A nurse is working in a field hospital during a suspected bioterrorism attack with anthrax exposure at a sports stadium. Which action should the nurse take first when triaging patients who may have been exposed?

In a mass casualty bioterrorism event with suspected anthrax exposure, the nurse's first priority is personal safety and preventing further contamination. Establishing decontamination procedures and donning appropriate PPE protects healthcare workers and prevents secondary contamination of the healthcare facility.

In a mass casualty bioterrorism event involving anthrax, safety and infection control measures must be the top priority. The nurse's first action is to establish decontamination procedures and don appropriate personal protective equipment (PPE) before patient contact.

Anthrax is a bacterial infection caused by Bacillus anthracis, which can be used as a bioterrorism weapon. Anthrax spores can survive in the environment for long periods and can be transmitted through inhalation, skin contact, or ingestion. In a suspected anthrax attack, the risk of exposure to healthcare workers is very high if appropriate precautions are not implemented immediately.

Decontamination procedures are essential to prevent the spread of anthrax spores throughout the healthcare facility. This includes setting up clear decontamination zones, removing contaminated clothing, and thorough washing with soap and water. Healthcare workers must don appropriate PPE, including respiratory protection (N95 or higher), gowns, gloves, and face protection, before patient contact.

Patient isolation, prophylactic antibiotic administration, and reporting to authorities are all important measures, but they cannot be safely performed without first ensuring the safety of healthcare workers through proper decontamination and PPE protocols. The principle of "protect yourself first" is fundamental to emergency response, as healthcare workers who become victims themselves cannot effectively help patients.

This approach aligns with CDC bioterrorism response guidelines and the basic principles of emergency nursing in mass casualty situations.

Understanding the Priority: Safety Before Treatment

In a suspected bioterrorism event involving anthrax, the immediate priority is not patient treatment, but rather ensuring the safety of the healthcare providers and preventing the secondary spread of contamination. The foundational principle in hazardous material (hazmat) and biological disaster response is that responders must protect themselves first to remain capable of providing care. The systematic review on hospital preparedness for Chemical, Biological, Radiological, Nuclear, and Explosive (CBRNe) disasters emphasizes that inadequate preparedness and equipment modernization are critical gaps that undermine a hospital's ability to manage these high-risk situations effectively ^[2]. If a nurse becomes contaminated or infected, they not only become a patient themselves but also a vector for further transmission, potentially collapsing the entire response system.

Rationale for the Correct Answer (Option 2)

The action of establishing decontamination procedures and donning appropriate personal protective equipment (PPE) directly addresses the most immediate threats: the safety of the healthcare team and the containment of the biological agent. This step is the cornerstone of the "scene safety" and "personal protection" phases of disaster response. A qualitative study on factors affecting hospital response in biological disasters identified that the lack of standard protocols and insufficient protective equipment are major barriers to effective performance . By first securing the environment through decontamination and self-protection, the nurse creates a safe zone where triage and treatment can subsequently occur without amplifying the disaster. This aligns with the core finding that hospital preparedness is not solely about medical countermeasures but fundamentally about the systemic capacity to operate safely under threat .

Why the Other Options Are Incorrect

- Option 1: Immediately isolate all potentially exposed patients in negative pressure rooms. Anthrax is not transmitted from person to person via the airborne route, so negative pressure isolation is not a primary infection control measure for the organism itself. More importantly, this action is premature. Moving potentially contaminated patients into the hospital's clean treatment areas before they are decontaminated would spread the powder substance throughout the facility, contaminating surfaces, equipment, and air handling systems. This would endanger all other patients and staff, directly contradicting the preparedness measures that require containment as a first step ^[2].

- Option 3: Begin prophylactic antibiotic administration to all potentially exposed individuals. While post-exposure prophylaxis with antibiotics like ciprofloxacin or doxycycline is a critical medical intervention for anthrax, it is not the first action. Administering prophylaxis before decontamination is clinically inappropriate, as patients may still have the agent on their skin or clothing, leading to ongoing exposure. Furthermore, the logistical step of mass dispensing of medication requires a secure and organized environment, which is only possible after initial safety and decontamination measures are in place. The audit of military hospital preparedness highlights that a structured, phased response is essential, where medical treatment follows initial containment and triage .

- Option 4: Contact the CDC and local health department to report the incident. Communication and notification are vital components of a bioterrorism response, triggering external resources and epidemiological investigations. However, this is a command-level function that occurs after the immediate, life-saving, on-the-ground actions of self-protection and containment are initiated. The first nurse on the scene must act to stop the immediate threat to life and health before activating the broader communication cascade. The PRISMA-based review of hospital preparedness indicates that a comprehensive and standard evaluation system is lacking, meaning that a nurse's immediate, correct clinical judgment at the point of contact is the most crucial element of the initial response .