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Chemical Incidents in the Emergency Department: If and When
EDITORIALS
Chemical Incidents in the Emergency Department: If and When Peter Pons, MD Department of Emergency Medicine Denver Health and Hospital Authority Denver, CO Richard C Dart, MD, PhD Rocky Mountain Poison and Drug Center Denver, CO Reprints not available from the authors. 47/1/99939
Chemical Incidents in the Emergency Department: If and When See related article, p. 205. [Pons P, Dart RC: Chemical incidents in the emergency department: If and when. Ann Emerg Med August 1999;34:223225.] In this issue, Burgess et al 1 have described a series of decisions and steps needed to manage a victim of hazardous material contamination brought to an emergency department for medical attention and treatment. The issue of hazardous material contamination of patients has recently been brought to the attention of our nation in general and the emergency medical community in particular as a result of the concerns raised in the aftermath of several terrorist incidents. Perhaps the most notable and alarming acts were the sarin releases in Japan producing some fatalities and hundreds of casualties. To improve domestic readiness for such an incident occurring in the United States, the Nunn-LugerDomenici Act provided federal funding to prepare emergency responders and health care providers in the management of victims of a weapon of mass injury.
AUGUST 1999
34:2
ANNALS OF EMERGENCY MEDICINE
2 2 3
EDITORIALS
Of concern, however, is the lukewarm reception that this education effort has received in the medical community. The reasons for this are not clear. Perhaps it is difficult for anyone to believe that an incident involving a chemical or biologic weapon will actually occur in the United States, let alone in the very community we live and practice in. Further, the resulting casualties and medical needs of such an incident appear overwhelming, leaving the impression of futility. Why bother to prepare? However, reality demands that the emergency physician prepare for the contaminated patient. Although the need for managing such an incident seems remote, in fact, victims of hazardous materials exposure are brought to, and treated in, our EDs every day. As the authors point out, in 1 state alone, more than 2,000 individuals had a hazardous materials exposure during a 4-year period and on average 1 patient a day sought care at a hospital. There are uncounted ways we may encounter contaminated victims. The housekeeper who mixes 2 cleaning chemicals together, the homeowner who accidentally spills a pesticide, the numerous industrial sites using chemicals for manufacturing, the daily transportation of hazardous materials through our communities by rail or truck. Thus, appropriate preparation to receive, decontaminate, and treat a contaminated patient must be an essential component of an ED’s readiness. Several issues mentioned by the authors bear further comment. The authors appropriately indicate the importance of identifying the chemical agent. Clearly, accurate knowledge of the specific agent will guide patient management. However, identification of the hazardous material is all too often inaccurate or not immediately available. Emergency medical personnel must act without this information. Therefore ED personnel must be trained in “syndrome recognition.” Triage personnel, nurses, and physicians should know and recognize the common constellation of symptoms and signs indicating hazardous material contamination. Although this is particularly important for the early recognition of an incident involving a weapon of mass injury, it is no less important in dealing with the multitude of potential contaminants found in our communities. The prompt recognition and management of a patient’s presentation as being consistent with a hazardous material exposure may prevent many undesirable actions such as evacuation of the ED or hospital. The authors stress the importance of external consultation to the ED to aid in contaminant identification and patient treatment. They point out that there should be a means for the ED to contact hazardous materials teams
2 2 4
and field responders at an incident site. Ideally the reverse should be in place. It should be considered a responsibility of the EMS system that hospitals be notified whenever a hazardous materials incident occurs and emergency responders are dispatched to a potentially contaminated location. In this way, EDs can prepare to receive not only casualties transported by the EMS system but also those who may transport themselves to a hospital. This has the added advantage of reducing the dependence for syndrome recognition by ED personnel before actual identification that a presenting patient is in fact a potential hazardous material victim. In addition to communication with field personnel, the authors stress the need for, importance, and benefit of consultation with trained, experienced medical toxicologists. However, the reality of emergency care again dictates the need for readiness on the part of EDs and their personnel and not dependence