Beyond the Rule of Thumb
Survival Tip 18
By Steven De Lisi
At some point in their careers, most first responders likely will deal with a patient who has been contaminated with a hazardous material. Contamination is often the result of accidents that occur at work, home, or on the highways, but it also may be intentional, such as when a corrosive material is splashed onto a victim's face during a criminal assault. These incidents require quick yet decisive action in order to minimize harm to the patient and to avoid contaminating first responders, their equipment, and any health care facility to which the patient may be transported.
It is critical to remember that patient contamination may not be obvious to first responders on arrival at an incident. Examples include vehicle accidents in which containers of hazardous materials break open on impact and release their contents within the passenger compartment, and EMS calls for a "general illness" in which there is no physical evidence of contamination. During this latter situation, first responders should ask what activities the patient was involved in before that person became ill. They may discover that the patient was working with a hazardous material and was not following proper procedures for its use.
Usually, the best initial action is to move patients away from the source of contamination, since most exposures are the result of skin contact or inhalation, and putting distance between the product and its container will likely reduce those levels of exposure. When doing so, the safest way is to move patients without providing physical assistance or otherwise touching them. If first responders know of or suspect contamination before reaching the patient, they should encourage this individual to retreat to safety by providing voice directions. Remember that because of chemical injuries, a patient's vision may be compromised or that person may be disoriented.
Regardless of the difficulties a patient may encounter when attempting to leave a contaminated area, first responders should always resist the urge to rush in and help. Any first responder considering the rescue of a patient suspected of hazardous material contamination must first determine if such attempts at rescue will contaminate the responder as well, both from what is already on the patient and from any of the chemical released to the air or surrounding surfaces.
Other considerations include whether the rescue attempt will allow for quick entry and exit, or if it will require a laborious effort involving freeing a patient from some form of entrapment. If the presence of a vapor or gas is threatening the patient, can first responders safely use a fog stream to divert these materials away from the patient? Can they minimize their exposure by using a long pike pole to grab hold of a patient's clothing to move them to safety? When considering rescue, first responders must always acknowledge the potential for serious injury or death to themselves and any others they may contact.
First responders must also consider the effects of the material on the patient and remember that if structural firefighter protective clothing and SCBA is inadequate to provide for their safety, then the chance for survival of a patient who is likely wearing no protective clothing may be marginal. This can quickly turn a rescue into nothing more than a body recovery.
When deciding whether to enter a contaminated area for rescue, first responders can refer to the Emergency Response Guidebook (ERG) for assistance. In particular, the ERG2004 states, "Each guide (orange-bordered page) includes a statement about the use of structural fire fighters' protective clothing (SFPC) in incidents involving those materials referenced by that guide. Some guides state that SFPC provides limited protection. In those cases, the responder wearing SFPC and SCBA may be able to perform an expedient (quick 'in-and-out') operation (such as an immediate rescue)." See 'References' below.
First responders can also use information from the Hazardous Materials Guide for First Responders, which is available from the Federal Emergency Management Agency. Several of the specific material guides from this document include the statement, "Do not put yourself in danger by entering a contaminated area to rescue a victim." **
Whether or not first responders perform a rescue, they must never forget that anyone with known or suspected contamination must be subject to decontamination, especially before receiving any level of medical care. The Hazardous Materials Guide for First Responders states that "Removal of hazardous material from the skin, eyes or clothing of a victim (decontamination) is usually the most important first aid action that can be initiated." ** It further states that "in general, using large quantities of water to rinse off materials is almost always the first choice for decontamination in the field." ** However, this document also cautions first responders that some materials "are so toxic that first aid should not be performed on contaminated victims because of the risk of serious injury to the responder." **
Water used for patient decontamination can be from fire apparatus or even a garden hose. Regardless, before ever attempting a rescue during a hazardous materials incident, first responders should always ensure that a reliable water supply for decontamination is available and located in a safe area before making entry. If using fire apparatus for a water source, the pump should be engaged before making entry.
