Touch and go - Issue 171 - Magazine | Monocle

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On an Alabama highway, a cargo truck carrying pesticide has stalled while crossing a railway track. A few moments later, it is struck by a freight train transporting an unknown chemical contaminant, which begins to leak. Any number of people could have been exposed. Nearby, at a small hospital in the town of Anniston, a “decontamination line” has been set up in a car park. When monocle arrives, the scene is a flurry of ambulances; workers in Tyvek biohazard suits are cutting away the clothing worn by victims, who then progress through a long tent where any remaining contaminants are scrubbed away. Instructions are being shouted as more ambulances pull in. A man sits shivering in a white robe, a smudge of blood on his face.

For all the drama and intensity, this is not a real-world emergency but a high-fidelity simulation of what is rather coldly called a “mass casualty incident”. This hospital no longer treats actual patients: the “victims” are local actors or, in some cases, medical mannequins; the people in charge are instructors. This whole exercise, the culmination of a week’s training of emergency personnel from across the US, is happening on the grounds of the Center for Domestic Preparedness (cdp), a 50-hectare complex run by the US Department of Homeland Security’s Federal Emergency Management Agency (Fema) on the site of the former Fort McClellan, a nearly century-old military complex that closed in 1999. 

Technician on a break in the mannequin ward

Since 1998, notes Kent Latimer, Fema’s director of training delivery, the complex has instructed more than 1.3 million firefighters, police, doctors and nurses in how to act in emergencies ranging from biological-weapon attacks and hurricanes to active shooter incidents. The centre’s unofficial motto is “training the best for the worst”, says Latimer. Most of the instruction takes place in specially designed simulation environments. The former army hospital is now the country’s only facility dedicated solely to training healthcare professionals in disaster preparedness and response. A few metres away, a cylindrical railway tanker sits next to some parked cars. “That’s a simulation of a 4-metre railcar,” says Latimer, with “domes” housing different chemicals. The car was built by Advanced Entertainment Technologies, a Californian company that specialises in theme park attractions and film sets, with a sideline in hazmat training props. Nearby, there’s another car, which can be tipped on its side. In the distance, what sounds like a high-school sports fixture is in progress. “For our public-safety training, we play loud crowd sounds to simulate what it would be like working in a crowded environment,” says Latimer.

Throughout the year, the cdp will run hundreds of these exercises – and with good reason. In 2022, for example, there were more than 1,000 train derailments in the US. In the most notorious case, a train carrying hazardous materials derailed in Palestine, Ohio, a year ago and residents are still reporting lingering health issues. The city halls of Chicago and Milwaukee, which host, respectively, the Democratic and Republican national conventions later this year, have sent emergency responders here for training in how to accommodate large and potentially hostile crowds. In 2017 there were so many natural disasters in the US – hurricanes in the southeast, wildfires in the west, flooding in the Midwest – that the cdp had to suspend training and send its workforce to help in real disaster zones. “So many people have things on their transcripts [school records] and yet, when they get out in the field, can they execute?” says Tony Russell, who helped oversee the federal response to Hurricane Katrina in 2005 and now leads the cdp. He draws on his experience in the Marine Corps. “In the military, we would train under ‘live fire’ conditions,” he says. “So you could hear, feel and smell when someone was firing at you.” He wants the same for the cdp. “You can read it in a book but how does someone react to being really hot or cold, or being stressed out? Until you feel those things, you don’t know – and that is going to affect whether you can actually perform a task.”

Simulated leak 
Tending to a medical mannequin
Mock patients wear T-shirts signalling that they are naked
Local actor playing the role of a victim

One of the most striking examples of the cdp’s realism is at its Chemical, Ordnance, Biological and Radiological Training Facility (or “Cobra”). A red-brick building with a soaring central atrium, it looks like a mid-century church that has been fenced off by intimidating coils of razor wire. Formerly the site of the US Army’s Chemical Corps Training School, it is the only place in the country where emergency responders can go for “live agent” training – meaning that they will be exposed to actual variants of nerve agents such as sarin, which was used in the deadly 1995 terrorist attack on the Tokyo subway, and VX, a lethal compound derived from pesticide research. “They are weapons-grade,” says Cobra operations manager James Johnstone. “They will kill you.” 

Nerve agents are so called for their effect on the nervous system. “They will cause convulsions and secretions, and you’ll lose your bladder,” says Johnstone. The facility can also expose participants to biological agents such as anthrax or ricin; there are no known antidotes for these so the cdp uses attenuated, non-lethal versions of them. “We haven’t had a nerve agent down here in seven to 10 days,” says Johnstone, somewhat reassuringly, as we enter the facility. A sophisticated “negative pressure” air-handling system quickly sucks the contamination out of the various bays and through a set of charcoal and Hepa filters. “This is the cleanest air in Alabama,” he says with a smile. Why incur the added expense, and risk to human life, by using actual nerve agents? “We had one responder who came in, he was a 30-year firefighter, he’s been in all kinds of events,” says Johnstone. “As we were getting ready to go into the hot area, he says, ‘I’m not going to do it.’” By adhering to strict realism, the centre hopes to prompt realistic responses. “Practise like you fight,” says Johnstone.