on outside assistance. First, although access to trained toxicologists is often available relatively quickly, access to trained and experienced toxicologists is much less common. Hazardous material exposure is not an infrequent occurrence, but actual experience on the part of emergency physicians as well as toxicologists is limited. Second, just as emergency responders must not depend on immediate response and assistance from outside agencies in the event of a major hazardous materials incident, so too must EDs and hospitals be prepared to manage the initial phases of a hazardous materials exposure and not depend on outside consultants to fill this role. Outside assistance requires time for mobilization and response under the best of circumstances. Crucial decision points will have been passed before outside assistance could conceivably respond. Further, most of these actions do not require detailed toxicologic information. There are 2 ways that a toxicologist might be of assistance early (not immediately) in the course of a chemical incident. If quickly available at the scene, a medical toxicologist could provide medical care after initial stabilization and treatment, thereby freeing the emergency physician to proceed with initial management of other patients; for example, continuing doses of atropine or monitoring of patients who have been treated with the cyanide kit. Second, the toxicologist can provide information and experience that are important in determining the treatment and disposition of the patient. Should an asymptomatic patient with phosgene exposure be discharged from the ED? Finally, the realities and practicalities of the decontamination process must be examined. All educational materi-
ANNALS OF EMERGENCY MEDICINE
34:2 AUGUST 1999
EDITORIALS
als, chapters, books, and articles (this one included) on hazardous materials exposure management discuss the need for victim decontamination. The need for personal protective equipment (PPE) for those personnel performing decontamination is often presented. Unfortunately, all of these materials discuss PPE in very general terms without giving specific guidelines and recommendations. When is full protection in a Level A suit required? When is a self-contained breathing apparatus needed? Which exposures can safely be decontaminated inside the ED? When does the full hospital have to be evacuated? How much PPE is needed if a victim is able to transport himself to the hospital? Who pays for the training? And equipment? Another important consideration is the decontamination fluid runoff. The authors assume that a separate containment system or tank exists in that plastic pools, decontamination stretchers, or sealed containers will be available to hold the contaminated effluent. Is this in fact the case? Certainly the cost for a containment tank is not insignificant, and purchasing and maintaining other containment apparatus is often less than ideal. Numerous unanswered questions remain. Can the effluent be allowed to run down sewers or storm drains? Is dilution of the runoff to decrease contaminant concentration an acceptable alternative to containment? The authors have done a commendable job of providing a general overview and recommendations regarding the numerous issues, objectives, and actions that may occur or be needed in a hazardous materials incident. The challenge for emergency medicine is to fully develop and adapt this information in every ED. A hazardous material incident or terrorist act will happen to you. It may seem cliché, but the saying applies: it is not a question of if, only when. 1. Burgess JL, Kirk M, Borron SW, et al: Emergency department hazardous materials protocol for contaminated patients. Ann Emerg Med 1999;34:205-212.
AUGUST 1999
34:2
ANNALS OF EMERGENCY MEDICINE
2 2 5
Chemical Incidents in the Emergency Department: If and When Peter Pons, MD Department of Emergency Medicine Denver Health and Hospital Authority Denver, CO Richard C Dart, MD, PhD Rocky Mountain Poison and Drug Center Denver, CO Reprints not available from the authors. 47/1/99939
Chemical Incidents in the Emergency Department: If and When See related article, p. 205. [Pons P, Dart RC: Chemical incidents in the emergency department: If and when. Ann Emerg Med August 1999;34:223225.] In this issue, Burgess et al 1 have described a series of decisions and steps needed to manage a victim of hazardous material contamination brought to an emergency department for medical attention and treatment. The issue of hazardous material contamination of patients has recently been brought to the attention of our nation in general and the emergency medical community in particular as a result of the concerns raised in the aftermath of several terrorist incidents. Perhaps the most notable and alarming acts were the sarin releases in Japan producing some fatalities and hundreds of casualties. To improve domestic readiness for such an incident occurring in the United States, the Nunn-LugerDomenici Act provided federal funding to prepare emergency responders and health care providers in the management of victims of a weapon of mass injury.
