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(St David’s Cathedral)

Benson loved Charles. Charles liked to let on that he had some kind of unspecified bladder problem, which gave him a ready-made excuse to prowl the hallways at Chavez, looking for people to fink on.

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I had no intention of being caught by him again. I'd planned this well in advance. Charles would never get me again. I emailed my server at home, and it got into motion. A few seconds later, Charles's phone spazzed out spectacularly. I'd had tens of thousands of simultaneous random calls and text messages sent to it, causing every chirp and ring it had to go off and keep on going off.

The attack was accomplished by means of a botnet, and for that I felt bad, but it was in the service of a good cause. Botnets are where infected computers spend their afterlives. That message tells the botmaster -- the guy who deployed the worm -- that the computers are there ready to do his bidding. Botnets are supremely powerful, since they can comprise thousands, even hundreds of thousands of computers, scattered all over the Internet, connected to juicy high-speed connections and running on fast home PCs.

Those PCs normally function on behalf of their owners, but when the botmaster calls them, they rise like zombies to do his bidding. There are so many infected PCs on the Internet that the price of hiring an hour or two on a botnet has crashed. Mostly these things work for spammers as cheap, distributed spambots, filling your mailbox with come-ons for boner-pills or with new viruses that can infect you and recruit your machine to join the botnet. I'd just rented 10 seconds' time on three thousand PCs and had each of them send a text message or voice-over-IP call to Charles's phone, whose number I'd extracted from a sticky note on Benson's desk during one fateful office-visit.

Needless to say, Charles's phone was not equipped to handle this. First the SMSes filled the memory on his phone, causing it to start choking on the routine operations it needed to do things like manage the ringer and log all those incoming calls' bogus return numbers did you know that it's really easy to fake the return number on a caller ID? There are about fifty ways of doing it -- just google "spoof caller id".

Charles stared at it dumbfounded, and jabbed at it furiously, his thick eyebrows knotting and wiggling as he struggled with the demons that had possessed his most personal of devices. The plan was working so far, but he wasn't doing what he was supposed to be doing next -- he was supposed to go find some place to sit down and try to figure out how to get his phone back.

Once the memory was totally filled, it would have a hard time loading the code it needed to delete the bogus messages -- and there was no bulk-erase for texts on his phone, so he'd have to manually delete all of the thousands of messages. Darryl shoved me back and stuck his eye up to the door. A moment later, his shoulders started to shake. I got scared, thinking he was panicking, but when he pulled back, I saw that he was laughing so hard that tears were streaming down his cheeks. She was really enjoying it.

We shook hands solemnly and snuck back out of the corridor, down the stairs, around the back, out the door, past the fence and out into the glorious sunlight of afternoon in the Mission. Valencia Street had never looked so good. I checked my watch and yelped. Van spotted us first. She was blending in with a group of Korean tourists, which is one of her favorite ways of camouflaging herself when she's ditching school. Ever since the truancy moblog went live, our world is full of nosy shopkeepers and pecksniffs who take it upon themselves to snap our piccies and put them on the net where they can be perused by school administrators.

She came out of the crowd and bounded toward us. Darryl has had a thing for Van since forever, and she's sweet enough to pretend she doesn't know it. She gave me a hug and then moved onto Darryl, giving him a quick sisterly kiss on the cheek that made him go red to the tops of his ears.

The two of them made a funny pair: Darryl is a little on the heavy side, though he wears it well, and he's got a kind of pink complexion that goes red in the cheeks whenever he runs or gets excited. He's been able to grow a beard since we were 14, but thankfully he started shaving after a brief period known to our gang as "the Lincoln years.

Very, very tall. Like basketball player tall. Meanwhile, Van is half a head shorter than me, and skinny, with straight black hair that she wears in crazy, elaborate braids that she researches on the net. She's got pretty coppery skin and dark eyes, and she loves big glass rings the size of radishes, which click and clack together when she dances.

He always ran a step behind the conversation when it came to Van. How's your every little thing? Darryl nearly fainted. Jolu saved him from social disgrace by showing up just then, in an oversize leather baseball jacket, sharp sneakers, and a meshback cap advertising our favorite Mexican masked wrestler, El Santo Junior. Jolu is Jose Luis Torrez, the completing member of our foursome. He went to a super-strict Catholic school in the Outer Richmond, so it wasn't easy for him to get out. But he always did: no one exfiltrated like our Jolu. He liked his jacket because it hung down low -- which was pretty stylish in parts of the city -- and covered up all his Catholic school crap, which was like a bulls-eye for nosy jerks with the truancy moblog bookmarked on their phones.

Somewhere in there we should find the wireless signal. Van made a face. That part of San Francisco is one of the weird bits -- you go in through the Hilton's front entrance and it's all touristy stuff like the cable-car turnaround and family restaurants. Go through to the other side and you're in the 'Loin, where every tracked out transvestite hooker, hard-case pimp, hissing drug dealer and cracked up homeless person in town was concentrated.

What they bought and sold, none of us were old enough to be a part of though there were plenty of hookers our age plying their trade in the 'Loin. None of the other players are going to go near it until tomorrow at the earliest. This is what we in the ARG business call a monster head start. After me, she was hands-down the most hardcore player in our group. She took winning very, very seriously. We struck out, four good friends, on our way to decode a clue, win the game -- and lose everything we cared about, forever.

The physical component of today's clue was a set of GPS coordinates -- there were coordinates for all the major cities where Harajuku Fun Madness was played -- where we'd find a WiFi access-point's signal. That signal was being deliberately jammed by another, nearby WiFi point that was hidden so that it couldn't be spotted by conventional wifinders, little key-fobs that told you when you were within range of someone's open access-point, which you could use for free.

We'd have to track down the location of the "hidden" access point by measuring the strength of the "visible" one, finding the spot where it was most mysteriously weakest. There we'd find another clue -- last time it had been in the special of the day at Anzu, the swanky sushi restaurant in the Nikko hotel in the Tenderloin. The Nikko was owned by Japan Airlines, one of Harajuku Fun Madness's sponsors, and the staff had all made a big fuss over us when we finally tracked down the clue.

They'd given us bowls of miso soup and made us try uni, which is sushi made from sea urchin, with the texture of very runny cheese and a smell like very runny dog-droppings. But it tasted really good. Or so Darryl told me. I wasn't going to eat that stuff. The network's name was HarajukuFM, so we knew we had the right spot.

Darryl and Van had phones with built-in wifinders, while Jolu, being too cool to carry a phone bigger than his pinky finger, had a separate little directional fob. You're looking for a sharp drop off in the signal that gets worse the more you move along it. I took a step backward and ended up standing on someone's toes. A female voice said "oof" and I spun around, worried that some crack-ho was going to stab me for breaking her heels. Instead, I found myself face to face with another kid my age. She had a shock of bright pink hair and a sharp, rodent-like face, with big sunglasses that were practically air-force goggles.

She was dressed in striped tights beneath a black granny dress, with lots of little Japanese decorer toys safety pinned to it -- anime characters, old world leaders, emblems from foreign soda-pop. You can come back in one hour and it'll be all yours. I think that's more than fair. I looked behind her and noticed three other girls in similar garb -- one with blue hair, one with green, and one with purple. Behind me I felt Van start forward. Her all-girls school was notorious for its brawls, and I was pretty sure she was ready to knock this chick's block off. We felt it first, that sickening lurch of the cement under your feet that every Californian knows instinctively -- earthquake.

My first inclination, as always, was to get away: "when in trouble or in doubt, run in circles, scream and shout. Earthquakes are eerily quiet -- at first, anyway -- but this wasn't quiet. This was loud, an incredible roaring sound that was louder than anything I'd ever heard before. The sound was so punishing it drove me to my knees, and I wasn't the only one. Darryl shook my arm and pointed over the buildings and we saw it then: a huge black cloud rising from the northeast, from the direction of the Bay.

There was another rumble, and the cloud of smoke spread out, that spreading black shape we'd all grown up seeing in movies. Someone had just blown up something, in a big way. There were more rumbles and more tremors. Heads appeared at windows up and down the street. We all looked at the mushroom cloud in silence. I'd heard sirens like these before -- they test the civil defense sirens at noon on Tuesdays. But I'd only heard them go off unscheduled in old war movies and video games, the kind where someone is bombing someone else from above.

Air raid sirens. The wooooooo sound made it all less real. There were speakers on some of the electric poles, something I'd never noticed before, and they'd all switched on at once. We looked at each other in confusion. What shelters? The cloud was rising steadily, spreading out.

Was it nuclear? Were we breathing in our last breaths? The girl with the pink hair grabbed her friends and they tore ass downhill, back toward the BART station and the foot of the hills. A dozen SFPD cruisers screamed past us. My friends nodded. We closed ranks and began to move quickly downhill.