Studies conducted by the Walter Reed National Military Medical Center, adds fema’s Latimer, have found that training in actual contaminated environments is superior to artificial settings. He gives an example of a responder wearing a claustrophobic airtight ensemble on a hot day. “When the going gets tough and it’s all hot and sweaty and you’re wearing a mask and you just need a little breath of fresh air...” he says. “What do you think a first responder’s going to do if they’re training in a simulated environment?” He feigns lifting a mask off his face. “You don’t take it seriously because you know it’s a simulation.”

Checking for harmful substances in the ‘Lucky’s bar’ area
Preparing a simulated arrow wound
Special-effects style display of wounds 

The cdp has spent several million dollars to upgrade the army’s facility from generic “training bays” to a simulated urban environment, a sort of mash-up of Nashville’s bustling Second Avenue (site of a 2020 bombing) and the New York subway. A warren of rooms and hallways, overseen by a control room, have been fitted with vinyl depicting environments ranging from a subway platform (complete with newspaper box and rubber rat) to a bar called Lucky’s. Before responders, clad in Grade A PPE (personal protective equipment), are allowed into the facility, they are exposed to a small dose of isoamyl acetate, or banana oil. “It’s very detectable when you smell it and it’s familiar,” says Johnstone. If participants smell banana, it means that their mask is not working. But it could also mean something else,” he says. “Somebody says, ‘I smell banana oil’, and they’re not smelling banana oil. They just don’t want to go in.” But even this psychological component has value here. “We would rather tap them out here than in the real world,” says Johnstone.

Back at the Anniston hospital, an actor named Ezra Gilreath is getting ready for his star turn. According to today’s script, he is a farmer named Cole Pollard who has lost his legs after becoming entangled in a piece of agricultural equipment. Gilreath, sporting sideburns and a pink shirt, sits on a gurney. His actual legs are tucked out of sight and what the world sees are two bleeding stumps. The crimson appendages are a highly realistic medical training device manufactured by Norwegian company Laerdal. Today’s exercises are all part of an Integrated Capstone Event, a chance for the assembled responders to put their training to work in an intense, multi-hour simulation of a regional hospital facing a sudden influx of patients. In addition to the patients coming from the train derailment, the responders have to deal with the standard pressures of a hospital environment. “We’re a relatively small hospital and our emergency department only has 13 beds,” says Rick Bearden, the cdp’s exercise manager. “On a normal day, in any town in America, those 13 beds will be full.” During a sudden “no-notice event”, the staff must scramble to reallocate scarce resources. To keep things interesting, cdp managers will throw a few curve balls. “This is like the script of a play,” says Bearden, pointing to a computer spreadsheet. Known as the Master Scenario Event List, it contains some 200 events, featuring everything from power outages to cardiac arrests.

One of these events calls for a patient with an emergency double amputation to suddenly appear at the already stretched hospital. Gilreath, the fictional farmer, is one of several dozen live actors the cdp will use. Some lie on stretchers, others shuffle through the “decon[tamination] line” wearing T-shirts reading “I’m naked” so that responders can treat them appropriately. The blood smeared on actors comes from a plastic jug of Ben Nye stage blood; the flavour is “zesty mint, in case they need to put it in their mouths”, says Katelyn Deerman, a training manager at the cdp. If today’s event unfolds like a film, the mannequin ward is the special-effects department. There’s a bottle of Hershey’s syrup (used to simulate diarrhoea), “vomit” (Pond’s cold cream and oats) and a range of latex wounds – everything from gunshot lesions to boils and blisters.

Background information
Cleaning up

As the morning unfolds, the heart of the action is the hospital’s command centre. Rob Carter, a physician and instructor, says that the administrators are managing the crisis in real time, with everything acted out to the letter. “The emergency department is asking for blood products,” he says. “That doesn’t just happen with the flip of a light switch. We make them call the blood bank.” Faithful to one of the script’s plot points, the hospital’s internal communications are down. “So we have to run down to radiology?” a nurse asks. Carter expresses slight concern over the team’s performance. “The tone of the room is loud, it seems a little disorganised,” he says. The reason, he suspects, is that the person in charge is “getting in the weeds”. Rather than prioritising the big decisions, “they’re trying to fix everything”.

Back in the mannequin ward, Gilreath is ready to be wheeled to the emergency department. The staff cover their ears. “Ezra is the best screamer,” says Deerman. Suddenly, it’s go time. Gilreath unleashes a series of Oscar-worthy cries of “My legs!” as he is wheeled into the glaring light of the emergency ward. A team of nurses surrounds him, the doctor introduces herself. “You can come with me, ma’am,” a nurse says to the mother. “No,” she says repeatedly, her face a knot of anguish and concern. “I’m not leaving him.” His vitals are checked, tourniquets applied. “We got fluids?” someone asks. “Let’s get him up to the operating room.” The patient is whisked out, trailing blood on the gleaming floor. The room goes quiet. 

At some point in the next few weeks there will be a new crisis – a hurricane or an earthquake – and a new cast of characters. Simulating these sorts of emergencies helps to resolve a real-world dilemma. Events like these don’t happen so frequently that emergency responders can learn on the job but they are common enough that someday these responders will get the call – and it won’t be a drill. –– L

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