ED preparation for mass contamination

Jaco Slabbert18 February 2009

• Introduction• Types of contamination• Preparation• Equipment• Decontamination• Security and Traffic control• Media• Cape Town perspective

Mass casualty events – ER challenges

• High impact, low-probability events• Delayed notification• Self presenting patients• Convergence of medical staff• Convergence of the media• Convergence of family, friends• Lack of supplies• Less than 20% of victims receive decon on scene• High index of suspicion

Types of contamination

• Chemical

• Biological

• Radiological

• Nuclear

Chemical contamination• Peloponnesian war 429 BC – Spartans and

Thebans created a hot fire, and added brimstone and pitch

• Henry III – finely pulverized lime used by English sailors

• 1899 Boer War – picric acid

• WW I – Mustard gas

Tokyo subway sarin attack

• 5510 people seeked medical attention• 640 chemically contaminated patients arrived

at a single hc facility, using private transport• 23% ED staff contaminated• In one instance 11 doctors were affected

treating 2 patients

Preparation

• Planning – ER layout, hospital’s capacity, outdoor decontamination area.

• Table top exercise• Full-scale, live exercise• Virtual live exercise (VLE)

VLE

• University of Alberta Hospital,Edmonton,Ca• 136 simulated patients created,using data

from actual pt. encounters• 15 physicians and 18 nurses• MD-delay / Workup-delay• Results:↓ pt flow, under-triage• Conclusions:inexpensive,discovery of new

approaches,triage accuracy

Equipment

• Protection of staff

• Decontamination of casualties

• Specialist medical supplies

Personal protective equipment

• Levels A – D• A:fully encapsulating chemical-resistant+SCBA• Protect head, face and eyes, the ears, the body,

the hands and feet.• Protect against unknown chemicals• B:splash protection,chemical-resistant,SCBA• C:full-faced,air-purifying respirator• Filter change times monitored• D:standard work uniform,gloves,mask

Decontamination equipment

• Scissors• Clean, warm or tepid water• Buckets (10 litre capacity)• Decontaminent/liquid soap : 10 ml added to a 10

litre bucket• Sponges/ soft brushes/ wash cloths• Disposable towels,gowns,slippers. Blankets• Plastic bags and plastic bins• Nsaline and drip sets for eye and wound irrigation

Specialist medical supplies

• Medical equipment may become contaminated(wheelchairs, stretchers)

• Antidotes

Decontamination• ↓absorption and ↓ spread of contamination

• Remove clothing : 80-90% of contamination.

• Rinse affected areas

• Wipe with a sponge or soft brush

• Rinse for a second time

• 3-5 minutes

Limitations to decontamination

• PPE suits require filter change – takes time• Staff needs to be rotated: fatique,heat• PPE suits are cumbersome• Space in decon tents are limited• Decon units can clear 2 ambulatory pts every

10 minutes

Questions about decontamination that await further scientific evaluation

• Will victims remove their clothing?• How long will victims remain at the scene

awaiting decontamination?• What impact does modesty or inclement

weather have on clothing removal?• How long should victims be showered and

what water volume is required?• Can victims be effectively managed and

communicated to by staff in PPE?

Security and Traffic control

• “Lockdown”• Difficulty containing contaminated patients• Family• Media• Ambulances – “clean and dirty”circuits• Nonessential vehicles

Case Report

• Singapore – chlorine gas released from pump room at a local swimming pool

• 54 pts seeking treatment – 36 presented to Singapore General Hospital over 90 minutes

• Hospital Decontamination Station outside of ED

• ED Staff donned Level-C protective gear• Entrances to ED were secured

• Disaster plan activated• ED re-organized to triage, treat and evacuate

victims as well as manage existing patients• HAZMAT incident, not causing severe injuries• Well executed• Valuable lessons learned

Hospital decontamination and the Paediatric patient

• Psychosocial needs• Communication• Chaperones• Removal of clothing• Holding infants• Process of decontamination

Cape Town perspective

• Fire Service• 7 Medical Battallion – Simonstown• Dilution is the solution• Fire hoses at hospitals• TBH Pharmacy – 160 ampules Atropine in

Disaster cupboard in F1, 896 ampules in main pharmacy

Tygerberg Hospital

Groote Schuur Hospital

G.F.Jooste Hospital