AUGUST 1999
34:2
ANNALS OF EMERGENCY MEDICINE
2 2 3
EDITORIALS
Of concern, however, is the lukewarm reception that this education effort has received in the medical community. The reasons for this are not clear. Perhaps it is difficult for anyone to believe that an incident involving a chemical or biologic weapon will actually occur in the United States, let alone in the very community we live and practice in. Further, the resulting casualties and medical needs of such an incident appear overwhelming, leaving the impression of futility. Why bother to prepare? However, reality demands that the emergency physician prepare for the contaminated patient. Although the need for managing such an incident seems remote, in fact, victims of hazardous materials exposure are brought to, and treated in, our EDs every day. As the authors point out, in 1 state alone, more than 2,000 individuals had a hazardous materials exposure during a 4-year period and on average 1 patient a day sought care at a hospital. There are uncounted ways we may encounter contaminated victims. The housekeeper who mixes 2 cleaning chemicals together, the homeowner who accidentally spills a pesticide, the numerous industrial sites using chemicals for manufacturing, the daily transportation of hazardous materials through our communities by rail or truck. Thus, appropriate preparation to receive, decontaminate, and treat a contaminated patient must be an essential component of an ED’s readiness. Several issues mentioned by the authors bear further comment. The authors appropriately indicate the importance of identifying the chemical agent. Clearly, accurate knowledge of the specific agent will guide patient management. However, identification of the hazardous material is all too often inaccurate or not immediately available. Emergency medical personnel must act without this information. Therefore ED personnel must be trained in “syndrome recognition.” Triage personnel, nurses, and physicians should know and recognize the common constellation of symptoms and signs indicating hazardous material contamination. Although this is particularly important for the early recognition of an incident involving a weapon of mass injury, it is no less important in dealing with the multitude of potential contaminants found in our communities. The prompt recognition and management of a patient’s presentation as being consistent with a hazardous material exposure may prevent many undesirable actions such as evacuation of the ED or hospital. The authors stress the importance of external consultation to the ED to aid in contaminant identification and patient treatment. They point out that there should be a means for the ED to contact hazardous materials teams
2 2 4
and field responders at an incident site. Ideally the reverse should be in place. It should be considered a responsibility of the EMS system that hospitals be notified whenever a hazardous materials incident occurs and emergency responders are dispatched to a potentially contaminated location. In this way, EDs can prepare to receive not only casualties transported by the EMS system but also those who may transport themselves to a hospital. This has the added advantage of reducing the dependence for syndrome recognition by ED personnel before actual identification that a presenting patient is in fact a potential hazardous material victim. In addition to communication with field personnel, the authors stress the need for, importance, and benefit of consultation with trained, experienced medical toxicologists. However, the reality of emergency care again dictates the need for readiness on the part of EDs and their personnel and not dependence on outside assistance. First, although access to trained toxicologists is often available relatively quickly, access to trained and experienced toxicologists is much less common. Hazardous material exposure is not an infrequent occurrence, but actual experience on the part of emergency physicians as well as toxicologists is limited. Second, just as emergency responders must not depend on immediate response and assistance from outside agencies in the event of a major hazardous materials incident, so too must EDs and hospitals be prepared to manage the initial phases of a hazardous materials exposure and not depend on outside consultants to fill this role. Outside assistance requires time for mobilization and response under the best of circumstances. Crucial decision points will have been passed before outside assistance could conceivably respond. Further, most of these actions do not require detailed toxicologic information. There are 2 ways that a toxicologist might be of assistance early (not immediately) in the course of a chemical incident. If quickly available at the scene, a medical toxicologist could provide medical care after initial stabilization and treatment, thereby freeing the emergency physician to proceed with initial management of other patients; for example, continuing doses of atropine or monitoring of patients who have been treated with the cyanide kit. Second, the toxicologist can provide information and experience that are important in determining the treatment and disposition of the patient. Should an asymptomatic patient with phosgene exposure be discharged from the ED? Finally, the realities and practicalities of the decontamination process must be examined. All educational materi-
ANNALS OF EMERGENCY MEDICINE
34:2 AUGUST 1999
EDITORIALS
als, chapters, books, and articles (this one included) on hazardous materials exposure management discuss the need for victim decontamination. The need for personal protective equipment (PPE) for those personnel performing decontamination is often presented. Unfortunately, all of these materials discuss PPE in very general terms without giving specific guidelines and recommendations. When is full protection in a Level A suit required? When is a self-contained breathing apparatus needed? Which exposures can safely be decontaminated inside the ED? When does the full hospital have to be evacuated? How much PPE is needed if a victim is able to transport himself to the hospital? Who pays for the training? And equipment? Another important consideration is the decontamination fluid runoff. The authors assume that a separate containment system or tank exists in that plastic pools, decontamination stretchers, or sealed containers will be available to hold the contaminated effluent. Is this in fact the case? Certainly the cost for a containment tank is not insignificant, and purchasing and maintaining other containment apparatus is often less than ideal. Numerous unanswered questions remain. Can the effluent be allowed to run down sewers or storm drains? Is dilution of the runoff to decrease contaminant concentration an acceptable alternative to containment? The authors have done a commendable job of providing a general overview and recommendations regarding the numerous issues, objectives, and actions that may occur or be needed in a hazardous materials incident. The challenge for emergency medicine is to fully develop and adapt this information in every ED. A hazardous material incident or terrorist act will happen to you. It may seem cliché, but the saying applies: it is not a question of if, only when. 1. Burgess JL, Kirk M, Borron SW, et al: Emergency department hazardous materials protocol for contaminated patients. Ann Emerg Med 1999;34:205-212.
AUGUST 1999
34:2
ANNALS OF EMERGENCY MEDICINE
2 2 5