The release of biohazardous agents could affect many people. Preparedness is crucial for adequate responses to accidental or deliberate release of biohazardous agents. It is believed that exercises based on simulated incident scenes are effective methods for the training of firefighters and biohazard response teams. Structured evaluations are important methods used to identify areas of ineffectiveness and to assure the quality of responses to releases of biohazards.

A local fire department conducted a full-scale biohazard exercise in an elementary school. The firefighters practiced prohibiting entry to the area, establishing security zones, evacuating victims, assessing hazards, preventing further dissemination, and sampling and keeping the suspicious material in safe custody.Trained observers systematically evaluated the exercise following a standardized evaluation protocol. A set of data collection templates were created based on standard operating procedures extracted from current guidelines.

There were 60 firefighters, eight members of the incident command, 16 simulated victims, and 18 trained observers that participated in the exercise. Out of 31 standard operating procedures, 20 were in accordance with the guidelines, 10 were performed incorrectly, and one was not applicable. Major problems related to the assessment and handling of the suspicious material, the use of protective equipment, and decontamination of victims. Reasons for incomplete and/or conflicting documentation included insufficient knowledge and training of observers, imprecise instructions about documentation, and the size of observation zones.

Intensive education and training of response activities is necessary. Each fire department should perpetually reassess their technical equipment and specific skills and their communication and command structures. The applied documentation system performed well in disclosing discrepancies between observed response activities and current recommendations. Using external observers provided transparent and independent data. However, intensive observer training is necessary. Observer training should include detailed, written instructions and short guidelines that could be available during the exercise.

During the last few decades, various global disasters have ren-dered nations helpless (such as Thailand's tsunami and earthquakes in Turkey, Pakistan, Iran, and India). A lack of knowledge and resources make it difficult to address such disasters. Preparedness for a national disaster is expensive, and in most cases, unachievable even for modern countries. International collabo-ration might be useful for coping with large-scale disasters. Preparedness for international collaboration includes drills. Two such drills held by the Israeli Home Front Command and other military and civilian bodies with the nations of Greece and Turkey are described in this article.

The data were gathered from formal debriefings of the Israeli teams collaborating in two separate drills with Greek and Turkish teams.

Preparations began four months before the drills were conducted and included three meetings between Israeli and foreign officials. The Israeli and foreign officials agreed upon the drill layout, logistics, communications, resi-dence, real-time medicine, hardware, and equipment. The drills took place in Greece and Turkey and lasted four days. The first day included meetings between the teams and logistics preparations. The second and third days were devoted to exercises. The drills included evacuating casualties from a demoli-tion zone and treating typical injuries such as crush syndrome. Every day ended with a formal debriefing by the teams' commanders. The fourth day included a ceremony and transportation back home. Members in both teams felt the drills improved their skills and had an important impact on creating common language that would enhance cooperation during a real disaster.

A key factor in the management of large-scale disasters is coor-dination between countries. International drills are important to create com-mon language within similar regulations.

Theoretically, simulation of disastrous situations has many advantages in that it prepares hospital staff to cope with the real scenario. It is a challenge to create the database and custom-making a friendly software while still keeping it representative of a real situation. This article describes experience with developing and implementing the use of simulation software as a drilling technique used by Israeli hospitals.

The application was developed using SIMAN/ARENA software. Knowledge and a database for a basic multi-casalty incident (MCI) were developed in the pilot phase. It contains detailed description of the casualties which can be compared with the real hospital capabilities (staff and infrastructure). A consensus committe decided the crucial model issues and estaalished the thresholds for quality performance indicators. Interfaces to the each hospital's information management systems (IMS) were developed and the various output documents of each exercised step were updated. Before drilling, the hospital managerial staff received notice and had to prepare the data on the anticipated resources required The simulation staff, as well as representatives from the hospitals, then conducted the limited scale drill (LSD).

During the LSD, the trained hospital staff were given two types of input: 1) copies of reports on patients entering the stations and had to enter them into its IMS; and 2) timed telephone notifications of problems in each station. During a 90 minutes drill, there were about 15 timely reports and 20 telephone problems. The evaluation of the LSD were based mainly on the following: 1) observing the staff solving various problems; 2) constructing a detailed picture of the situation; and 3) measuring the effectiveness of the hospital IMS. The drill ended with a discussion. Lessons are drawn from each drill in order to find methods for optimizing the conduct of the hospital. An animation tool proved to be useful in describing bottle necks in emergency room, diagnostic department, and operating rooms.

Simulation techniques and a preparatory limited scale drill have advantages in evaluating and improving preparedness of hospitals for managing an MCI before a full scale drill is carried out.