This chapter is dedicated to Borderlands Books, San Francisco's magnificent independent science fiction bookstore. Borderlands is basically located across the street from the fictional Cesar Chavez High depicted in Little Brother, and it's not just notorious for its brilliant events, signings, book clubs and such, but also for its amazing hairless Egyptian cat, Ripley, who likes to perch like a buzzing gargoyle on the computer at the front of the store.

Borderlands is about the friendliest bookstore you could ask for, filled with comfy places to sit and read, and staffed by incredibly knowledgeable clerks who know everything there is to know about science fiction. Even better, they've always been willing to take orders for my book by net or phone and hold them for me to sign when I drop into the store, then they ship them within the US for free! They were running or walking, white-faced and silent or shouting and panicked. Homeless people cowered in doorways and watched it all, while a tall black tranny hooker shouted at two mustached young men about something.

The closer we got to the BART, the worse the press of bodies became. By the time we reached the stairway down into the station, it was a mob-scene, a huge brawl of people trying to crowd their way down a narrow staircase. I had my face crushed up against someone's back, and someone else was pressed into my back. Darryl was still beside me -- he was big enough that he was hard to shove, and Jolu was right behind him, kind of hanging on to his waist.

I spied Vanessa a few yards away, trapped by more people. Get your hands off of me! I strained around against the crowd and saw Van looking with disgust at an older guy in a nice suit who was kind of smirking at her. She was digging in her purse and I knew what she was digging for. At the mention of the word mace, the guy looked scared and kind of melted back, though the crowd kept him moving forward. Up ahead, I saw someone, a middle-aged lady in a hippie dress, falter and fall.

She screamed as she went down, and I saw her thrashing to get up, but she couldn't, the crowd's pressure was too strong. As I neared her, I bent to help her up, and was nearly knocked over her. I ended up stepping on her stomach as the crowd pushed me past her, but by then I don't think she was feeling anything.

I was as scared as I'd ever been. There was screaming everywhere now, and more bodies on the floor, and the press from behind was as relentless as a bulldozer. It was all I could do to keep on my feet. We were in the open concourse where the turnstiles were. It was hardly any better here -- the enclosed space sent the voices around us echoing back in a roar that made my head ring, and the smell and feeling of all those bodies made me feel a claustrophobia I'd never known I was prone to. People were still cramming down the stairs, and more were squeezing past the turnstiles and down the escalators onto the platforms, but it was clear to me that this wasn't going to have a happy ending.

I looked to Vanessa -- there was no way she'd hear me. I managed to get my phone out and I texted her. I saw her feel the vibe from her phone, then look down at it and then back at me and nod vigorously. Darryl, meanwhile, had clued Jolu in. He shrugged. Van worked her way over to me and grabbed hold of my wrist. I took Darryl and Darryl took Jolu by the other hand and we pushed out. It wasn't easy. We moved about three inches a minute at first, then slowed down even more when we reached the stairway.

The people we passed were none too happy about us shoving them out of the way, either. A couple people swore at us and there was a guy who looked like he'd have punched me if he'd been able to get his arms loose. We passed three more crushed people beneath us, but there was no way I could have helped them. By that point, I wasn't even thinking of helping anyone. All I could think of was finding the spaces in front of us to move into, of Darryl's mighty straining on my wrist, of my death-grip on Van behind me.

We popped free like Champagne corks an eternity later, blinking in the grey smoky light. The air raid sirens were still blaring, and the sound of emergency vehicles' sirens as they tore down Market Street was even louder. There was almost no one on the streets anymore -- just the people trying hopelessly to get underground.

A lot of them were crying. I spotted a bunch of empty benches -- usually staked out by skanky winos -- and pointed toward them. We moved for them, the sirens and the smoke making us duck and hunch our shoulders. We got as far as the benches before Darryl fell forward. We all yelled and Vanessa grabbed him and turned him over. The side of his shirt was stained red, and the stain was spreading. She tugged his shirt up and revealed a long, deep cut in his pudgy side. Darryl groaned and looked at us, then down at his side, then he groaned and his head went back again.

Vanessa took off her jean jacket and then pulled off the cotton hoodie she was wearing underneath it. She wadded it up and pressed it to Darryl's side. Vanessa's mother is a nurse and she'd had first aid training every summer at camp. She loved to watch people in movies get their first aid wrong and make fun of them. I was so glad to have her with us. We sat there for a long time, holding the hoodie to Darryl's side. He kept insisting that he was fine and that we should let him up, and Van kept telling him to shut up and lie still before she kicked his ass. I felt like an idiot.

I whipped my phone out and punched The sound I got wasn't even a busy signal -- it was like a whimper of pain from the phone system. You don't get sounds like that unless there's three million people all dialing the same number at once. Who needs botnets when you've got terrorists? I looked where he was pointing, thinking I'd see a cop or an paramedic, but there was no one there.

He was right. Every five seconds, a cop car, an ambulance or a firetruck zoomed past. They could get us some help. I was such an idiot. Vanessa didn't like it, but I figured a cop wasn't going to stop for a kid waving his hat in the street, not that day. They just might stop if they saw Darryl bleeding there, though. I argued briefly with her and Darryl settled it by lurching to his feet and dragging himself down toward Market Street.

The first vehicle that screamed past -- an ambulance -- didn't even slow down. Neither did the cop car that went past, nor the firetruck, nor the next three cop-cars. Darryl wasn't in good shape -- he was white-faced and panting. Van's sweater was soaked in blood. I was sick of cars driving right past me.

It was a military-looking Jeep, like an armored Hummer, only it didn't have any military insignia on it. The car skidded to a stop just in front of me, and I jumped back and lost my balance and ended up on the road. I felt the doors open near me, and then saw a confusion of booted feet moving close by.

I looked up and saw a bunch of military-looking guys in coveralls, holding big, bulky rifles and wearing hooded gas masks with tinted face-plates. I barely had time to register them before those rifles were pointed at me. I'd never looked down the barrel of a gun before, but everything you've heard about the experience is true.

You freeze where you are, time stops, and your heart thunders in your ears. I opened my mouth, then shut it, then, very slowly, I held my hands up in front of me. The faceless, eyeless armed man above me kept his gun very level. I didn't even breathe. Van was screaming something and Jolu was shouting and I looked at them for a second and that was when someone put a coarse sack over my head and cinched it tight around my windpipe, so quick and so fiercely I barely had time to gasp before it was locked on me.

I was pushed roughly but dispassionately onto my stomach and something went twice around my wrists and then tightened up as well, feeling like baling wire and biting cruelly. I cried out and my own voice was muffled by the hood. I was in total darkness now and I strained my ears to hear what was going on with my friends. I heard them shouting through the muffling canvas of the bag, and then I was being impersonally hauled to my feet by my wrists, my arms wrenched up behind my back, my shoulders screaming.

I stumbled some, then a hand pushed my head down and I was inside the Hummer. More bodies were roughly shoved in beside me. I heard Jolu respond, then felt the thump he was dealt, too. My head rang like a gong. We're just high school students. I wanted to flag you down because my friend was bleeding. Someone stabbed him. I kept talking. We've got to get my friend to a hospital --". Someone went upside my head again. It felt like they used a baton or something -- it was harder than anyone had ever hit me in the head before.

My eyes swam and watered and I literally couldn't breathe through the pain. A moment later, I caught my breath, but I didn't say anything. I'd learned my lesson. Who were these clowns? They weren't wearing insignia. Maybe they were terrorists! I'd never really believed in terrorists before -- I mean, I knew that in the abstract there were terrorists somewhere in the world, but they didn't really represent any risk to me. There were millions of ways that the world could kill me -- starting with getting run down by a drunk burning his way down Valencia -- that were infinitely more likely and immediate than terrorists.

Terrorists killed a lot fewer people than bathroom falls and accidental electrocutions. Worrying about them always struck me as about as useful as worrying about getting hit by lightning. Sitting in the back of that Hummer, my head in a hood, my hands lashed behind my back, lurching back and forth while the bruises swelled up on my head, terrorism suddenly felt a lot riskier. The car rocked back and forth and tipped uphill. I gathered we were headed over Nob Hill, and from the angle, it seemed we were taking one of the steeper routes -- I guessed Powell Street.

Now we were descending just as steeply. If my mental map was right, we were heading down to Fisherman's Wharf. You could get on a boat there, get away. That fit with the terrorism hypothesis. Why the hell would terrorists kidnap a bunch of high school students? We rocked to a stop still on a downslope. The engine died and then the doors swung open. Someone dragged me by my arms out onto the road, then shoved me, stumbling, down a paved road. A few seconds later, I tripped over a steel staircase, bashing my shins. The hands behind me gave me another shove. I went up the stairs cautiously, not able to use my hands.

I got up the third step and reached for the fourth, but it wasn't there. I nearly fell again, but new hands grabbed me from in front and dragged me down a steel floor and then forced me to my knees and locked my hands to something behind me. More movement, and the sense of bodies being shackled in alongside of me.

