478 JOURNAL OF EMERGENCY NURSING 27:5 October 2001

C L I N I C A L N O T E B O O K

T he World Trade Organization (WTO) wasformed in 1995 with an initial membership of81 countries. It originated with the General

Agreement on Tariff and Trade1 (GATT), which, during a 50-year period, provided the first structure for world trade. TheWTO now includes 135 countries and 30 observers. PresidentClinton invited the WTO to hold its 1999 ministerial meet-ing in the United States. Of 40 potential US sites, Seattle wasselected by the White House to be the host city. The first WTOmeeting in the United States was important, given the newmarkets opening in Asia. The meeting, involving thousands ofministers, politicians, and support staff, was scheduled to takeplace from November 29 through December 3, 1999, at theWashington State Convention Center in downtown Seattle,with some activities scheduled at the large industrial sites ofBoeing and Microsoft in the surrounding area.

Following the World Trade Center and Oklahoma Citybombings and Tokyo’s sarin gas incidents, concern about USvulnerability to terrorist attack on home soil had escalated sig-nificantly. In September 1996, Congress passed the DefenseAgainst Weapons of Mass Destruction Act,2 the so-calledNunn-Lugar-Domenici legislation, providing for the trainingof leaders in domestic preparedness in approximately 120 UScities. The training, in a “train the trainer” format, is con-ducted by the US Army Chemical and Biological DefenseCommand.

Citywide preparation

Approximately a year in advance, in 1998, the Seattlehealth care community was notified of the upcomingWTO meeting in Seattle. We were given the dates, the

Emergency Care During

the 1999 World Trade Organization

Meeting in Seattle

Authors: Chris Martin, RN, and E. Anne Newcombe, RN,Seattle, Wash

Chris Martin is Director of Emergency Services and E. AnneNewcombe is Assistant Nurse Manager, Harborview Medical Center,Seattle, Wash.

For reprints, write: Chris Martin, RN, Harborview Medical Center,325 Ninth Ave, Seattle, WA 98104; E-mail: clmartin@u.washington.edu.

J Emerg Nurs 2001;27:478-80.

Copyright © 2001 by the Emergency Nurses Association.

0099-1767/2001 $35.00 + 0 18/9/118573doi:10.1067/men.2001.118573

October 2001 27:5 JOURNAL OF EMERGENCY NURSING 479

CLINICAL NOTEBOOK/Martin and Newcombe

venues, and the names of some of the guests. (Fidel Castrowas rumored to be a guest, although ultimately he did notattend.) Planning involved the hospital community, pre-hospital providers, fire departments, and law enforcementpersonnel. The WTO conference provided a variety ofchallenges for the community, including health care, secu-rity, traffic, and accommodations, to name a few. Disastermanagement planning was the main focus of the hospitals.

The event, scheduled over several days, presented thepotential for a mass casualty incident. Maintaining a fulllevel of service to patients with limited, and preferably no,disruption during this period was important to all of thehospitals. Preparatory meetings were held and a plan wasdeveloped. The use of existing hospital disaster plans,because they were familiar to the planners, was important.

Role of Harborview Medical Center

Harborview Medical Center (HMC), a 350-bed facilityproviding level I pediatric and adult trauma care to thePacific Northwest and Alaska, is also home of the SeattleFire Department Medic One program. In the County ofKing Disaster Plan,3 HMC functions as “HospitalControl,” which requires a biweekly “bed count” of avail-able beds in the local hospitals, including ED and operat-ing room capacities, via a 800-megahertz radio system.Prior to and during the WTO meeting, the frequency of“bed counts,” or hospital capacity updates, was increased,and a secure Web site was implemented to enable otherhospitals to update their own bed count status. This systemwas invaluable in preparing for the WTO meeting.Because of the identified potential for an incident involv-ing chemical or biologic agents, an inventory of ventilatorsand some pharmaceutical agents (eg, atropine, cipro-floxacin, and diazepam) was conducted.

If a mass casualty incident occurs, HMC is alsoresponsible for coordinating placement of triaged patientsin surrounding hospitals. The scene triage officer notifiesHMC, which performs the hospital bed count and triagespatients, based on patient need and bed availability. Thiswell-tried and tested system provides fast disposition ofpatients to appropriate hospitals.

Bioterrorism preparedness

In February 1998, Seattle conducted bioterrorism train-ing. An assistant nurse manager and the clinical educatorof the HMC emergency department participated in thistraining. On the basis of the training, a 6-part course onnuclear, biologic, and chemical agents was developed. Thepurpose of the course, covering decontamination, recogni-tion of exposure, and emergency management, was toheighten awareness, not to produce experts. During 1999,all registered nurses and medical assistants in the HMCemergency department attended the course. An edited ver-sion of the course was provided for nonmedical staff mem-bers (eg, engineering, security, and housekeeping). Staffwere also taught to use personal protective equipment forprotection in case chemical agents were used. By educat-ing staff and providing resource materials, most staff fearswere alleviated.

