Hazmat Triage

Photo by Gregg Ellman A fire in a plastics recycling plant in Mansfield, TX, in August 1996 sent flames shooting five stories high and produced a huge cloud of black smoke. The fire apparently was ignited when lightning struck a pile of discarded plastic.

The emergency department goes on "trauma alert" but lacks key information. What is the nature of the hazardous material involved? Are the patients contaminated or exposed?

There are many concerns associated with the management of hazmat patients both at the scene and in the emergency department. The number-one concern should always be protecting personnel in the field and in the hospital setting. Upon arrival at the scene of a hazmat emergency, we must determine whether the chemical or radiological agent involved poses a life or health risk.

Contaminated Or Exposed?

Confusion exists as to the difference between a contaminated patient and an exposure patient. An example of the difference between the two would be as follows: A patient is to go to a hospital radiology department for an X-ray. The X-ray is taken and the individual leaves. He has been exposed to radiation but is not contaminated. He is not a threat to others. If this same individual went to the nuclear medicine department and spilled iodine 131 (radioactive) on his skin, he becomes radiologically contaminated. He is a source of contamination and a threat to others.

The same would be true if a fire department responded to a location where a 55-gallon drum of benzene was leaking. People in the area may be exposed to the product, and smell it, but they are not contaminated. They could even exhibit symptoms associated with their exposure but they are not contaminated. If, however, they walk into the leaking benzene, they are contaminated and pose a threat to themselves and to others.

The chemical should dictate procedures in the field and in the hospital setting. The patient's medical condition is a concern but not always the primary concern; if a patient is contaminated with cyanide, for example, that is our primary concern.

When we as firefighters and emergency responders call into the hospital from the field and report that we are at the scene of a hazmat incident, we should categorize our patients. This will tell the incident commander, and any other responding agencies, what type of hazmat patients we have. We will be able to tell hospitals in the area more than just that we have 14 hazmat patients.

CATEGORY I Major injuries/illness; hazardous material contamination.
CATEGORY II Major injuries and illness; non-hazardous material contamination.
CATEGORY III Minor injuries/illness; hazardous material contamination.
CATEGORY IV Minor injuries/illness; non-hazardous material contamination.
CATEGORY V Major/minor injuries/illness; hazardous material exposure.

By using common sense and a very basic numbering system, we can identify our patients by not only chemical concerns, but also by medical condition. The categories are:

• Category I. This category will identify the patient as your number-one concern, both in the field and hospital setting. This patent would meet the following criteria:
  1. Major injury/illness. This tells people at the scene, enroute to the scene and at the hospital that you have a medically unstable patient(s).
  2. Hazardous chemical contamination. The patient, in addition to being medically unstable, is contaminated with a hazmat agent.

This patient poses a threat to the EMS/fire/hospital staff. This patient must be grossly decontaminated prior to transport, as the chemical identification dictates this procedure.

• Category II. This category will identify the patient as being your number-two concern, both in the field and hospital setting. The patient will meet the following criteria:
  1. Major injury/illness. You have a medically unstable patient.
  2. Non-hazardous chemical contamination (i.e., bleach, tar, alcohol or antifreeze). This patient, in addition to being medically unstable, is contaminated with a non-hazardous chemical which does not pose a threat to EMS/fire/hospital personnel.

This patient should be transported immediately, without delay. The chemical does not pose a threat to the EMS personnel or to the hospital staff, so this patient does not have to be decontaminated prior to transport.

• Category III. This category identifies your patient as being your number-three concern. The patient will meet the following criteria:
  1. Minor injuries. You have a patient with minor injuries/illness, and is medically stabilized.
  2. Hazardous chemical contamination. The patient is contaminated with a hazmat agent that poses a threat to EMS/fire/hospital personnel.

This patient must be completely decontaminated prior to transport to a medical facility, unless his medical condition changes. If his condition worsens, he would be upgraded to Category I hazmat patient status, and would require gross decontamination prior to transport.

• Category IV. This category will identify your patient as being your least concern. The patient will meet the following criteria:
  1. Minor injuries/illness. You have a patient with minor injuries/illness who is medically stabilized.
  2. Non-hazardous chemical contamination. The patient is contaminated with a non-hazardous chemical.

This patient is medically stabilized and is contaminated with a non-hazardous chemical agent. This patient should be completely decontaminated prior to transport.

• Category V. This category will identify hazmat patients who have been exposed to a chemical/radiological agent. These patients are not contaminated. They will meet the following criteria:
  1. Major/minor injuries. These patients can have either major or minor injuries/illness based on your medical evaluation. They may be medically compromised from their injuries or from inhalation or ingestion of a hazardous material agent.
  2. Exposure to a chemical/radiological agent. These are exposure patients; they are not chemically/radiologically contaminated.They may have signs and symptoms associated with exposure to the agent involved but are not contaminated and do not have to be decontaminated.

This patient does not pose a threat to EMS/fire/hospital personnel, as they are not contaminated. The priority of transport of these patients should be based solely on their medical condition.

Prepare For The Worst

If we do not know what the chemical/radiological agent is, we should play it as our worst-case scenario. Some fire departments and hazmat teams have the philosophy that all patients must be decontaminated prior to transport. This is not a bad philosophy, if you don't know what the chemical is. However, if you know what the chemical is and it does not pose a health/life risk, then these patients should be transported immediately if their medical conditions warrant.