Medical Aspects of Chemical Warfare (2008) - The Black Vault

Medical Aspects of Chemical Warfarecapable of providing a definitive care capability (levelIV and V) are located outside the theater of operationsin large land-based installations. 1,11,12In contrast, the Coast Guard has limited capabilitiesto receive casualties. Coast Guard personnel canprovide first aid for victims rescued from ships or thewater. The primary Coast Guard role is to offer forceprotection and safety regulation for vessels and ports,to minimize the possibility of a chemical attack ormajor toxic industrial chemical incident. Their muchsmaller 300-foot Coast Guard cutters are staffed byindependent duty corpsmen and physician’s assistantscapable of providing first aid for chemical casualties,including administration of atropine autoinjectorsand basic decontamination with water, soap, andhypochlorite solutions. These medical assets can alsoparticipate as part of requested federal resources inresponse to a mass casualty event. The Coast Guarddeep-draft vessels scheduled to enter operation in 2007will have capabilities to operate in a chemical hazardenvironment for up to 72 hours. 13Medical response planning and evacuation of casualtiesto ships is the responsibility of the JTF surgeon,a physician of any specialty, usually embarked on thelead ship and a staff member of the JTF Commander.The JTF Commander, usually at least a one-star admiral,is responsible for coordination of Naval assetsin support of land-based objectives of the operationaltheater commander. During shore-to-ship operations,the Army is usually responsible for medical rotarywingsupport for patient transport; otherwise the Navyand USMC perform this service. The Air Force is theprincipal fixed-wing air asset for the transportation ofpatients from the theater of operations to the continentalUnited States (ie, to level V) during joint operations. 5By doctrine, patients must be decontaminated beforetransport to Naval vessels; however, a thoroughdecontamination of patients may not be possiblewith a high operational tempo. Navy documentsprovide detailed instruction for the decontaminationand processing of patients brought on board ship byrotor-winged aircraft and landing craft before theyare brought below decks. 14 Large Navy vessels at seahave extensive water supplies for decontaminationpurposes. Their evaporators daily produce thousandsof gallons of fresh water. Additionally, appropriatelyprotected personnel can quickly use fire hoses to washdown external areas with salt water.MANAGEMENT OF CHEMICAL CASUALTIES FROM A CIVILIAN PERSPECTIVEThe accidental release of toxic substances occursregularly in the United States from fixed storage andindustrial facilities and from containers during transportation.Most common among these substances areammonia, pesticides, volatile organic compounds, acids,and petroleum products. 15 US hazardous materials(HAZMAT) response teams have gained experiencein managing these accidental releases. Events suchas the 1984 release of the carbaryl pesticide precursormethylisocyanate, in Bhopal, India, which killed andinjured thousands, and the more limited yet lethal attacksby the Aum Shinrikyo cult in Matsumoto (1994)and later Tokyo (1995), Japan, killing less than a dozenbut injuring scores more, demonstrate that intentionalacts of sabotage and terrorism can create large numbersof casualties in unprotected civilian populations. 16–18Until recently, no effort had been made to standardizeguidelines for the management of mass casualtiesfrom such events. In February 2003, Homeland SecurityPresidential Directive-5 was signed into law byPresident George W Bush, initiating the developmentof the National Incident Management System. 19 Thissystem serves as the template for the management ofmass casualty events in the United States, whether theyare caused by a terrorist attack, accident, or naturalevent (such as a hurricane). It provides a frameworkto coordinate the response of the government, privatesector,and nongovernmental organizations. Structureis added to this framework through the National ResponsePlan (NRP), which provides the actual coordinationmechanisms for various agencies, including fire,rescue, and emergency medical services, for effectivecommunication and teamwork. 20 These documents,along with others developed by the Department ofHomeland Security, Department of Health and HumanServices, Occupational Safety and Health Administration(OSHA), Joint Commission on Accreditationof Hospital Organizations, and other agencies, havesought to foster more standardization in the disasterand medical response to mass casualty events fromall hazards. This entire response plan was first fullyimplemented in response to Hurricane Katrina, whichdevastated the US Gulf Coast in August 2005, and isundergoing further modification based on the manylessons learned from the disaster.Local responses to chemical releases vary. Typically,when a casualty-causing chemical event occurs,those who can flee the scene on foot or by privateor commercial vehicle are the victims first seen atthe nearest medical facility. As demonstrated inTokyo, their arrival may be the first indicator for amedical facility, and a community, that an event hasoccurred. 21,22 When the event is reported to authorities,local fire departments and HAZMAT teams, if492