BY GLEN D. RUDNER
Several years ago the first responding apparatus took on the responsibility of decontaminating the large number of victims who may have been contaminated by an accidental release of an industrial chemical or the intentional release of weapons of mass destruction (WMD). Today, those first responder companies are responsible not only for mass decontamination but also for treating, triaging, and transporting these victims-turned-patients to the hospital or care areas. Several questions have arisen concerning this situation, and they should be addressed.
First response communities, because of a large funding stream of grants, have purchased a large amount of equipment for terrorism preparedness and for researching, detecting, and monitoring the products. They have bought personal protective equipment (PPE) to protect themselves on entry, for investigation, and also for victims after they have been decontaminated. They have purchased decontamination trailers, showers, pools, and other products to expedite decontamination and have even purchased trailers and vehicles to transport the equipment to the incident scene.
SOME QUESTIONS REMAIN
Despite all these purchases and the training exercises, we still have some remaining questions: How effective has our decontamination process been? How efficient has the mass decontamination been? And most important, how ready is the hospital system for the handoff of these victims-turned patients? In posing these questions, we should ask ourselves, have we prepared ourselves to transfer this responsibility to the hospital and its staff? These pointed questions deserve some discussion, not just here but at the Local Emergency Planning Committee (LEPC) and other emergency planning meetings where the facts must be discussed.
In looking back at the mass-decontamination methods that have been discussed, we are still using many different approaches throughout the country. Some people are still advocating that we install water heaters on fire engines so we can deliver 70°F water to the victims. If we have 5,000 victims and have to flow 1,000 gallons per minute of water and each person needs to go through the shower for 1½ minutes, I do not believe we can deliver that much warm water at a moment’s notice, at least not at the incident scene.
Others are still advocating the use of fire hoses as they were used for riot control in the 1960s and 1970s. There are some who believe that the hospital should be moved to the incident scene to expedite patient care. There is some validation for this idea.
EFFECTIVENESS OF OUR DECONTAMINATION PROCESS
The primary way to answer this question is by (1) identifying the product that has been used (detection), (2) determining its chemical and physical properties, and (3) monitoring the victims after they have been decontaminated to ensure that the product has been removed. Herein lies one of the major problems we have today.
The first responder community feels that once it has set up and completed mass decontamination, the victim is ready for transport. Yet, this is where the hazardous materials technicians or hazardous materials operations level-trained personnel with mission-specific training in detection and monitoring equipment play an important role. The tactical plan must include a discussion of detection and monitoring. It must also include the plan for trained personnel who can use the appropriate technology and interpret the data for the EMS sector. Once this has been done, the hospital can get a better picture of what it will be dealing with once the victim arrives.
EFFICIENCY OF THE DECONTAMINATION PROCESS
This is a two-pronged question. How many victims have been serviced and turned into patients? Or, are victims leaving the site before being decontaminated and, therefore, unaccounted for at the scene? The victims who have been serviced (decontaminated, triaged, treated, and transported) have been accounted for and can be placed in and appropriately moved through the system. This is crucial in maintaining patient accountability and control for the hospital system.
THE HANDOFF TO THE HOSPITAL SYSTEM
As for the handoff to the hospital system, a clear pathway and planned response must be established. For large-scale events, this means that the hospital must have an established plan that will not set redundancy of operations (decontamination procedures) as a priority. This will be accomplished by meeting with first response agencies to discuss the methodology of decontamination (did they use soap and water, plain water, dry decon only, strip only, or no decontamination?) and detection (screening) prior to being sent to triage. By doing this, the handoff to hospital personnel becomes more fluid.
The second issue is how well the decontamination was conducted. Detection devices can be used to determine the effectiveness of the decontamination process. The only personnel who should be able to do this are the haz mat technicians and specialists. They should be at the end of the decontamination line with the appropriate equipment for the hazard. This should be done in conjunction with the EMS branch as it starts triage.
At present, there are very few, if any, detection technologies hospital emergency room personnel can use. The majority of the equipment requires many hours of initial training and then refresher training to remain competent in its use, especially when there is an emergency of the proportions that have been predicted. It is, therefore, imperative that the hospitals concentrate their training and efforts toward treatment of symptoms.
The question that, of course, is the most important to answer is, how ready is the hospital system for the handoff of this victim-turned-patient? Since March 20, 1995, hospital systems across the globe have been trying to learn how to deal with a mass-casualty incident that involves a large number of chemically contaminated patients. Considering that there have been many industrial accidents that have caused the same problems, the hospital systems are still having a difficult time with this.
At the incident site, the victims were brought to a casualty collection point, where their symptoms were assessed by the first responder to determine which victims were contaminated. Those thought to be contaminated were put through the decontamination process; they removed some or all of their clothing and moved into the decontamination showers, using copious amounts of water and, if they had the ability, a soap solution. Once thoroughly washed, they were given a cover and brought to an area where detection determined if the decontamination was successful in removing the product. There is no reason the victims should be decontaminated again at the hospital, and that information should be accepted by the hospital.
Unfortunately, the problem is that responders and hospital personnel often get into a “discussion” as to “how clean is clean.” Some of the factors that can directly influence this “discussion” include the following:
- Failure to recognize that the victim has already been decontaminated and has had his cleanliness assessed through detection instruments.
- Hospital systems expect doctors and nurses to simultaneously perform hazardous materials technician-level skills as well as their professional duties. These skills can include the use of personal protective clothing and equipment and selection of decon methods and procedures,
- Some hospital systems are still expecting the first responders to rush to the hospital, abandon the incident, and assist in decontaminating incoming patients at the hospital.
Many of these issues have been addressed across the country, but the process of recognizing the problem, planning a solution, and implementing that solution is a different matter. Although things are improving, the reality is that many of us still have to work hard to prepare the hospital system to integrate with the first response community.
The first responder-hospital integration process is a critical element in the successful management of incidents involving contaminated patients. The hospital must have faith that the first-response community is competent to implement the appropriate decontamination process and to evaluate the effectiveness of that process with the appropriate detection devices and equipment, as available. Many of our first responder communities have been integrating with their local hospitals and creating partnerships. There is still much to do to make it work. This is an education process in which we all must be willing to participate.
GLEN D. RUDNER has been the hazardous materials response officer for the Virginia Department of Emergency Management, assigned to the Northern Virginia area, for the past eight years. He is responsible for coordinating state assets and response during hazardous materials and terrorism incidents. He has 28 years experience in public safety, including 12 years as a career firefighter/hazardous materials specialist for the City of Alexandria (VA) Fire Department and eight years as a volunteer EMT, firefighter, and officer with the LaGrange (NY) Volunteer Fire Department. Over the past 10 years, he has been involved in developing and delivering many local, state, federal, and international programs for numerous organizations.
