Bernard Heilicser, DO, MS, FACEP, FACOEP-D
Medical Director & Medical Manager, IL-TFI USAR
We often talk about decontamination as something accomplished prior to a patient arriving at our emergency department. Fortunately, this is usually what occurs. However, in our chaotic and disturbing world, we cannot always rely on this to have been adequately or fully performed, nor the probability of self-presenting patients from the scene. Additionally, to be best, and safely, prepared, we truly need to know what is happening in the field, or our driveway, before we see the patient.
With the multitude of dangerous chemicals traversing our highways and train tracks on a daily basis, the potential for hazardous material and other contaminants becoming clinical events cannot be overlooked. The easy availability of these new weapons, by terrorists, adds to our concerns.
Here is a brief overview of decontamination as practiced by trained responders at an operational level.
If we define decontamination as the process of removing and/or neutralizing contaminants, then we understand how the potential for secondary contamination determines the need and selection of emergency decontamination in the first place.
Why decontaminate? To protect first responders, our citizens, and to minimize the spread of hazardous materials. The rapid identification of contaminants is essential. We need to know what we are dealing with so as to avoid inappropriate, if not harmful, treatments. Lack of information, contact with contaminants and inadequate decontamination may be disastrous. Primary decontamination in the field may have been relatively inadequate. Successful decontamination mandates a written plan. This should identify and address the different types of decontamination:
- Emergency – may be simply spraying the exposed individual or placing them in a shower
- Formal – time to set up the more sophisticated equipment, including pools, showers, sprays and scrubbing
- Mass – multiple exposed which may include ambulatory and non-ambulatory
- Fine – more detailed and specific contaminant removal
The appropriate personal protective equipment should be clearly indicated and used.
There are two general types of decontamination: physical removal and chemical (or in combination). Physical removal of contaminants includes loose materials and may be sufficient. Chemical removal involves neutralization, rinsing and disinfection and sterilization. The needed equipment should be known and readily available.
All first responders to a decontamination event need to be made aware of the circumstances. This is especially true for emergency medical services. Every individual must participate in a job briefing, chiefly addressing safety. Emergency activations and all contingencies must be known. Additionally, the nature of the problem should be stated, specific duties should be defined, and any criminal or terrorist activity presented. Respective agency participation and function should be clear. All personnel must state their understanding of the plans and the goals.
Actual decontamination scene set-up is beyond the scope of this article. However, consideration of locations, wind direction and speed, approaching weather, available resources and logistical locations are essential. Defining, marking and enforcing the hot zone, warm zone and cold zone is imperative. How will confinement be maintained? Confinement tarps, water supply, entry from the hot zone, washing and rinsing pools, drying line, removal of wet and dry personal protective equipment, all require coordination.
When planning for a decontamination event, it should be remembered no one plan will cover every eventuality. Training and practice is paramount.
In the emergency department we must be vigilant. We have all done that disaster drill, or actually experienced, an organophosphate exposed patient brought in, not recognized, and has now effectively shut down our department, or worse. We must ask, how do I identify the contamination, when is decontamination necessary, where should it be set-up, and how do we handle emergency decontamination?
The mantra of plan, prepare, practice is certainly true. I would add, don’t practice until you get it right, practice until you get it right every time.
With appreciation to the Illinois Mutual Aid Box Alarm System Division 24 Haz Mat Team.