When using water for patient decontamination, first responders should attempt to construct a means to contain runoff water, but only if time allows. If not, then whenever possible these operations should avoid paved surfaces and instead be conducted on porous areas such as grass or soil which are less likely to result in the escape of this runoff. It is also easier to remove contaminated soil or grass afterwards as compared to removing contamination from paved areas.
Other types of patient decontamination may be required. For some materials, the ERG2004 states "removal of solidified molten material from skin requires medical assistance" ** or "in case of contact with substance, wipe from skin immediately, then flush skin or eyes with running water for at least 20 minutes." ** First responders are encouraged to obtain advice from information sources such as the ERG, the Hazardous Materials Guide for First Responders, applicable MSDS, and perhaps even poison control centers to determine appropriate methods for decontamination and patient care following contamination with a hazardous material.
First responders should remember that efforts to decontaminate anyone with water during extremely cold weather will only add to the patient's medical problems due to the potential for hypothermia. Therefore, whenever possible, if an indoor shower facility is available, especially during cold weather, the first responders may wish to consider its use while acknowledging that this could potentially contaminate the facility.
Thorough decontamination requires removal of contaminated clothing. These items should be isolated and not allowed to remain in areas where someone else can encounter them and become contaminated. Ambulatory patients should be instructed to remove their contaminated clothing, but first responders should have some means to cover these individuals, such as with disposable coveralls or bed linen from an ambulance.
Ensure that anyone administering medical care, including prehospital and hospital providers, is aware that the patient had been previously contaminated, and provide the name of the material(s) involved. References the applicable MSDS, if available; copies of this document should accompany patients when transported to health care facilities. If the MSDS is not available at the scene, first responders may be able to contact the material's manufacturer or other sources, such as a poison control center or the Chemical Transportation Emergency Center (CHEMTREC), and have a copy of the MSDS sent to the facility electronically.
Notifications regarding contaminated patients should include the medical helicopters' crews. Some of these services may refuse to transport these patients because of the potential for flight crews to be affected by a hazardous material. First responders should check with operators of medical helicopters in their area to learn about policies dealing with these situations.
First responders should also remember that any attempt at victim decontamination in the field does not always eliminate the need for additional decontamination on arrival at a health care facility. Furthermore, some victims of hazardous materials contamination may arrive at a health care facility in a private vehicle without ever having been decontaminated. If that site does not have the means to decontaminate these patients, first responders may themselves have to respond to the facility to provide this service.
When dealing with contaminated patients, be smart, be safe, and remember, everyone goes home!
- Determine how EMS providers in your jurisdiction plan to deal with contaminated patients. Do they have access to structural fire fighters protective clothing and SCBAs (not just filter respirators) for their protection? Have they been trained to perform patient decontamination? If not, what do they plan to do when confronted with a contaminated patient?
- Contact those who provide medical helicopter services to your jurisdiction. Determine if they will transport patients who have been contaminated with a hazardous material even if these individuals have been decontaminated in the field.
- Determine how health care facilities in your jurisdiction plan to deal with the arrival of a patient who needs decontamination. This research should include not only hospitals, but also "quick care" facilities.
Click here for more info on Steven De Lisi's book, Hazardous Materials Incidents: Surviving the Initial Response.
Steven M. De Lisi is a 27-year veteran of the fire service and is currently Deputy Chief for the Virginia Air National Guard Fire Rescue located at the Richmond International Airport. De Lisi is a Hazardous Materials Specialist and a former chairman of the Virginia Fire Chiefs Association's Hazardous Materials Committee. He is also an adjunct instructor for the Virginia Department of Fire Programs and a former member of the NFPA committee on hazardous materials protective clothing. De Lisi began his career in hazardous materials response in 1982 as a member of the HAZMAT team with the Newport News (VA) Fire Department. Since then, he has also served as a Hazardous Materials Officer for the Virginia Department of Emergency Management and in that capacity provided on-scene assistance to first responders involved with hazardous materials incidents in an area that included more than 20 local jurisdictions.
U.S. Department of Transportation. 2004 Emergency Response Guidebook, p. 350. 223 (respectively).
Federal Emergency Management Agency, U.S. Fire Administration. Hazardous Materials Guide for First Responders, 1998. p.8, p. 223. (respectively)