Responding to a terrorist attack involving chemical nerve agents is one of the most challenging situations emergency response personnel may face. A dramatic example of the consequences of a terrorist chemical attack occurred in Japan in 1995 when members of a doomsday cult released the nerve agent sarin in the Tokyo subway system. Terrorists transported the sarin onto subway trains in lunch boxes and soda bottles and released the agent by puncturing the containers using umbrellas with sharpened tips. In this terrorist attack, 12 people were killed, 5,500 were exposed, 3,227 patients went to the 41 hospitals in the Tokyo area, and more than 100 first responders were treated for chemical exposure. Eight hours elapsed before the incident was identified as a terrorist attack. This incident illustrates the critical need for first responders to be prepared should they respond to a chemical attack involving nerve agents.

The covert and deadly nature of these attacks, coupled with the fact that most agencies are unprepared to deal with them, makes responding to a nerve agent attack the responder’s worst nightmare. In responding to such events, it is critical to use precautions such as preincident planning, on-scene size-up procedures, personal protective equipment, and self-decontamination methods to avoid exposure. Even in a best-case scenario, responders may not be aware of the true nature of a nerve agent incident until they are exposed to the agent and “become part of the problem.” Should a nerve agent exposure occur, it will be critical for the responders involved to recognize the signs and symptoms of nerve agent exposure and to quickly self-administer Mark I nerve agent antidote kits.


Nationally, there is a significant need for training to prepare for these low-probability, high-impact events. Although the 2007 edition of National Fire Protection Association (NFPA) 473, Standard for Competencies for EMS Personnel Responding to Hazardous Materials Incidents, is expected to address this type of training, there are presently no national EMS standards that offer guidance for providing the training. To close this gap within the state of Alabama, the Alabama Department of Public Health (ADPH) launched a training initiative in 2005 intended to prepare first responders to survive exposure to a nerve agent.

The Alabama initiative used a train-the-trainer approach developed through a partnership with ADPH and two agencies at the University of Alabama at Birmingham [UAB-the South Central Center for Public Health Preparedness (SCCPHP) and the Center for Labor Education and Research (CLEAR)]. Through the partnership, ADPH provided funding for the training and Mark 1 training kits, SCCPHP coordinated outreach and course scheduling, and CLEAR developed training materials and delivered the training.

The target audience for the program was provided by the 348 EMS agencies located within the six public health planning regions of the state (photo 1). Using the train-the-trainer approach, designated trainers from the EMS agencies attended the training sessions provided by UAB/CLEAR. Following the training, the agency trainers were given a kit to use in training other members of their agencies. In all aspects of the training, a major emphasis was on responder precautions for avoiding exposure. The use of Mark 1 kits by responders for self-injection was included as a last resort if the precautions failed to prevent exposure.

(1) The Mark 1 kit training initiative targeted 348 EMS agencies in all six of the public health planning regions of Alabama. (Photos courtesy of authors.)
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Ninety-five EMS instructors from various EMS agencies and community colleges across the state attended the eight train-the-trainer courses. In addition, two teleconference sessions were broadcast to 67 public health departments throughout the state. Each trainee was given a teaching kit consisting of a Mark 1 training DVD, Mark 1 trainer units (photo 2), and a reference CD-Rom with training resources (e.g., the PowerPoint® presentation used in the training). The trainer kits included course skill check-off forms and specific instructions for documenting the training and reporting the secondary training numbers to ADPH.

(2) The trainer kits distributed by ADPH included Mark 1 trainer units that can be used to simulate self-administration of a nerve agent antidote kit.
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ADPH, the licensing agency for prehospital care providers within the state, requires documentation of the training before issuing the Mark 1 kits. To enhance distribution of the kits, ADPH developed field pouches that hold three Mark 1 kits (photo 3). One side of the pouch is imprinted with the Mark 1 kit dosing schedule; the other side has the “four don’ts” for responder safety. The ADPH initiative calls for distributing three Mark 1 kits per crew member for each emergency transportation unit in service and having each agency participate in the training.

(3) ADPH created pouches for storing the Mark 1 kits.
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Although the probability of a nerve agent attack in Alabama may be considered low, the potential consequences are too high to ignore, especially for first responders. The ADPH initiative was designed to meet the challenge of providing highly specific training to a large number of trainees statewide. The train-the-trainer approach was used in conventional and teleconference training sessions as a means of reaching large numbers of secondary trainees to meet the challenge. As incidents such as the Tokyo subway attack illustrate, it is critical that we continue to develop and use innovative programs to train the trainers to save our own.

Note: A free copy of the training materials used in this project, including the Power Point® presentations and teleconference, may be obtained by contacting Battalion Chief Sam Hansen at hansen@uab.edu.

SAM HANSEN, EMT-P, EFO, CET, a 34-year veteran of the fire service, is a battalion chief with the Vestavia Hills (AL) Fire Department. He has a B.S. degree in public safety administration and associate’s degrees in emergency medical services and fire science. He completed the National Fire Academy’s Executive Fire Officer Program (2002) and the Commission on Fire Service Accreditation’s Chief Officer Designation (2006). Hansen is a WMD/hazardous materials instructor for the University of Alabama at Birmingham, Center for Labor Education & Research, and the National Emergency Response and Rescue Training Center, Texas A&M University. He co-authored Confined Space Entry and Emergency Response (2002) and Emergency Responder Training Manual for the Hazardous Materials Technician (2004).

ALAN VEASEY, MAEd, MPH, is program director for the Workplace Safety Training Program at the University of Alabama at Birmingham’s Center for Labor Education and Research. He has a master of public health degree in occupational safety and health and a master of arts degree in education. He formerly served as a firefighter/EMT and is a certified trainer for hazardous materials emergency response and first response to terrorism incidents involving weapons of mass destruction. Veasey has been providing occupational safety and health-related training to the public and private sector trainees since 1988. He has coauthored several textbooks, written numerous magazine and peer-reviewed journal articles, and served as coordinator and technical advisor for the History Channel during the filming of the segment “HazMat” for the Suicide Missions video series.

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