official channels to any of the hospitals, who were operating entirely on their own and communicating view their own information loops.
 It is worth noting that this was prior to the rise of social media, though the internet was already in use.
 Procter, et al. Yokoyama, et al.
 Stone, Fred P., The ‘Worried Well’ Response to CBRN Events: Analysis and Solutions (Maxwell AFB: Air University, 2007), 26. Stone’s analysis of the problem downplays the idea of worried well and instead adopts the term Low Risk Patients, arguing the worried well term denigrates real issues among that population. While this paper draws different conclusions as to the nature and extent of the problem, Stone’s “LRP Response Plan,” outlined in his work, is a useful guide for worried well planning.
 Ibid., 26-33.
 Stone, 32-33.
 Ibid. See also Boscarino, J.A., C.R. Figley, and R.E. Adam, “Fear of terrorism in New York after the September 11 terrorist attacks,” International Journal of Emergency Mental Health 5 (2003): 199-209.
 This was an issue during the SARS outbreaks.
 Perry and Lindell, 119. See also C.S. North and B. Pfefferbaum, “Research on the mental health effects of terrorism,” Journal of the American Medical Association 288 (2002): 633-636.
 Bowler, et al.; Procter, et al.; Sharan, P. G. Chaudhary, S.A. Kavathekar, and S. Saxena, “Preliminary report of psychiatric disorders in survivors of a severe earthquake,” American Journal of Psychiatry 153 (1996):556-558.; S. Galea, J. Ahern, H. Resnick, D. Kilpatrick, M. Bucuvalas, and J. Gold “Psychiatric sequelae of the September 11 terrorist attacks in Manhattan, New York City,” New England Journal of Medicine 346 (2002):982-987.
 Perry and Lindell, 119.
 R.W. Perry, and M.K. Lindell, “Hospital planning for weapons of mass destruction incidents.” Journal of Postgraduate Medicine 52, no. 2 (April 2006): 116-120.