BY ROB SCHNEPP
Everyone on Earth looks into the daytime sky and sees the sun. It seems different to someone in the Sahara desert desperately searching for the tiniest bit of shade than it does to a commercial fisherman in Barrow, Alaska, where the winter sun is an infrequent visitor. No matter where you live, however, the sun is an unchanging constant that governs life, regulating the planet in a consistent and predictable way.
Unfortunately, in the clear blue sky of prehospital care at haz-mat/weapons of mass destruction (WMD) incidents, there is no sun. Currently on planet EMS, there is no standardized guidance that governs the haz-mat/EMS interface for the emergency medical technician (EMT) in Lexington, Kentucky, or the firefighter/paramedic in Orange County, California; no consistent methodology on medical treatment protocols, decontamination procedures, triage, and treatment decisions; or anything else regarding the overall handling of people exposed to industrial chemicals or WMD. Truly, there is a link missing in the response chain from the time an exposed person changes from a haz-mat “victim” to a medical patient requiring medical evaluation/care and possible transport to the hospital. For the sake of consistency in this article, the terms exposure or exposed will be inclusive of industrial chemical/WMD incidents in which responders or civilians suffer an illness or injury. In reality, each response region or agency has its own sun, creating a confusing EMS galaxy where inconsistency is the only consistency when it comes to handling exposed patients.
EMS AND HAZ-MAT TRAINING GAPS
After 24 years of firefighting and many years of treating exposed patients in the hospital setting, Dr. Jim Augustine, medical director for the Atlanta (GA) Fire Department, feels strongly about EMS as it relates to haz-mat response. “For the most part, EMS has been left in the lurch,” he says. “Collectively, EMS-specific job functions have not been clearly defined, and EMS personnel across the board have not been adequately trained to provide care at haz-mat incidents.”
When asked about the role of EMS responders at haz-mat incidents, Augustine explains that, in his opinion, the emergency response community has “missed the boat” because, “EMS does have a role at haz-mat incidents, but we keep forgetting about it. Haz-mat responders and civilians alike,” he emphasized, “want to be treated by someone who knows what he’s doing.”
The lack of direction for treating exposed patients may stem from a natural skills gap existing in paramedic training and most haz-mat training programs across the country. Very little time is devoted to managing human chemical exposures in either discipline, and there is an unspoken assumption that when an exposed patient is encountered, the next group of responders will know how to handle the situation. The haz-mat responders, for example, might make a rescue, perform decon, and turn the patient over to a group of medical personnel, assuming the medical personnel know what to do from a treatment standpoint. In many cases, the ambulance crew or EMS providers outside the hot zone are simply looking to get the patient to the hospital as quickly as possible, doing basic life support, and hoping for the best. In many cases, that’s all that can be done.
There are times, however, when the proper intervention could mean the difference between life and death. According to Augustine, there aren’t many antidotes or treatments for chemical exposures, but when you do need them, “skillful administration is the key to a good patient outcome. There are times when the game is on the line and someone, very quickly, needs to be there to carry out the right treatment plan. It could be for us, the responders, or for the civilian victim. In the end, though, how you perform on the scene boils down to training, and EMS responders just aren’t getting the right training.”
Regrettably, in certain areas of the country, there isn’t a high level of sophistication when it comes to handling exposed patients in the hospital setting. The Occupational Safety and Health Administration (OSHA), along with a number of other agencies and industry-wide experts, recognized that the hospital community needed help, and in 2004 issued a guidance document titled OSHA Best Practices for Hospital Based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances. Intended to help the hospital community better prepare for its role in handling exposed patients, the document provided recommendations on personal protective equipment, decontamination, and adequate respiratory protection. The document supplied a much needed sun, shining a guiding light on a woefully underprepared segment of the response community.
Until guidance is put into place at the national level, there are several basic principles any response agency providing EMS at haz-mat/WMD incidents can adopt. The following is a list of actions, intended to help your agency insert the missing link when it comes to patient care at haz-mat/WMD incidents. As with any tactical operation, the situation may dictate deviations or modifications of any procedure. This list is not intended to serve as a step-by-step guide. The goal is to stimulate thinking about triage, treatment, and transport of the exposed patient. “Basically, EMS personnel should be thinking differently at a haz-mat incident,” Augustine advises. “You just never know what may end up happening so it’s best to be prepared and trained for a variety of situations and patient presentations.”