Groans and muffled sounds. Then a long, timeless eternity in the muffled gloom, breathing my own breath, hearing my own breath in my ears. I actually managed a kind of sleep there, kneeling with the circulation cut off to my legs, my head in canvas twilight. My body had squirted a year's supply of adrenalin into my bloodstream in the space of 30 minutes, and while that stuff can give you the strength to lift cars off your loved ones and leap over tall buildings, the payback's always a bitch. I woke up to someone pulling the hood off my head. They were neither rough nor careful -- just Like someone at McDonald's putting together burgers.

The light in the room was so bright I had to squeeze my eyes shut, but slowly I was able to open them to slits, then cracks, then all the way and look around. We were all in the back of a truck, a big wheeler. I could see the wheel-wells at regular intervals down the length. Steel desks lined the walls with banks of slick flat-panel displays climbing above them on articulated arms that let them be repositioned in a halo around the operators.

Each desk had a gorgeous office-chair in front of it, festooned with user-interface knobs for adjusting every millimeter of the sitting surface, as well as height, pitch and yaw. Then there was the jail part -- at the front of the truck, furthest away from the doors, there were steel rails bolted into the sides of the vehicle, and attached to these steel rails were the prisoners. I spotted Van and Jolu right away. Darryl might have been in the remaining dozen shackled up back here, but it was impossible to say -- many of them were slumped over and blocking my view.

It stank of sweat and fear back there. Vanessa looked at me and bit her lip. She was scared. So was I. So was Jolu, his eyes rolling crazily in their sockets, the whites showing. I was scared. What's more, I had to piss like a race-horse. I looked around for our captors. I'd avoided looking at them up until now, the same way you don't look into the dark of a closet where your mind has conjured up a boogey-man. You don't want to know if you're right.

But I had to get a better look at these jerks who'd kidnapped us. If they were terrorists, I wanted to know. I didn't know what a terrorist looked like, though TV shows had done their best to convince me that they were brown Arabs with big beards and knit caps and loose cotton dresses that hung down to their ankles. Not so our captors. They could have been half-time-show cheerleaders on the Super Bowl. They looked American in a way I couldn't exactly define. Good jaw-lines, short, neat haircuts that weren't quite military. They came in white and brown, male and female, and smiled freely at one another as they sat down at the other end of the truck, joking and drinking coffees out of go-cups.

These weren't Ay-rabs from Afghanistan: they looked like tourists from Nebraska. I stared at one, a young white woman with brown hair who barely looked older than me, kind of cute in a scary office-power-suit way. If you stare at someone long enough, they'll eventually look back at you. She did, and her face slammed into a totally different configuration, dispassionate, even robotic. The smile vanished in an instant. It's going to get pretty smelly back here, you know? She turned to her colleagues, a little huddle of three of them, and they held a low conversation I couldn't hear over the fans from the computers.

She turned back to me. She shook her head and looked at me like I was some kind of pathetic loser. She and her friends conferred some more, then another one came forward. He was older, in his early thirties, and pretty big across the shoulders, like he worked out. He looked like he was Chinese or Korean -- even Van can't tell the difference sometimes -- but with that bearing that said American in a way I couldn't put my finger on. He pulled his sports-coat aside to let me see the hardware strapped there: I recognized a pistol, a tazer and a can of either mace or pepper-spray before he let it fall again.

He touched something at his belt and the shackles behind me let go, my arms dropping suddenly behind me. It was like he was wearing Batman's utility belt -- wireless remotes for shackles! I guessed it made sense, though: you wouldn't want to lean over your prisoners with all that deadly hardware at their eye-level -- they might grab your gun with their teeth and pull the trigger with their tongues or something.

My hands were still lashed together behind me by the plastic strapping, and now that I wasn't supported by the shackles, I found that my legs had turned into lumps of cork while I was stuck in one position. Long story short, I basically fell onto my face and kicked my legs weakly as they went pins-and-needles, trying to get them under me so I could rock up to my feet. The guy jerked me to my feet and I clown-walked to the very back of the truck, to a little boxed-in porta-john there. I tried to spot Darryl on the way back, but he could have been any of the five or six slumped people.

Or none of them. I jerked my wrists. You either cut my wrists free or you're going to have to aim for me. A toilet visit is not a hands-free experience. The guy didn't like me, I could tell from the way his jaw muscles ground around. Man, these people were wired tight. He reached down to his belt and came up with a very nice set of multi-pliers. He flicked out a wicked-looking knife and sliced through the plastic cuffs and my hands were my own again. He shoved me into the bathroom. My hands were useless, like lumps of clay on the ends of my wrists.

As I wiggled my fingers limply, they tingled, then the tingling turned to a burning feeling that almost made me cry out. I put the seat down, dropped my pants and sat down. I didn't trust myself to stay on my feet. As my bladder cut loose, so did my eyes. I wept, crying silently and rocking back and forth while the tears and snot ran down my face.

It was all I could do to keep from sobbing -- I covered my mouth and held the sounds in. I didn't want to give them the satisfaction. Finally, I was peed out and cried out and the guy was pounding on the door. I cleaned my face as best as I could with wads of toilet paper, stuck it all down the john and flushed, then looked around for a sink but only found a pump-bottle of heavy-duty hand-sanitizer covered in small-print lists of the bio-agents it worked on.

I rubbed some into my hands and stepped out of the john. He turned me around and grabbed my hands and I felt a new pair of plastic cuffs go around them. My wrists had swollen since the last pair had come off and the new ones bit cruelly into my tender skin, but I refused to give him the satisfaction of crying out.

He shackled me back to my spot and grabbed the next person down, who, I saw now, was Jolu, his face puffy and an ugly bruise on his cheek. One by one, all the prisoners went to the can, and came back, and when they were done, my guard went back to his friends and had another cup of coffee -- they were drinking out of a big cardboard urn of Starbucks, I saw -- and they had an indistinct conversation that involved a fair bit of laughter.

Then the door at the back of the truck opened and there was fresh air, not smoky the way it had been before, but tinged with ozone. In the slice of outdoors I saw before the door closed, I caught that it was dark out, and raining, with one of those San Francisco drizzles that's part mist. The man who came in was wearing a military uniform. A US military uniform. He saluted the people in the truck and they saluted him back and that's when I knew that I wasn't a prisoner of some terrorists -- I was a prisoner of the United States of America.

They set up a little screen at the end of the truck and then came for us one at a time, unshackling us and leading us to the back of the truck. As close as I could work it -- counting seconds off in my head, one hippopotami, two hippopotami -- the interviews lasted about seven minutes each. My head throbbed with dehydration and caffeine withdrawal. I was third, brought back by the woman with the severe haircut. Up close, she looked tired, with bags under her eyes and grim lines at the corners of her mouth.

I hated myself for the automatic politeness, but it had been drilled into me. She didn't twitch a muscle. I went ahead of her to the back of the truck and behind the screen. There was a single folding chair and I sat in it. Two of them -- Severe Haircut woman and utility belt man -- looked at me from their ergonomic super-chairs. They had a little table between them with the contents of my wallet and backpack spread out on it. This wasn't an idle question. If you're not under arrest, there are limits on what the cops can and can't do to you. For starters, they can't hold you forever without arresting you, giving you a phone call, and letting you talk to a lawyer.

And hoo-boy, was I ever going to talk to a lawyer. The screen was showing the error message you got if you kept trying to get into its data without giving the right password. It was a bit of a rude message -- an animated hand giving a certain universally recognized gesture -- because I liked to customize my gear. They can't make you answer any questions if you're not under arrest, and when you ask if you're under arrest, they have to answer you.

It's the rules. I would like to see some form of identification from both of you. We found a number of suspicious devices on your person. We found you and your confederates near the site of the worst terrorist attack this country has ever seen. Put those two facts together and things don't look very good for you, Marcus. You can cooperate, or you can be very, very sorry. Now, what is this for? We googled you, you know. You've posted a lot of very ugly stuff on the public Internet.

Severe haircut lady looked at me like I was a bug. You need to get past that. You are being detained as a potential enemy combatant by the government of the United States. If I were you, I'd be thinking very hard about how to convince us that you are not an enemy combatant. Very hard. Because there are dark holes that enemy combatants can disappear into, very dark deep holes, holes where you can just vanish. Are you listening to me young man? I want you to unlock this phone and then decrypt the files in its memory. I want you to account for yourself: why were you out on the street?

What do you know about the attack on this city? My phone's memory had all kinds of private stuff on it: photos, emails, little hacks and mods I'd installed. All the FAQs on getting arrested were clear on this point. Just keep asking to see an attorney, no matter what they say or do.

There's no good that comes of talking to the cops without your lawyer present. These two said they weren't cops, but if this wasn't an arrest, what was it? This chapter is dedicated to Barnes and Noble, a US national chain of bookstores. As America's mom-and-pop bookstores were vanishing, Barnes and Noble started to build these gigantic temples to reading all across the land.

