BY ROB SCHNEPP
At a fundamental level, a weapons of mass destruction (WMD) incident is about people. It calls on human responders to make humane, intelligent decisions about a population of victims. No matter what gets dispersed, released, or blown up, the first concern is for the sick and the injured. So, who gets tasked with the job of dealing with the human element? Everyone and anyone at first; however, after the initial chaos, the medical management of the affected population falls on the shoulders of paramedics, EMTs, and the hospital community.
It won’t matter if your department is a fully staffed advanced life support (ALS) provider and transport agency or is staffed with a few EMTs. If the event happens in your backyard, you’ll be doing whatever you can to help the people who need it.
For much of the fire service, there’s a training and skills gap in the area of prehospital management of toxicological emergencies—those injuries caused by chemical nerve agents and other chemical or biological toxicants. Consider this: Most haz-mat or paramedic programs don’t go into much detail about chemical exposures or other toxicological illness. Other than decontamination considerations, do most haz-mat programs offer much detail regarding chemically exposed patients? How about paramedic training? There’s a ton of information about congestive heart failure and seizures, but how much training focuses on the adverse health effects of hydrofluoric acid, irritant gas exposures, understanding the different presentations of chickenpox and smallpox, or dealing with nerve agent exposures?
Many departments across the country are addressing that gap by implementing some form of toxicological-based EMS training. The intent is to augment the knowledge base and, in some cases the scope of practice of existing medics and EMTs, and better prepare them to handle some of the nontraditional medical situations found at WMD incidents. Some are calling it “toxmedic” or “hazmedic” training. Regardless of the name, the goal is to be more effective at handling acute toxicological emergencies.
WHAT IN THE WORLD IS A “HAZMEDIC”?
In broad terms, and for the purpose of this article, a hazmedic is a currently licensed paramedic with some level of specialized training in toxicology. The training can be as extensive as the two-week Advanced Life Support Response to Hazardous Materials class offered at the National Fire Academy, better known as R247, or as little as a four-hour awareness class in chemical exposures taught by a local paramedic. There is no national standard for hazmedic training, and that’s good news and bad news. The good news is the discipline is new enough to allow a great deal of flexibility in how you approach the training. The bad news is there is no standardized curriculum.
There are some recognized programs out there, like the one at the Fire Academy or the two-day Advanced Hazmat Life Support (AHLS) class offered by the University of Arizona Health Sciences Center. The AHLS curriculum is not for the faint of heart and packs a lot of information into 16 hours. Dr. Frank Walter, chief of the Section of Medical Toxicology at the University of Arizona, believes strongly in the concept of prehospital care for toxicological emergencies and even more strongly in training paramedics to recognize and treat those exposures. “Look at it this way,” Walter says. “Hazmedics are the guardian angels for the haz-mat responders and those patients that may become exposed to chemicals or other toxic substances. The AHLS program is designed to provide those ‘angels’ with the tools to recognize and diagnose the class or type of exposure and implement a plan for treatment.”
Some hazmedic training programs recommend treatment protocols and drug therapies not commonly found in the standard paramedic drug box. Some examples include calcium gluconate for hydrofluoric acid exposures, cyanide kits, methylene blue for methemoglobenemia, and pyridoxine (vitamin B6) for hydrazine exposures. We won’t be delving into the finer points of drug therapy in this article, but suffice it to say that there is a handful of common poisoning antidotes.
Basically, a hazmedic should function as a prehospital resource for acute toxicological illness, chemical exposures, and overall responder health and safety and should have the ability to do the following:
- Recognize the setting of, or potential for, a chemical exposure, toxicological illness, or biological warfare agent exposure.
- Render appropriate treatment for nerve agent and general industrial chemical exposures.
- Recommend decontamination procedures for contaminated patients.
- Serve as a special toxicological reference at any incident.
- Assist with pre- and post-incident medical monitoring for haz-mat incidents and determine haz-mat team member status (for example, “Cleared for entry,” “Restricted from entry,” “Send to rehab,” and “Treatment and/or transportation required”).
- Assist with WMD-specific training to fire department personnel and outside jurisdictions.
Essentially, a hazmedic should be more in tune with the human element of any incident, and although hazmedic training programs are most beneficial for paramedics, EMTs and first responders can utilize much of the same information.
Dr. Kent Olson, medical director for the California Poison Control System, comments on the benefit of having medics receive a higher level of toxicology training: “There is definitely an advantage to increasing the overall ability of paramedics to recognize toxicological emergencies in the field. In addition to recognizing the presence of those emergencies, a hazmedic could render some specific prehospital care including antidote delivery.”
Generally speaking, the hazmedic should be more acutely aware of those situations that impact human health and safety. Whether or not the hazmedic is attached to a haz-mat team, the position should function at a higher level of knowledge when toxicological incidents are suspected or encountered.
