Testimony came from state emergency management officials and medical personnel. Reasons given include a lack of coordination among medical, emergency management and law enforcement agencies, and the inability to detect a biological attack in a timely manner. This preparedness shortfall has been acknowledged by the Clinton Administration and it is reported that the Department of Health and Human Services is working to improve the situation.
Concerns about a lack of preparedness for chemical and biological incidents on the part of the medical system may, in some cases, go beyond the terrorism arena. Many hospital emergency departments are not even prepared to deal with victims of accidental hazardous materials incidents. (Because agents used in terrorist attacks are hazardous materials, no differentiation is made in this column when referring to them when discussing procedures unless they are unique to a particular material.) Patients could contaminate a hospital emergency department and close it to other types of emergencies until it can be decontaminated.
While this has been identified as a national problem, the solution rests largely with the states and, in particular, local communities. Even if federal and state resources are available to assist in a hazmat release, such help would be hours away at best - and most patients from a disaster reach the hospital within 90 minutes. Thus, hospital emergency departments must be prepared for hazmat patients and deal with them using their own resources for an extended period.
Much of the attention at a hazmat or terrorist scene is focused on treating victims and mitigating the incident. Response personnel also need to take into consideration treatment beyond the scene, i.e., the hospital, and in particular the emergency room. Many hospitals, particularly smaller ones, are not prepared to accept potentially contaminated victims from a hazardous materials or terrorist incident. While it is not necessary that every hospital emergency department have the capability of receiving contaminated victims, response personnel should know which hospitals do have that ability.
Three situations can arise from hazmat or terrorist incidents:
- One patient has been contaminated and is transported to a hospital emergency department.
- A single incident has occurred, causing many casualties.
- A disaster disrupts a large segment of a community.
The successful outcome of a hazmat or terrorist incident will depend on good pre-planning, which must include the local medical system. In addition to decontamination ability, hospitals should be identified that have the expertise to handle poison exposures, including stocks of antidotes.
When a community has more than one hospital, certain ones may be designated as hazmat facilities for the purpose of receiving patients from the emergency medical system. All other hospitals should at least have the ability to provide basic decontamination and care for people exposed to hazardous materials.
Contaminated victims may show up at hospital emergency rooms on their own. After the sarin nerve agent attack in the Tokyo subway, only 600 to 700 of the estimated 5,500 victims were transported to hospitals by ambulance. The remaining victims arrived in private cars, taxis and city buses.
Mass-casualty incidents involving hazardous materials may overwhelm all hospitals in a community. There may not be enough doctors and nurses, supplies, equipment or bed space to treat victims. Without a pre-plan that makes contingencies for mass-exposure incidents, the impact of the disaster on the community will only be compounded by the medical system. Once plans are developed, they must be practiced and personnel trained to follow them.
Hazmat and terrorist training generally focuses on emergency responders. In many areas, however, little attention is given to training doctors, nurses and other emergency room personnel to decontaminate victims and provide treatment for chemical and biological exposure.
Preparation to treat biological exposure is of critical importance. Emergency departments may be the first to see patients from a biological exposure. Victims may report to emergency departments, clinics or doctors' offices. Some victims may even be brought in by ambulance without EMS personnel realizing that the patients are victims of biological exposure. Symptoms of biological agents can be confused with the flu or other illnesses, and patients may be sent home.
When dealing with a known biological incident, decontamination should be performed. The decontamination solution should be a disinfectant or bleach, followed by a soap-and-water rinse if the exposure is confirmed. If the presence of a biological agent is not confirmed, as in the case of the recent anthrax scares, soap-and-water decontamination is sufficient. The Centers for Disease Control (CDC) may be consulted to determine proper disinfectant solutions.
Preparing The Emergency Department
Emergency room personnel should be able to recognize hazards from chemical and biological exposure and determine appropriate protective equipment. When reports from the field of patient conditions include nausea, dizziness, itching/burning eyes or skin, or cyanosis, personnel should recognize that hazardous materials could be involved. It is important that emergency room personnel have positive identification of the hazardous material and determine its toxic characteristics.
A number of databases are available for emergency room personnel to research hazardous materials. Call-up systems can be accessed through telephone lines or database systems that are available in house on a local personal computer. Books and telephone resources, such as CDC and Chemtrec, are also available.
Personnel should also be aware of basic chemical terminology and toxicology. This is necessary for personnel to be able to communicate effectively with responders in the field, read and understand Manufacturer Safety Data Sheets (MSDS) and other resources, access toxicology databases and provide proper patient care. Important toxicological information includes routes of exposure, target organs, effects of acute and chronic exposure, local and systemic toxic effects, minimum lethal doses, dose/ response and occupational exposure limits.