They're passionate and knowledgeable about the field and it shows in the excellent selection on display at the stores. Barnes and Noble, nationwide. They re-shackled and re-hooded me and left me there. A long time later, the truck started to move, rolling downhill, and then I was hauled back to my feet. I immediately fell over. My legs were so asleep they felt like blocks of ice, all except my knees, which were swollen and tender from all the hours of kneeling.

Hands grabbed my shoulders and feet and I was picked up like a sack of potatoes. There were indistinct voices around me. Someone crying. Someone cursing. I was carried a short distance, then set down and re-shackled to another railing. My knees wouldn't support me anymore and I pitched forward, ending up twisted on the ground like a pretzel, straining against the chains holding my wrists. Then we were moving again, and this time, it wasn't like driving in a truck. The floor beneath me rocked gently and vibrated with heavy diesel engines and I realized I was on a ship! My stomach turned to ice.

I was being taken off America's shores to somewhere else , and who the hell knew where that was? I'd been scared before, but this thought terrified me, left me paralyzed and wordless with fear. I realized that I might never see my parents again and I actually tasted a little vomit burn up my throat.

The bag over my head closed in on me and I could barely breathe, something that was compounded by the weird position I was twisted into. But mercifully we weren't on the water for very long. It felt like an hour, but I know now that it was a mere fifteen minutes, and then I felt us docking, felt footsteps on the decking around me and felt other prisoners being unshackled and carried or led away. When they came for me, I tried to stand again, but couldn't, and they carried me again, impersonally, roughly. The cell was old and crumbled, and smelled of sea air. There was one window high up, and rusted bars guarded it.

It was still dark outside. There was a blanket on the floor and a little metal toilet without a seat, set into the wall. The guard who took off my hood grinned at me and closed the solid steel door behind him. I gently massaged my legs, hissing as the blood came back into them and into my hands. Eventually I was able to stand, and then to pace. I heard other people talking, crying, shouting. I did some shouting too: "Jolu! The nearest voices sounded like drunks losing their minds on a street-corner.

Maybe I sounded like that too. Guards shouted at us to be quiet and that just made everyone yell louder. Eventually we were all howling, screaming our heads off, screaming our throats raw. Why not? What did we have to lose? The next time they came to question me, I was filthy and tired, thirsty and hungry. Severe haircut lady was in the new questioning party, as were three big guys who moved me around like a cut of meat. One was black, the other two were white, though one might have been hispanic.

They all carried guns. It was like a Benneton's ad crossed with a game of Counter-Strike. They'd taken me from my cell and chained my wrists and ankles together. I paid attention to my surroundings as we went. I heard water outside and thought that maybe we were on Alcatraz -- it was a prison, after all, even if it had been a tourist attraction for generations, the place where you went to see where Al Capone and his gangster contemporaries did their time. But I'd been to Alcatraz on a school trip. It was old and rusted, medieval. This place felt like it dated back to World War Two, not colonial times.

There were bar-codes laser-printed on stickers and placed on each of the cell-doors, and numbers, but other than that, there was no way to tell who or what might be behind them. The interrogation room was modern, with fluorescent lights, ergonomic chairs -- not for me, though, I got a folding plastic garden-chair -- and a big wooden board-room table. A mirror lined one wall, just like in the cop shows, and I figured someone or other must be watching from behind it. Severe haircut lady and her friends helped themselves to coffees from an urn on a side-table I could have torn her throat out with my teeth and taken her coffee just then , and then set a styrofoam cup of water down next to me -- without unlocking my wrists from behind my back, so I couldn't reach it.

Hardy har har. Even once you tell us what we want to know, even if that convinces us that you were just in the wrong place at the wrong time, you're a marked man now. We'll be watching you everywhere you go and everything you do. You've acted like you've got something to hide, and we don't like that. It's pathetic, but all my brain could think about was that phrase, "convince us that you were in the wrong place at the wrong time.

I had never, ever felt this bad or this scared before. Those words, "wrong place at the wrong time," those six words, they were like a lifeline dangling before me as I thrashed to stay on the surface. This isn't the worst place we can put you, not by a damned sight. She set them down on the table one after the other. You unlock the phone for us today. If you do that, you'll get outdoor and bathing privileges.

You'll get a shower and you'll be allowed to walk around in the exercise yard. Tomorrow, we'll bring you back and ask you to decrypt the data on these memory sticks. Do that, and you'll get to eat in the mess hall. The day after, we're going to want your email passwords, and that will get you library privileges. The word "no" was on my lips, like a burp trying to come up, but it wouldn't come. This is about your security, Marcus.

Say you're innocent. You might be, though why an innocent man would act like he's got so much to hide is beyond me. But say you are: you could have been on that bridge when it blew. Your parents could have been. Your friends. Don't you want us to catch the people who attacked your home? It's funny, but when she was talking about my getting "privileges" it scared me into submission. I felt like I'd done something to end up where I was, like maybe it was partially my fault, like I could do something to change it.

But as soon as she switched to this BS about "safety" and "security," my spine came back. I thought I lived in a country with a constitution. I thought I lived in a country where I had rights. You're talking about defending my freedom by tearing up the Bill of Rights. A flicker of annoyance passed over her face, then went away. No one's attacked you. You've been detained by your country's government while we seek details on the worst terrorist attack ever perpetrated on our nation's soil.

You have it within your power to help us fight this war on our nation's enemies. You want to preserve the Bill of Rights? Help us stop bad people from blowing up your city. Now, you have exactly thirty seconds to unlock that phone before I send you back to your cell. We have lots of other people to interview today. She looked at her watch. I rattled my wrists, rattled the chains that kept me from reaching around and unlocking the phone.

Yes, I was going to do it. She'd told me what my path was to freedom -- to the world, to my parents -- and that had given me hope. Now she'd threatened to send me away, to take me off that path, and my hope had crashed and all I could think of was how to get back on it. So I rattled my wrists, wanting to get to my phone and unlock it for her, and she just looked at me coldly, checking her watch. She wanted me to say it out loud, here, where she could record it, where her pals could hear it.

She didn't want me to just unlock the phone. She wanted me to submit to her. To put her in charge of me. To give up every secret, all my privacy. God help me, I submitted to her will. She smiled a little prim smile, which had to be her ice-queen equivalent of a touchdown dance, and the guards led me away. As the door closed, I saw her bend down over the phone and key the password in.

You might be wondering at this point what dark secrets I had locked away on my phone and memory sticks and email. I'm just a kid, after all. The truth is that I had everything to hide, and nothing. Between my phone and my memory sticks, you could get a pretty good idea of who my friends were, what I thought of them, all the goofy things we'd done. You could read the transcripts of the electronic arguments we'd carried out and the electronic reconciliations we'd arrived at. You see, I don't delete stuff.

Why would I? Storage is cheap, and you never know when you're going to want to go back to that stuff. Especially the stupid stuff. You know that feeling you get sometimes where you're sitting on the subway and there's no one to talk to and you suddenly remember some bitter fight you had, some terrible thing you said? Well, it's usually never as bad as you remember. Being able to go back and see it again is a great way to remind yourself that you're not as horrible a person as you think you are. Darryl and I have gotten over more fights that way than I can count.

And even that's not it. I know my phone is private.

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I know my memory sticks are private. That's because of cryptography -- message scrambling. The math behind crypto is good and solid, and you and me get access to the same crypto that banks and the National Security Agency use. There's only one kind of crypto that anyone uses: crypto that's public, open and can be deployed by anyone. That's how you know it works. There's something really liberating about having some corner of your life that's yours , that no one gets to see except you.

It's a little like nudity or taking a dump. Everyone gets naked every once in a while. Everyone has to squat on the toilet. There's nothing shameful, deviant or weird about either of them. But what if I decreed that from now on, every time you went to evacuate some solid waste, you'd have to do it in a glass room perched in the middle of Times Square, and you'd be buck naked? Even if you've got nothing wrong or weird with your body -- and how many of us can say that? Most of us would run screaming.

Most of us would hold it in until we exploded. It's not about doing something shameful. It's about doing something private. It's about your life belonging to you. They were taking that from me, piece by piece. As I walked back to my cell, that feeling of deserving it came back to me. I'd broken a lot of rules all my life and I'd gotten away with it, by and large. Maybe this was justice. Maybe this was my past coming back to me.

The following discussion reviews existing OSHA regulations, letters of interpretation, and published literature relevant to the selection of PPE for healthcare workers receiving contaminated victims. Many recent sources note that the quantity of contaminant on victims is restricted. For example, OSHA has made a clear distinction between the site where a hazardous substance was released and hospital-based decontamination facilities OSHA, a, a.

This distinction is important because it helps define the maximum amount of contaminant to which healthcare workers might be exposed i. Horton et al. The quantity of contaminant that healthcare workers might encounter can be dramatically less than the amount to which the victim was exposed or that was originally deposited on the victim. Gas or vapor releases can expose victims to toxic concentrations, but tend to evaporate and dissipate quickly. Georgopoulos et al. Unless the substance release occurs immediately adjacent to a hospital, it is not anticipated that victims will be able to reach the hospital within that period of time, or the more realistic minute period that Georgopoulos et al.