A PRACTICAL SOLUTION TO A COMPLEX SITUATION
The fire service, like any other profession, runs in cycles. According to some, the golden age of the fire service ended when we started running medical calls and further eroded when haz-mat teams came in vogue. There are those who believe we’ve strayed too far from our original mission—to fight fire—and the fire service is all about cardioversion, intubations, hot zones, and level A suits. That topic is certainly up for debate, but one thing is certain: The fire service is changing and will continue to do so. To some degree, it’s out of our hands. Like it or not, the threat of a terrorist event is real and must, to some practical degree, be addressed. In this day and age, mass-casualty events are the hot topic of conversation, and though there are many opinions on what the greatest threat is, most people agree that no matter what, people are going to get hurt. Based on that notion, the fire service is giving more thought to dealing with human chemical, biological, and nuclear exposures.
Bill McCammon, chief of the Alameda County (CA) Fire Department, explains his desire for a hazmedic program: “First, our department needs to be able to protect our own people. We’re no good to the public if we can’t function ourselves. Second, we recognize that our mission has expanded. In addition to everyday haz-mat situations, we recognize that a WMD event requires us to plan for significant exposure scenarios.”
Trying to balance daily operations with the increased need to prepare for a catastrophe is a real challenge: Many agencies are struggling to address the terrorism “issue” while trying to stay focused on the everyday work of being a fire department.
Out of necessity, most departments have accepted the idea that they need to function as “all risk” departments and remain willing to embrace whatever is required to stay useful to the community.
If implemented correctly, a hazmedic program does not have to detract from the other services the department provides. It can, in fact, have a positive effect on the overall mission of the agency. “In our department,” McCammon says, “we look at it as a way to increase our present capacity to deliver services.”
Barbara Bovee, a paramedic training coordinator for the Phoenix (AZ) Fire Department, agrees. “The toxmedic program in Arizona is not just a WMD program; it’s designed to function at a much broader level,” she says. That “broader level” is an increased ability to deal with toxicological emergencies and those exposures occurring at nonterrorism-related incidents.
Steve Auch, director of EMS for the Indianapolis (IN) Fire Department, sees a hazmedic program as “absolutely beneficial.” Though the Indianapolis Fire Department does not have a hazmedic program in place, he is investigating the options. Auch agrees that a hazmedic program is primarily for the safety of the responders but understands the critical role hazmedics can play in any haz-mat response. He also sees a benefit to expanding the scope of practice and offering the additional training. “I see it as a morale booster. Paramedics usually enjoy the additional knowledge and training. We’re constantly looking at ways to make the paramedic position more attractive,” says Auch.
The Alameda County Fire Department is opting for an integrated approach to the hazmedic position—a cross-pollination of training—for paramedics and haz-mat technicians. Fully licensed paramedics are given toxicology and haz-mat technician training and are assigned to the haz-mat stations. Paramedics are part of the haz-mat team and ultimately become hazmedics. Essentially, it brings the entire haz-mat/paramedicine component under one roof. McCammon explains the logic: “First, we looked at the haz-mat response capabilities of the entire region. Based on that, it made sense to expand our system by training the medics to be haz-mat techs and giving them the additional toxicology component.”
HAZMEDICS: GETTING STARTED
As with any program, an agency looking into hazmedic training should ask some questions. Here’s a list of things to consider before jumping into any type of toxicological-based training program:
- What is our current ability to provide, and how do we provide emergency medical services—e.g., ALS transport, basic life support (BLS) transport, engine company medics, and so on?
- How will adding this new level of training affect that?
- Will we be committed to staying current on the skills, knowledge, and abilities required to be proficient?
- How many toxmedics should we have?
- Where will they be stationed?
- Should they have haz-mat training? If so, what level?
- Do we have to change the existing scope of practice to accommodate new drugs and/or treatment protocols?
- What role will the regional poison control center have?
- What hazmedic training program will we use? Should we develop our own?
- Who else is doing this, and are they happy with the outcome? Are neighboring jurisdictions doing anything like this?
- If we add antidotes to our drug box, how much will they cost?
- How will we restock those antidotes?
- How many antidotes should we carry? In other words, how many patients will a hazmedic be able to treat?
It’s important to realize that the long-term benefit of a hazmedic program may not be easy to gauge. Success can’t be measured by the amount of antidotes used or the number of poisoning calls run. The benefit lies in increasing the underlying knowledge base of existing paramedics and equipping them to handle infrequent but potentially catastrophic patient presentations.
A FINAL THOUGHT
Unfortunately, the fire service can’t depend on past practice to guarantee future success. Why? Because the rules of engagement, to some degree, have changed. The threats of today are different from those we faced a few years ago, and we must look for new and inventive ways to protect our taxpaying public and ourselves. Hazmedic programs, regardless of what they look like, take us in that direction.
In addition to the WMD arena, statistics show that people are hurt and killed each year by accidental and intentional chemical exposures. While infrequent, chemical exposures may create potentially complex patient presentations and require a more specialized approach. A well-trained hazmedic should be able to recognize those situations—pediatric ingestions of rat poison; corrosive skin exposures; and toxic gas inhalations like arsine, germane, or other semiconductor gases, for example—and handle them with confidence.
The University of Arizona’s Dr. Walter best sums up the value of hazmedic training this way: “Chance favors the prepared mind.” That’s something all responders would like to have—an edge, a better chance at performing up to or above the level of the problem at hand.
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, 1999) and is an editorial advisory board member of fireEMS and Fire Engineering.