Emergency department personnel also need varying degrees of personal protective equipment (PPE), including chemical protective clothing and, in some instances, respiratory protection. The amount and type of protective equipment is determined by the frequency of incidents that occur in a given area, the types of chemicals present in and transported through the community, proximity to industries or major transportation routes that have a potential for hazardous materials incidents, and the funding available to purchase the equipment. In some areas, incidents occur so infrequently that using the services and resources of the local fire department or hazmat team may be necessary to accomplish not only decontamination, but provide for PPE needs.
If the decision is made to maintain an ability to perform decontamination in house, appropriate PPE and training for donning and use will be necessary. Personnel must be trained in the use of PPE before they use it in an incident. Training and equipment must also conform to Occupational Safety and Health Administration (OSHA) and other applicable regulations and standards. OSHA's 29 CFR1910.120 final rule as it applies to emergency medical personnel states that: "Training shall be based on the duties and functions to be performed by each responder of an emergency response organization." In addition, protective equipment in emergency departments also requires routine maintenance, cleaning and resupply when used.
Patient Management
A fire department, hazmat team, EMS crew or other responding agency will notify an emergency department that a patient or patients exposed to hazardous materials are enroute. This should set in motion a pre-planned course of action. Such a pre-plan calls for personnel to be aware of their responsibilities and how to perform them, and necessary equipment to be readily available or easily accessed.
Emergency responders should provide the hospital with as much information as possible about the victim(s) before arrival, including:
- Type and nature of incident.
- Caller's telephone number.
- Number of patients.
- Signs/symptoms being experienced by patients.
- Nature of injuries.
- Name of chemical(s) involved.
- Extent of patient decontamination in the field.
- Estimated time of arrival.
EMS personnel should be notified if patient is to be brought to a special location or entrance to the emergency department to control potential contamination or to perform decontamination. Upon notification of a contaminated patient or patients in route, notifications are made according to the pre-plan, the decontamination area prepared and the decon team suited up.
Decontamination rooms should be well ventilated and, if possible, have ventilation systems that are separate from the rest of the hospital. Drains from the decontamination rooms should go to segregated holding tanks. These rooms should not contain sensitive equipment or supplies which could become contaminated and have to be trashed.
Prevention of contamination to the room should include protecting all door knobs, cabinet handles, light switches, and other areas where contamination may be spread. Floors should also be covered with plastic and taped to prevent slipping.
A basic decontamination setup should contain the following:
- Location for patients to undergo decontamination.
- Means to wash contaminants from patients.
- Containment for the runoff.
- Protection for personnel handling patients.
- Medical equipment to treat patients that is washable or disposable.
Decontamination team members should be pre-designated and trained in the appropriate protective equipment and procedures. Team members should include emergency physicians, emergency department nurses and aides, and support personnel such as security officers, maintenance workers and biological safety officers.
When patients arrive at the hospital, they should be met by the emergency physician-in-charge or an emergency department nurse to assess their condition and degree of contamination. Triage procedures may be implemented, if needed. All contaminated clothing should be removed. Clothing will need to be double bagged in plastic, sealed and labeled.
If decontamination is necessary, the decon team should bring a prepared stretcher to the ambulance and transport the patient directly to the decon area. Open wounds should be protected to prevent them from being contaminated. Priority is always given to the ABCs (airway, breathing and circulation) while personnel conduct decontamination.
Effective decontamination involves a thorough washing of patients. The contaminant should be reduced to a level that is no longer a threat to patients or personnel.
Because victims may arrive at an emergency room on their own, the hospital must have the ability to conduct decontamination when needed and protect personnel before treatment can begin. Decontamination in the hospital setting can range from a typical decontamination line setup outside the emergency room or in the parking lot, to a dedicated decontamination room inside the hospital. In some cases, local hazmat teams may be called upon to set up decontamination outside emergency rooms.
Prepare For The Worst
Differences exist between a mass-casualty disaster and one involving hazardous materials. These include the need for decontamination of patients and personnel, and identifying effective safety measures to protect personnel. Standard triage procedures are used for hazmat disasters, except in cases of extremely toxic materials. Without antidotes, many victims of toxic exposure may not be treatable and efforts should be focused on those who can be saved.
Without trained and equipped emergency responders and hospital emergency departments, hazmat incidents and biological terrorist attacks may lead to a disaster for the local medical system. Proper planning, training and equipment at the emergency department will greatly reduce the impact of an incident on the community.
Robert Burke, a Firehouse® contributing editor, is the fire marshal for the University of Maryland and has served on state and county hazmat response teams. Burke is a veteran of over 17 years in career and volunteer fire departments, serving as assistant chief and deputy state fire marshal. He holds an associate's degree in fire protection technology and a bachelor's degree in fire science, and is pursuing a master's degree in public administration. Burke is an adjunct instructor at the National Fire Academy and Maryland Fire and Rescue Institute, and is the author of the textbooks Hazardous Materials Chemistry For Emergency Responders, published in 1997, and Counter-Terrorism for Emergency Responders, to be published this year. He can be reached on the Internet at [email protected].