It is important to note, however, that limited exposure might be possible. In an isolated incident reviewed by these authors, unprotected healthcare workers experienced skin and respiratory irritation from highly toxic volatile substances chlorine gas thought to have permeated victims' clothing.

Removal of victim's clothing, or, better yet, decontamination of victims before they arrive at the hospital have a marked effect on the quantity of contaminant that first receivers encounter.

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Pre-hospital decontamination can eliminate the risk of secondary contamination Horton et al. Removing contaminated clothing can reduce the quantity of contaminant associated with victims by an estimated 75 to 90 percent Macintyre et al. The clothing is cut away using blunt-nose shears to eliminate stretching, flapping, wringing, or excessive handling of fabric that might contribute to worker exposure or additional victim exposure. Showering with tepid water and a liquid soap with good surfactant properties is widely considered an effective and preferred method for removing the remaining hazardous substance from victims' skin and hair Goozner et al, ; Macintyre et al.

Army promotes this method for chemicals both chemical weapons and toxic industrial chemicals , radiological particles, and biological agents USACHPPM, a. No further injury to healthcare workers was mentioned. See Appendix A, Section 2. When the nature of the contaminant is known, the hospital can adjust the decontamination procedures to best remove the specific hazard. As a final step in minimizing first receiver exposure to hazardous substances, the accepted industrial hygiene practice is for the healthcare workers also to shower following contact with contaminated victims and cleanse equipment as part of decontamination procedures.

Hospital A uses a strict protocol for personnel to decontaminate themselves while removing gloves, protective suits, boots, and hooded powered air-purifying respirators PAPRs. Hospital C includes decontamination of the shower system and associated equipment as part of those procedures. Several studies have reviewed public data and reports regarding victims of hazardous materials emergencies and associated secondary contamination of healthcare workers. First receivers rarely reported adverse health effects. Those workers who experienced symptoms were unprotected and tended to have close, extended contact with the contaminated victims.

Through , the database had captured information on over 44, hazardous materials events involving substances other than petroleum products. Respiratory tract and eye irritation were the primary symptoms and no employees required hospitalization. A separate survey of ED evacuations at hospitals in the state of Washington also found a low incidence of secondary contamination of ED staff. Over a 5-year period, hospitals reported only two evacuation incidents that also involved secondary contamination of staff, while ED evacuations due to hazardous substance incidents usually caused by releases within the hospital occurred 11 times.

Walter et al. These authors evaluated all fire department hazardous materials reports, along with the associated emergency medical services encounter forms and hospital records for a mid-size metropolitan area population , More than 70 percent of the hazardous materials incidents involved flammable materials e. Approximately 7 percent of the incidents involved highly toxic materials, all of which fell into the categories of mercury, pesticides, and cyanides. An additional 5 percent of the events were associated with toxic gases primarily carbon monoxide, with a few cases of anhydrous ammonia or chlorine exposure.

Corrosive materials accounted for another 10 percent of the incidents and primarily involved mineral acids and basic materials such as lime and sodium hydroxide. These findings may explain the results of Horton et al. Victims exposed to gases or vapors are not anticipated to be contaminated with substantial quantities of these materials upon arrival at the hospital. Hick et al. These cases included incidents in which healthcare workers were exposed to secondary contamination, generally for periods of less than one hour. However, even without personal protective equipment , the risks of significant injury appear to be low, as reflected in this review and analysis of published cases.

Okumura et al. Of these, the most affected were several physicians who spent up to 40 minutes attempting to resuscitate the initial victims of the incident. The victims had not been decontaminated. These and other worker exposures were attributed to the failure of healthcare providers to use PPE and the practice of placing still-clothed, contaminated victims in a poorly ventilated waiting area.

It is interesting to note that although sarin a notorious chemical warfare agent affected many of the healthcare providers, all exposed providers at one of the primary receiving hospitals were reportedly able to continue their duties Okumura et al. In the Tokyo terrorism incident, although victims' clothing was not removed and continued to be a source of contamination, unprotected first receivers experienced only limited exposures. Two studies conducted modeling of various phases of the victim disrobing and decontamination process in order to characterize first receiver exposure levels and evaluate the need for respiratory protection.

These studies point out the need for a carefully developed and implemented EMP that includes hazard-reducing work practices, appropriate respiratory protection, and full body protection. In the first study, Schultz et al. The test periods included 5 minutes with the victim resting on a decontamination cart to simulate a delay in clothing removal and decontamination , 2. This latter activity generated visible dust during particulate trials. Healthcare worker exposure levels for dust ranged from 1. The authors concluded that exposure levels were statistically lower than the applicable short-term exposure limits for these moderately toxic industrial chemicals; however, due to the uncertainties of hazardous materials management, "use of respiratory protective equipment should be continued.

In contrast to Schultz et al. The model takes into account the substance's relative toxicity, vapor pressure, and dispersion characteristics, as well as the probable amount and distribution of contaminant on the victim, and the amount of time the substance would require to evaporate from the victim. The model also considered the number of victims, the length of time between the victims' exposure and arrival at the hospital, atmospheric conditions, and how soon after arrival the victims' contaminated clothing can be removed.

Using Monte Carlo analysis and parameters set to consider extreme worst-case scenarios, the authors concluded that if contaminated clothing remains an ongoing source of contamination over a period of 6 hours of constant exposure, less than 2 percent of healthcare workers would be exposed to levels of sarin that would exceed the protection offered by a respirator providing at least 1,fold protection. Furthermore, related analysis showed that if contaminated clothing is removed immediately when the victim arrives at the hospital, "the level of sarin exposure to a healthcare worker would be negligible" and adequate protection would be provided by air purifying respirators with an assigned protection factor APF of 1, If correctly selected, fitted, used, and maintained, respiratory protective equipment reduces significantly the effective exposure level that an employee experiences.

The combination of high efficiency HE particulate filters plus organic vapor OV cartridges currently available for PAPRs will protect against many of the airborne hazards that first receivers might encounter e. Acid gas cartridges add an additional level of protection from gases such as chlorine, which generally will dissipate before victims arrive at the hospital, but which have been implicated in at least one case of healthcare worker injury. Despite the number of carbon monoxide victims treated at hospitals, there are no reported cases of healthcare workers being injured through secondary contamination from victims of carbon monoxide poisoning Horton et al.

As an applied example, Hospital A used some of these modeling techniques to complement a detailed HVA, a comprehensive staff training program, and a detailed EMP that makes safety and exposure reduction strong priorities. Thus, individuals involved in decontaminating victims at this hospital wear PAPRs, splash-resistant suits, a double layer of gloves, and chemical-protective boots.

Openings to the suits are closed with tape to create a barrier. No single glove or boot material will protect against every substance. Most glove manufacturers offer detailed guides to glove materials and their chemical resistance. Butyl rubber gloves generally provide better protection than nitrile gloves for chemical warfare agents and most toxic industrial chemicals that are more likely to be involved in a terrorist incident, although the converse applies to some industrial chemicals.

Foil-based gloves are highly resistant to a wide variety of hazardous substances and could also be considered when determining an appropriate protective ensemble. Hospitals must select materials that cover the specific substances that the hospital has determined first receivers reasonably might encounter. However, given the broad scope of potential contaminants, OSHA considers it of vital importance for hospitals also to select materials that protect against a wide range of substances.

A double layer of gloves, made of two different materials, or foil-based gloves resist the broadest range of chemicals. In general, the same material selected for gloves will also be appropriate for boots. Because boot walls tend to be thicker than gloves, boots of any material are likely to be more protective than gloves of the same material.

A combination of gloves, for example, butyl gloves worn over inner nitrile gloves, are often the best option for use by hospital workers during emergencies and mass casualties involving hazardous substances. However, hospitals are advised to select the combination that best meet their specific needs. Glove thickness is measured in mils, with a higher number of mils indicating a thicker glove. Using common examples, exam gloves are often approximately 4 mil, while general-purpose household kitchen gloves are mil, and heavy industrial gloves might be 20 to 30 mil.

Depending on the dexterity needed by the hospital worker, the glove selection can be modified to allow for the use of a glove combination that is thinner than that usually recommended for the best protection. As an example, the U. However, with increased thickness comes greater loss of manual dexterity. When advanced medical procedures must be performed before decontamination, thicker gloves might be too awkward, and, therefore, it might be necessary to use a butyl rubber glove of 7 mil over the nitrile glove, or a 14 mil butyl rubber glove alone USACHPPM, a.

If sterility is required and decontamination is not possible before procedures, a double layer of disposable 4 to 5 mil nitrile gloves might be the best option USACHPPM, a. Not all sources recommend double gloves; for example, the U. Among the sterile gloves readily available, those made of nitrile offer the best resistance to the widest range of substances but not all. Note that thinner gloves deteriorate tear and rip more rapidly than thicker gloves. When thinner gloves must be used, they should be changed frequently. Hendler et al. Clinicians wearing this equipment could perform endotracheal intubation effectively i.