When biologic agents are released into the population,a delay in recognition occurs, usually until an increase incertain unexplained syndromes creates suspicion. For thisreason, the Centers for Disease Control and Prevention(CDC) set up surveillance of certain medical symptomsbeginning a week before and ending a week after the WTOmeeting. Each emergency department in the area collecteddata on daily totals of identified syndromes, such as unex-plained death with a history of fever (not including trau-ma/surgery or cardiac cases), or diarrhea/gastroenteritis.The data were sent to the CDC for evaluation, and theneach hospital was provided with a 24-hour report of thecollected data.

During hazardous materials incidents that involvelarge numbers of patients, the Seattle Fire Departmentprovides HMC with extra decontamination facilities.During the WTO meeting, these units were prestagedthroughout the city, and the HMC emergency departmentconstructed makeshift showers on the ambulance ramp.Some asbestos removal was taking place on campus at thetime, and thus decontamination showers were borrowedfor the week. The Seattle Fire Department provided aninflatable tent fitted with showers and a gasoline-drivenpump/water heater which, in the event of a mass casualtyincident, the HMC engineering department would assem-ble in the street.

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CLINICAL NOTEBOOK/Martin and Newcombe

The protests

As WTO delegates began arriving on Monday, November29, 1999, so did protesters. Eventually, there would be30,000 protesters. Seattle was prepared, or so we thought,for the upcoming event, which had received extensivemedia coverage and was the subject of plenty of Internetactivity.

Civil unrest began early Tuesday as campaigners gath-ered in the street. One aim of the protesters was to delaythe opening ceremony, a goal they accomplished. As theday progressed, the impact of the demonstrators on theWTO meeting escalated. In an attempt to control the riot-ers, Seattle police used tear gas with limited success.Medical and administrative staff in the HMC radioroom—the nerve center during a disaster—closely moni-tored the street activity occurring just blocks away. By lateafternoon, Mayor Paul Schell asked Washington StateGovernor Gary Locke for National Guard assistance,which he granted.

Meanwhile, HMC staff, despite an unusually quietday, were wondering how they would get home. HMC hassome off-site parking for staff and provides a shuttle bus toand from the car park through the middle of downtown.Security personnel assured staff of clear access with no dis-ruption of service. However, staff were encouraged to weartheir HMC identification badges so they could be readilyidentified by police.

In an attempt to control the rioting, the mayorimposed a curfew in a 50-block downtown area, and teargas, pepper spray, and rubber bullets were used by lawenforcement officers. By Wednesday morning, the city hadquieted considerably, and the WTO meeting continued.Staff managed to get to work, and at the hospitals, businesswas conducted as usual. In all, 500 people were arrestedand taken to jail or other designated sites.

The conference continued through Friday, along withmany demonstrations and protests. The hospitalsremained on high alert throughout the week and treatedboth protesters (for exposure to tear gas and assaults) andprehospital care providers (for chest pain, exhaustion, andassaults). The final count of victims treated in the Seattlearea hospitals totaled more than 200, with a resulting

immense emotional and psychological impact on staff.Although we trained for bioterrorism and hazardous mate-rials, we were faced with tear gas and assaults instead.

Hospital Control continued to be manned andremained in contact with Emergency Operations Centersin the area. Injuries continued to be minor, and we caredfor a number of patients who had been exposed to tear gas.

Evaluation/lessons learned

Overall, we were well prepared and well staffed and hadgood contingency plans in place.

Preparing for the WTO meeting gave us the opportu-nity to plan and implement a functional decontaminationplan for the hospital. We built outside showers, outfitted 2decontamination carts with suits, powered air purifyingrespirators, and other supplies, and have trained staff intheir use. Our staff was educated about weapons of massdestruction. We increased the awareness of public health’srole in the event of a biologic event. We solidified and suc-cessfully tested the use of our Web-based hospital con-trol/capacity reports. As a hospital community, we sharedinformation and pooled resources to deal with both theanticipated and the unforeseen aspects of this historicevent.

REFERENCES1. General Agreement on Tariffs and Trade. Geneva: July 1986.2. Defense Authorization Bill, Pub. L. No. 104-201 (Sept. 23,

1996).3. Emergency support function update, King County disaster

plan. Seattle; King County: 1999.

Send descriptions of procedures in emergency care and/or quick-ref-erence charts suitable for placing in a reference file or notebook to:

Gail Pisarcik Lenehan, RN, EdD, FAANc/o Managing Editor, PO Box 489, Downers Grove, IL 60515

800 900-9659, ext 4044 • karen.halm@home.com