BROAD OBJECTIVES OF EMS PROVIDERS AT HAZ-MAT/WMD INCIDENTS
• Understand the nature of the event. Don’t become another victim.
• Obtain accurate information on the hazardous materials involved and the health effects of those materials, and determine the appropriate medical care. Be an aggressive thinker. Don’t wait until something bad happens to figure out a plan.
• Minimize continued exposure of victim(s) and secondary contamination of health care personnel by ensuring proper victim decontamination prior to transport.
• Provide appropriate prehospital emergency care and treatment based on your scope of practice.
• Determine transport priorities and destination decisions.
• Prevent secondary contamination of transport vehicles, equipment, and hospitals.
ESTABLISH AN EMS GROUP/SECTOR IN COLD ZONE TO SUPERVISE EMS OPERATIONS
• Understand your place in the Incident Command System (ICS).
• Aggressively collect information about the event and substances involved.
• Evaluate rescue situations based on risk and probable victim survivability.
• Assist with evacuation decisions based on the nature of the event.
• Identify decontamination and treatment areas.
• Notify receiving hospitals.
• Assist command and haz-mat personnel in reviewing haz-mat information and determining medical priorities.
• Be prepared for injured/ill haz-mat personnel and/or civilian victims.
TRIAGE INITIAL VICTIMS (IT MAY BE NECESSARY TO DON PROTECTIVE CLOTHING TO ASSIST IN TRIAGE.)
Decontamination and treatment decisions are made after determining the degree of contamination and assessing the victim’s illness, trauma, and burn status, and assigning them as Priority I, II, or III.
PRIORITY III: DECONTAMINATE FIRST
• Decontamination is the highest priority. These are victims with chemical contamination and associated burns (minor), trauma, or illness. The priority is complete and thorough decontamination.
PRIORITY II: MIXED PROBLEMS
• Medical care needs are balanced with the priority to decontaminate. Priority II is assigned to victims with significant illness, trauma, or burns who have not been decontaminated and have a dangerous level of contamination. Risk continues from ongoing exposure coupled with associated medical problems. Manage airway, breathing, circulation, and other threats to life simultaneously with decontamination.
PRIORITY I: MEDICAL CARE FIRST
• Medical care outweighs immediate decontamination, and victims should be grossly decontaminated only as priority to transport because of serious or critical illness, trauma, or burns. Decontamination must be performed as needed while addressing life threats.
TREATMENT AREA ACTIONS BASED ON PATIENT PRESENTATION
• Strip the victim (cutting or peeling off clothes) and cover with sheets. Prevent secondary contamination. Contain all clothing, and bag the victim’s valuables.
• Most chemicals should be flushed or irrigated with water. If at all possible, contain the runoff. Dust off dry powder substances or blot off liquids.
• Isolate airway from contaminated body using advanced airway techniques or high-flow oxygen masks. Treat airway problems aggressively.
• Cover open wounds to prevent contamination.
• Irrigate eyes with any sterile solution.
• Identify the source of the exposure and render treatment. Possible injuries and exposure agents include but may not be limited to
i. Gasoline, hydrocarbons, and solvents
iii. Inhalation injuries
iv. Organophosphates/nerve agents
vi. Eye injuries/exposures
vii. Blast injuries
viii. Exposures from clandestine drug labs
ix. Cyanide and other nitrogen-based agents
x. Biological agents
xi. Specialty substances: hydrofluoric acid, arsine gas, nitrogen trifluoride, etc.
• Minimize the number of transport units used; they may require decontamination before returning to service.
• Contaminate as few hospitals as possible; early notification is important.
• Hospital staff should be prepared to accept contaminated victims. There may be many self-transports that were not handled at the scene.
• If decontamination is continued en route to the hospital, make an effort to contain the runoff.
• Be capable of treating major trauma or burn wounds in contaminated victims.
• Obtain medical information on hazardous substance(s). Be prepared to pass along exact information to hospital staff.
• Coordinate with medical control hospital to establish single source of medical information related to toxin(s). Coordinate release of this information to media and public through incident command and media sector.