Intubation delays would cause subsequent decontamination procedures and medical treatment to be delayed by a corresponding amount of time. The optimal garment material for first receivers will protect against a wide range of chemicals in liquid, solid, or vapor form phase. Because first receivers might become contaminated with liquid or solid dust contaminants through physical contact with a contaminated victim, the ideal fabric will repel chemicals during incidental contact protection from gases is less important because, as shown earlier, gases generally will dissipate before a victim arrives at the hospital.

Additionally, the optimal garment will restrict the passage of vapors, both through the suit fabric and through openings in the suit. Finally, optimal clothing is also sufficiently flexible, durable, and lightweight for long-term wear up to several hours during physically active work. Manufacturers produce a variety of suit fabrics and designs, and several commercially available broad-spectrum protective fabrics might be appropriate, depending on the situations and hazards that the hospital anticipates first receivers reasonably might be expected to encounter.

Before selecting materials, contact the manufacturer for specific application guidance. Fabric and suit manufacturers can provide laboratory-testing information regarding specific materials. These suits were tested by placing sensors for the test vapor under the suits at 17 specific body locations.

Volunteers wore the protective gear while performing the activities normally associated with an actual first responder chemical response but did not involve physical acts, such as patient handling, that would likely be required of first receivers SBCCOM, Figure 1. The ability of protective garment fabric to withstand physical abrasion and tearing is also important.

When assisting non-ambulatory victims, first receivers might subject the protective garments to physical stresses that should be considered in garment selection. Evidence in the U. However, OSHA concludes that hospitals that make a conscientious effort can limit the secondary exposure of healthcare workers to a level at which chemical protective clothing including gloves, boots, and garments with openings taped closed and PAPRs will provide adequate protection from a wide range of hazardous substances to which first receivers most likely could be exposed.

This conclusion is based on the infrequency with which healthcare workers have been affected despite the numerous hazardous substance incidents , the experiences of hospitals treating contaminated victims, the nature of the injuries healthcare workers sustain when they are affected during both acts of terrorism and accidental releases , and the exposure models described above. OSHA believes that the 1,fold protection factor that has been attained by certain PAPRs in simulated workplace conditions, in combination with protective gloves, boots, and garments with openings taped closed, will be adequate to protect first receivers who are decontaminating victims.

Furthermore, OSHA believes the decontamination process itself, along with adequate employee training, will prevent injury to ED staff working in the Hospital Post-decontamination Zone. Based on information gathered from a wide variety of sources, OSHA has concluded that the PPE specified in Table 3 will provide adequate protection for first receivers exposed to unknown hazardous substances in most circumstances. Employers who meet the prerequisites in Tables 1 and 2 may use this best practices document as the OSHA-required generalized hazard assessment.

OSHA believes hospitals are becoming increasingly prepared for mass casualty incidents involving unidentified hazardous substances. As a result, OSHA anticipates that many and eventually most hospitals will meet the condition in Tables 1 and 2 that will help them manage secondary exposures such that employees can be effectively protected when using the first receiver PPE presented in Table 3. Recent incidents including the World Trade Center and anthrax attacks and current JCAHO requirements provide hospitals with strong incentive to take the necessary steps to prepare themselves and their staff to function safely during mass casualty incidents involving hazardous substance releases.

Many of the JCAHO requirements help hospitals better identify the actual conditions that they might face in an emergency, which in turn allows the hospitals to make realistic plans for managing emergencies in a way that minimizes the risk to employees. The JCAHO requirements, along with the hospital's commitment to maintaining JCAHO accreditation and OSHA compliance, provide the basis for conducting detailed HVAs, identifying the hospital's role in the community, coordinating plans with other organizations, conducting drills to test all phases of preparedness, training personnel, and implementing PPE and respiratory protection programs.

The additional exposure-limiting conditions, such as removing and safely containing contaminated clothing and other personal items as soon as victims arrive at the hospital, are primarily procedural and can be addressed through standard operating procedures and clear communication with victims and hospital staff. Other respirators that provide an APF of 1, or higher are also alternatives.

OSHA recommends PAPRs to ensure the appropriate level of protection for situations when the hazardous substance is unknown and unquantified. Non-powered APRs have a role in protecting first receivers when the hazardous substance has been identified and quantified. First receivers may use such respirators after accurate information confirms that a negative pressure respirator will adequately protect the wearer from the identified inhalation hazard. Any respiratory protection for first receivers must be included in a formal written respiratory protection program, as required by 29 CFR Hospitals can integrate the respirators into their existing respiratory protection program, which must include the following elements:.

OSHA has found it appropriate to define two functional zones during hospital-based decontamination activities. These zones, which guide the application of OSHA's recommendations, are:. The Hospital Decontamination Zone includes any areas where the type and quantity of hazardous substance is unknown and where contaminated victims, contaminated equipment, or contaminated waste may be present. It is reasonably anticipated that employees in this zone might have exposure to contaminated victims, their belongings, equipment, or waste.

This area will typically end at the ED door. In other documents this zone is sometimes called the "Warm Zone. The Hospital Post- decontamination Zone is an area considered uncontaminated. Equipment and personnel are not expected to become contaminated in this area. At a hospital receiving contaminated victims, the Hospital Post-decontamination Zone includes the ED unless contaminated.

In other documents this zone is sometimes called the "Cold Zone. The following pages contain three tables. The first two, Tables 1 and 2 , list steps that hospitals must take or conditions that must exist before relying upon the PPE specified in Table 3. These steps and conditions help limit employee exposures and are necessary to ensure that the PPE for both zones listed in Table 3 will adequately protect employees. In other words, OSHA has determined that the minimum first receiver PPE outlined in Table 3 should protect healthcare workers as they care for contaminated victims of mass casualty incidents within the two zones; however, hospitals need to meet certain exposure-limiting conditions outlined in Tables 1 and 2 to ensure that employees are adequately protected from all reasonably foreseeable hazards.

These PPE best practices are applicable to all hospitals that might receive victims contaminated with unknown substances; however, hospitals must complete the hazard assessment process and tailor the PPE selection to also address specific hazards they might reasonably be anticipated to encounter. These options include using more protective PPE to perform specialized activities or when conditions in Tables 1 and 2 cannot be met , or conducting an independent hazard assessment to support an alternative PPE selection.

TABLE 1. TABLE 2. TABLE 3. Hospital Decontamination Zone I. Includes, but not limited to, any of the following employees: decontamination team members, clinicians, set-up crew, cleanup crew, security staff, and patient tracking clerks. Hospital Post-decontamination Zone M. The training indicated for first receivers depends on the individuals' roles and functions, the zones in which they work, and the likelihood that they will encounter contaminated patients. For other employees, a briefing at the time of the incident will be appropriate.

In each case, the training must be effective , that is, be provided in a manner the employee is capable of understanding. This level of training is appropriate for anyone with a designated role in the Hospital Decontamination Zone. Both the required competencies and training time were recently confirmed in an interpretive letter OSHA, OSHA, however, allows these topics but not the minimum training time to be tailored to better meet the needs of first responders.

For example, the training might omit topics that are not directly relevant to the employee's role e. Training that is relevant to the required competencies counts toward the 8-hour requirement, even if the training is provided as a separate course. First Responder Awareness Level training also counts towards the 8-hour requirement for Operations Level training.

This point is clarified in a recent letter of interpretation issued by OSHA: " Depending on the employees' job duties and prior education and experience, more than eight hours of training may be needed" OSHA, OSHA reaffirmed this point in a letter of interpretation, stating " However, it is important to note that in most hospital settings it might be difficult to ensure that employees have sufficient experience to waive the training requirement. Most hospital employees do not have extensive experience with hazardous materials or PAPRs, and decontamination activities are performed infrequently.

Hospitals must document how training requirements are met. This is particularly important whenever hospitals allow employees to satisfy any portion of the training requirement through other related training or through demonstration of competence. Annual refresher training is specified under Instead, the standard requires that employees trained at the First Responder Operations Level "shall receive annual refresher training of sufficient content and duration to maintain their competencies, or shall demonstrate competency in those areas at least yearly.

The initial and annual refresher training to the HAZWOPER First Responder Operations Level must be provided to all hospital personnel who have been designated to provide treatment, triage, decontamination, or other services to contaminated individuals or who may reasonably be expected to come in contact with those individuals arriving at the hospital. Training core elements must include:. Under that standard, training must be provided to each employee who is required to use PPE.

At a minimum, that training must cover the following:. Employees must demonstrate their understanding of the training by showing they can use the PPE properly, prior to using the protective equipment in the workplace. Refresher training is warranted when the employee cannot demonstrate proficiency in the proper care and use of the PPE, when changes in the workplace render the previous training obsolete, or when changes in the type of PPE to be used render the previous training obsolete.

Specifically, any employee who must wear a respirator must be trained in the proper use and limitations of that device prior to its use in the workplace. The training must be comprehensive enough that the employee is able to demonstrate knowledge of the seven training topics specified in the standard and outlined below. The employee also must be able to demonstrate competence in wearing the complete PPE ensemble, including respirator, protective garment, gloves, boots, and other safety equipment required for the employee's role.

Refresher training is required at least annually , or sooner if changes in the workplace or type of respirator render previous training inadequate. Refresher training is also required if the employee does not demonstrate proficiency in the proper care and use of the respirator, or any other time when retraining appears necessary to ensure safe respirator use. Note that first receivers who wear respiratory protection must be deemed medically qualified to do so, following the process required by 29 CFR Employees who wear tight-fitting respirators also must be properly fit tested.

First Responder Awareness Level training is required for those employees who work in the contaminant-free Hospital Post-decontamination Zone, but might be in a position to identify a contaminated victim who arrived unannounced. This group includes ED clinicians, ED clerks, and ED triage staff who would be responsible for notifying hospital authorities of the arrival, but would not reasonably be anticipated to have contact with the contaminated victims, their belongings, equipment, or waste. The group also includes decontamination system set-up crew members and patient tracking clerks, if their roles do not put them in contact with contaminated victims, their belongings, equipment, or waste e.

First Responder Awareness Level training also is required for hospital security guards who work away from the Hospital Decontamination Zone, but who may be involved tangentially in a mass casualty event specifically, those security personnel who would not reasonably be anticipated to come in contact with contaminated victims, their belongings, equipment, or waste OSHA b. Security staff assigned to roles in the Hospital Decontamination Zone would require a higher level of training e. Training can be waived if the employee has had sufficient experience to objectively demonstrate competency in specific areas.

These areas are listed in 29 CFR Annual refresher training is required for employees trained at the Awareness Level. As with Operations Level refresher training, the class content must be adequate to maintain the employees' competence, and the hospital must document the training or the method used to demonstrate the employees' competence. A member of the staff who has not been designated, but is unexpectedly called on to minister to a contaminated victim, or perform other work in the Hospital Decontamination Zone, is considered "skilled support personnel.

These individuals must receive expedient orientation to site operations, immediately prior to providing such services OSHA, The orientation must include:. As part of the briefing, these personnel also must be medically cleared for respirator use and properly fit tested if wearing a tight-fitting respirator , as required by 29 CFR See Section 1. While a "just in time" briefing during the response is the only required training for these personnel, time and resource limitations inherent in a crisis likely will diminish the effectiveness of such training.

Hospitals should consider offering a basic level of training for other employees in the ED, such as housekeeping staff. This group could include those personnel who do not have a role in the decontamination process, reasonably would not be expected to encounter self-referred contaminated patients, and reasonably would not be expected to come in contact with contaminated victims, their belongings, equipment, or waste. OSHA's Hazard Communication Standard offers a useful model for appropriate training, which could include general information on the hospital's emergency procedures and plans for mass casualty incidents involving contaminated victims, steps the employees can take to protect themselves usually by leaving the area , and the measures the hospital has implemented to protect employees in the ED.

While not required under the OSH Act, such training could help to ensure that all staff in the ED understand what precautions and actions would and would not be expected of them if an incident occurred. Table 4 summarizes OSHA's current guidance on training first receivers for mass casualty emergencies. References to related OSHA interpretation letters are included. Employees are categorized according to zone namely, Hospital Decontamination Zone and Post-decontamination Zone ; whether they have designated roles in the zone; and the likelihood of contact with contaminated victims, their belongings, equipment, or waste.

Hospitals should note that the training levels presented are minimum training levels and can be increased or augmented, as appropriate, to better protect employees, other patients, and the facility in general. All employees with designated roles in the Hospital Decontamination Zone O This group includes, but is not limited to:.

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Briefing at the time of the incident Q , R. Other employees whose role in the Hospital Decontamination Zone was not previously anticipated i. Training similar to that outlined in the Hazard Communication Standard S. Other personnel in the Hospital Post-decontamination Zone who reasonably would not be expected to encounter or come in contact with unannounced contaminated victims, their belongings, equipment, or waste. The following appendices provide references and examples, which might be useful to hospitals developing or upgrading emergency management plans EMPs.

This Appendix supplements the Best Practices from OSHA by providing useful background information on how various aspects of a hospital's preparation, response, and recovery impact employee protection during hazardous substance emergencies. Look in Appendix A for:. The following discussion provides examples of ways hospitals have attempted to enhance employee protection as part of general preparedness for mass casualty emergencies involving contaminated victims. However, statements in this appendix cannot create nor diminish obligations under the occupational safety and health OSH Act.

In making preparations, hospitals must consider key assumptions regarding communication, resources, and victims. When developing plans, hospitals should anticipate:. Administrators making preparations for mass casualty incidents should note that hospitals are part of the community's critical infrastructure and continuity of operations must be maintained. The hospital emergency management plan EMP outlines how the facility will respond to an emergency. The plan should address the hazards the hospital will encounter, identify the hospital's role in the response, and serve as a road map for incident preparation, response, and recovery.

No organization can prepare fully for every conceivable emergency. To use resources effectively, a hospital requires information that will help emergency planners make informed decisions about the type, probability, severity, and impact of specific hazards to which the hospital might be subject. A hazard vulnerability analysis HVA assists a hospital in organizing this information, which is used to customize the hazard assessment for personal protective equipment PPE selection a critical aspect of the EMP.

The HVA and resulting preparations are only as specific to the individual hospital as the information on which preparation decisions are based. Important modifying factors include the hospital's role in the community, how up-to-date the hospital EMP is, and formal planning agreements between the hospital and other organizations that have roles in emergency response activities. With knowledge of these details, hospitals can customize EMPs and effectively tailor preparedness including employee protection to address the circumstances relevant to that hospital.

As noted previously, an HVA helps hospitals organize information and guide decision making. A thorough HVA can serve as the basis for informed decisions regarding the training and equipment employees will require to protect themselves under foreseeable emergency scenarios. The hospitals interviewed use variations of a few publicly available HVA formats. See Appendix F for examples of two formats additional examples are available from other sources. The tool is often slightly modified by the individual hospital to include additional information that the hospital finds helpful for making decisions or communicating with management.

A popular HVA, an electronic spreadsheet, prompts the user to enter a numerical rating e. JCAHO offers a matrix of threats that hospitals might consider. The user generates or the spreadsheet calculates a hazard vulnerability score based on the inputs. The inputs may be weighted to reflect the importance of certain information to the final score. Hospitals use both the final score and the individual numerical rating inputs to identify and rank priority areas that should receive administrative attention or resources.

Other hospitals use a tabular format HVA and more descriptive text input to guide the user through the analysis. The tables can provide more information, but are also more cumbersome for evaluating a large selection of threats. Because these formats are more likely to have been developed in-house, they tend to be more diverse.

None of the HVA formats have been validated to determine whether the inputs and final assessment accurately reflect hazard vulnerability. Nevertheless, an informal qualitative review conducted by the developer of one HVA spreadsheet tool suggested that independent users, when operating in similar hospital and community environments, do generally arrive at similar conclusions regarding vulnerability and priorities for improvement Saruwatari, By collaborating with Local Emergency Planning Committees LEPCs , hospitals can keep current with information on changes in threats in their localities.

As an example, Hospital D had rated "preparation for chlorine-related emergencies" as a top priority. When the local potable water facility changed processes, the threat of a large-scale chlorine emergency was eliminated from the community. Upon revising the HVA, Hospital D was able to redirect resources to address the next most urgent threat without waiting until the next annual review cycle.

Characteristics of the community e. This information should be considered in the HVA. These factors range from the number and condition of victims that the hospital might reasonably anticipate, to the rate at which hazard information could become available during an emergency. The community in which a hospital is located and the hospital's role in that community impact emergency preparations on several levels.

Hospital D's emergency manager suggested that the real objective of emergency planning is "community preparedness, and a hospital's preparedness represents only one component. Fully coordinated planning helps hospitals identify their roles in their communities. Roles vary considerably with individual circumstances, but ultimately have a strong impact on the conditions and hazards for which a hospital must plan employee protection. Examples of roles some hospitals fill or expect to fill in their communities include:.

The hospitals interviewed for this project also note that, in addition to a better coordinated community emergency response plan, they receive additional financial, informational, and business benefits from active participation in community-focused emergency preparedness and planning. The following list indicates benefits that hospitals can derive from an active role in community emergency preparedness:. Additionally, during the periodic EMP evaluation, hospitals should review the regulations to ensure the plan continues to be compliant.