That means that two of the three mission-critical segments of the emergency response mechanism (haz mat and hospitals) charged with responding to and handling the effects of a haz-mat/WMD incident of any proportion have access to industry-wide standards. Among other resources, hospitals have the OSHA First Receivers document and/or the American Society for Testing and Materials (ASTM) E 2413-04 document, Standard Guide for Hospital Preparedness and Response. Haz-mat teams can look toward the federal regulations for haz-mat-response competencies in the Code of Federal Regulations (CFR) 1910.120 subpart (q), commonly referred to as the HAZWOPER regulations, and/or the training competencies found in NFPA 471, Recommended Practice for Responding to Hazardous Materials Incidents, and NFPA 472, Standard for Professional Competence of Responders to Hazardous Materials Incidents. NFPA 473, Competencies for EMS Personnel Responding to Hazardous Materials Incidents, has been around since 1992 but has received only limited acceptance because in part of the complex array of responders who exist in today’s EMS world. NFPA 473 is presently undergoing a complete revision, and the next edition, scheduled for release in 2007, will address many of these issues. “A group of some of the brightest individuals with the greatest experience and expertise on EMS response has been formed to update NFPA 473,” says Dave Trebisacci, NFPA staff liaison to the Technical Committee on Hazardous Materials Response Personnel, which is overseeing the development of NFPA 473. “We are confident that the day is coming when NFPA 473 will become the go-to industry standard and fulfill this long-standing need.”
WHERE DO WE GO FROM HERE NOW?
Perhaps the best way to chart a course for change is to first identify what the final product should look like and then work backward toward the training objectives that support the original vision. In other words, once the mission-specific objectives are identified in terms of patient care at haz-mat/WMD incidents, it’s possible to identify the training required to support those objectives. To more fully define that end product from a philosophical standpoint, Augustine offers the following perspective. “Basically, a really excellent haz-mat response includes the medically trained responder who also understands the haz-mat side of things. That person is there to consider the actual or perceived medical effects of the exposure on the responders and the victims. He or she understands the specific needs in terms of triage, treatment and transport, and ultimately communicates with the hospital.”
The lessons learned from the recent terrorist bombings in London help to underscore Augustine’s comments. The bombings generated mass casualties (more than 50 deaths and 700 injuries) and required medical responders to operate in contaminated or otherwise dangerous areas. Radio communications were ineffective. Varying levels of medical care were delivered at the scene based on good triage, with 350 patients transported to area hospitals. A recent report published on the bombings, London Bombings 2005: The Immediate Pre-hospital Medical Response, advises that, “Every major incident is unique and provides lessons for emergency services. Like the recent incidents in Madrid and Istanbul, the London bombings were complicated because multiple incidents occurred simultaneously. Despite this, the seriously injured were rescued relatively quickly, provided with critical interventions on-scene where necessary, and transported to local hospitals.” These statements represent simple and straightforward learning points that can be applied to almost any type of incident.
Additionally, the London bombings illustrate the need for cooperation between all response disciplines. “At the end of the day, there needs to be collaboration among all providers, because we’ll all be there when the big incident happens anyway; most of us will be there even on the smaller ones,” says John Karolzak, Division General Manager for Rural/Metro Ambulance in Kentucky, Indiana, and Ohio.
A FINAL THOUGHT
John Karolzak agrees that there is no standard way that EMS is delivered across the country, which may ultimately complicate the specialized area of EMS at haz-mat incidents. “I always say that if you’ve seen one ambulance company operation, you’ve seen one ambulance company operation,” he says. “We’re a private ambulance company, which does business differently than another private company or a hospital-based operation or even a fire-based system. [EMS delivery systems] are all unique in one way or another and it just depends on where you are and what the prevailing thinking is. On top of that, I’m not aware of any standardized training program for treating contaminated patients. We do specific haz-mat/medical training for our people, but as far as a useful industry standard goes-it doesn’t exist.”
The one remaining skill set yet to be addressed, then, revolves around the first receivers of the First Receivers-EMS personnel responding to haz-mat/WMD incidents-the critical link in the chain of survival, bridging the gap between the hot zone and the hospital. ●
● ROB SCHNEPP is a captain/paramedic with the Alameda County (CA) Fire Department and serves as a hazardous materials specialist with the Region 4 Task Force of the FEMA Urban Search & Rescue team based in Oakland, California. He is the primary author of Hazardous Materials: Regulations, Response & Site Operations (Delmar Publishing, 1999) and is an editorial advisory board member of fireEMS and Fire Engineering.