Well-coordinated EMPs ensure that hospitals are aware of the capabilities of first responders and other hospitals, as well as what the local professional and response community expects from them. The following example demonstrates the value of coordinated EMPs. After problems were identified during a drill, Hospital D determined that healthcare workers needed faster access to information from hazardous materials incident sites. Initially, the fire department felt Hospital D's request for more timely information would be too burdensome during life-threatening emergencies.

When the two organizations met, however, they each learned the reasons behind the other's needs.

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As a result, the first responders recognized that, by coordinating efforts, they could enhance the first receivers' ability to provide rapid and appropriate care to victims. The fire department was able to modify its own EMP to incorporate direct communication between the hospital and a representative of the incident commander at the scene.

The hospitals interviewed for this project mentioned several methods by which they improve EMP coordination and communication:. Barbera and Macintyre suggest the following organizations with which hospitals should coordinate:. JCAHO requires "an orientation and education program for all personnel, including licensed independent practitioners, who participate in implementing the emergency management plan.

Other requirements of these standards might also apply e. A challenge for any hospital is the need to maintain a decontamination team, without compromising the ability of hospital departments to provide medical treatment for patients. Hospitals interviewed for this project use employees from a range of specialties to maintain minimal staffing levels in patient care areas. In addition to drawing limited staff from the ED, Hospital A suggests including individuals from departments such as mental health, facilities and engineering, and security on decontamination teams.

The hospitals also indicate that it is often possible to identify individuals in unrelated departments who are uniquely qualified to serve on the team due to previous military experience, work history, or volunteer service. Hospital A staffs a particularly large decontamination team over members by drawing from employees with relevant skills from past experience in fire departments, emergency medical services, rescue units, HAZMAT or hazardous waste handling, National Guard, and military reserve units.

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In these cases, the previous experience might be a more important selection criterion than the individual's day-to-day role in the hospital. Hospital A avoids assigning unwilling staff to their team, citing the advantages of volunteer team members' enthusiasm and willingness to participate in training and drills. The size of the decontamination team depends on the minimum number of people required to operate the decontamination system and implement the hospital's decontamination procedures.

Activities involving a few victims and small decontamination systems usually require only a few staff members, each of whom might fill several functional roles. According to Hick, the 5-person team would include one person handling triage and coordinating pre-decontamination treatment, two people working with non-ambulatory victims, and two team members working with ambulatory victims. During a major emergency in a metropolitan area, hospitals might be required to continue operations "at maximum capacity for at least 2 to 4 hours, with appropriate staff rotations" Hick et al.

Another hospital organization advocates a member minimum decontamination team, all wearing PPE. Although it is recognized that smaller hospitals would not be able to staff such a robust team, the rationale may illustrate useful points. Under this model, the Northern Virginia Hospital Alliance calls for a single "team leader," three team members responsible for conducting ambulatory decontamination one to assist in the undressing, one to supervise showering, and one to assist in the re-dressing , four team members to participate in the care of non-ambulatory patients, and four security personnel to preserve the perimeter of the Hospital Decontamination Zone.

First receiver training that was discussed previously in Section B is summarized here:. First Responder Operations Level training is required for employees including security staff who have a role in the Hospital Decontamination Zone, as well as the hospital's contamination cleanup crew. First Responder Awareness Level training is required for ED clerks and ED triage staff who might identify unannounced contaminated victims then notify the proper authority and security staff working outside the Hospital Decontamination Zone.

Information similar to hazard communication training is recommended for ED staff and other employees who work in the ED Hospital Post-decontamination Zone , provided contaminated victims would not have access to them. However, these curricula are not necessarily designed as 8-hour presentations some are longer, others are shorter and intended for use when employees are able to demonstrate specific areas of competency.

Hospital A and Hospital G opt to provide more than 8 hours of training to decontamination team employees. Hospital A requires staff who will have a direct role in decontamination activities to undergo 24 hours of initial training and an additional 16 hours of refresher training annually. Employees can satisfy some of the training requirement by attending monthly educational team meetings. Other training is provided using a standard course curriculum developed by the Department of Veterans Affairs. Hospital G is in the process of changing from a single yearly 8-hour course curriculum to a program that provides twelve 1-hour sessions.

The emergency planner believes that an annual training day is not the best condition for learning and skills retention. Under the new system, Hospital G divides the required training topics into 12 modules, one for each month, including several opportunities to don PPE over the course of a year. The monthly module will be presented several times on each shift. Although the net hours of training per student will be greater annually, the departments might find it less burdensome to release students for the shorter classes. Thus, instructors will teach fewer classes, resulting in a net savings in man-hours.

As mentioned earlier, 8 hours of First Responder Operations Level training might not be necessary for employees who have sufficient experience. These employees are allowed to demonstrate competency as an alternative to 8 hours of training. In most hospital settings, however, it might be difficult to ensure that employees have sufficient experience to waive the training requirement.

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Most hospital employees do not have extensive experience with hazardous materials and decontamination activities are performed infrequently, thus more than 8 hours of training may be helpful to ensure competence. Employees particularly benefit from the practical experience they gain during training provided as part of exercises and drills. These events also offer employees an opportunity to demonstrate competence in critical areas.

First responders at the awareness level shall have sufficient training or have had sufficient experience to objectively demonstrate competency in the following areas, as required by the HAZWOPER Standard, paragraph In addition to the HAZWOPER training topics, staff who might identify contaminated victims that arrive unannounced require specific instructions for handling the situation. Once ED clerks or staff suspect a patient is contaminated, they should be well trained in the following procedure:.

All the hospitals interviewed for this project provide Awareness Level training for staff who have a role during decontamination activities, but are not directly involved in patient decontamination. As with First Responder Operations Level training, there is considerable variability in the extent of training provided at the Awareness Level. The hospitals use curricula that range from 2 to 4 hours and most require an annual refresher course of 1 to 4 hours. These personnel shall be given an initial briefing at the site prior to their participation in any emergency response.

All other appropriate safety and health precautions e. OSHA recommends some form of basic training for employees who work in the Hospital Post-decontamination Zone and who would not be expected to come in contact with unannounced contaminated victims, their belongings, equipment, or waste. This training could take a format similar to hazard communication which might include at least the following:.

In developing a training program of this type, hospitals should consider which specific topics would best help this group of employees respond appropriately during an incident. All hospitals interviewed for this project conduct several types of drills. The hospitals note that the greatest value occurs when their EMPs are tested rigorously as part of the drill, when realistic scenarios are involved including interaction with outside organizations , and when the hospital follows the drill with a detailed evaluation and post-drill action plan for improvement. It is essential to the success of the EMP that drills are conducted and that they reflect the actual conditions, resources, and personnel that would be available during a real incident.

In addition to self-assessments, some hospitals find it helpful to receive a performance evaluation from an outside organization. Hospital C participated in a community-wide drill that was observed by a contractor hired specifically for that purpose. The hospital used the contractor's observations and comments to help prioritize the emergency management team's activities.

Alternatively, organizations that share post-drill analysis can critique each other. The hospitals interviewed for this project report that they use a combination of methods for communicating with employees during an incident. As new information becomes available hospitals use any combination of the following methods to pass information to those who need it:.

Overhead broadcasting systems, Intranet, and two-way radios are independent of external systems such as telephone service that might be impacted by a widespread emergency. A good EMP should consider the need for backup communications in the event of a power failure. Special care might be required in training healthcare workers regarding chemical, biological, or radiological hazards, particularly when the threat could be related to terrorism.

Lundgren and McMakin recommend conducting an audience analysis to assess factors that will impact how information might best be presented. Non-clinical workers want basic information on the hazards, presented by a credible source with a clear message, and preferably in "detailed, role-specific training sessions that are ultimately tested by drills" Thorne et al. To demonstrate training effectiveness, trainers should evaluate knowledge and skills by using objective measures such as pre- and post-training evaluations, as well as by observing performance.

Hospitals need to work with local emergency service organizations to provide clear, accurate information during large-scale emergencies. To avoid disseminating conflicting information, hospitals that use a National Incident Management System NIMS -compatible incident command system, such as HEICS, provide for an individual who will coordinate with other response groups and communicate with the media and other outside organizations.

Hospitals A through G all indicate that they typically conduct a thorough baseline evaluation of an employee's health at the time the person is hired. Based on hospital policy, the employee's job category, or the hazards associated with tasks the employee performs, additional periodic health monitoring might also be provided. In that case, the employee receives a baseline evaluation and any follow-up evaluations needed to obtain the necessary medical clearance, as discussed below.

One of the hospitals interviewed follows a somewhat more rigorous medical monitoring program. Under this program, each member assigned to the decontamination team receives a periodic physical exam often every 1 or 2 years , which includes a basic health screening. Evaluations for medical clearance to wear a respirator are incorporated into these exams.

The HAZWOPER Standard requires that employees be provided periodic medical evaluations annual or bi-annual if they exhibit signs or symptoms of exposure, or if it is anticipated that the employee would be exposed to hazardous substances, in excess of the established permissible exposure limit PEL , for 30 days per year or more.