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

Field Management of Chemical Casualtiesavailable, respond. Response time can range from 5 to30 minutes from initial release. 23,24 Once these teamsrespond, the area is cordoned off. Decontaminationunits are established by the fire department at theperiphery of the contaminated area (the hot zone).The initial processing of patients through decontaminationcan be 30 minutes or more after the initialtoxicant release. 23 In some communities, particularlyin rural areas, medical personnel do not have level IIemergency medical service (EMS) or hazardous materialsoperations training, so they cannot accompanyHAZMAT crews into contaminated areas. Frequently,local EMS personnel are not proficient in treatingcontaminated patients while wearing personal protectiveequipment (PPE), which relegates them totreating patients after decontamination. 25 Wearing appropriateself-protection ensemble while stabilizingpatients before decontamination procedures is a difficultchallenge for first responders. Victims are oftendecontaminated and only then seen by unprotectedEMS personnel, who place them on ambulances fortransport to hospitals. Because HAZMAT teams musttake time to secure the area and muster equipmentbefore they can begin decontamination, victims whodo not flee the scene before the arrival of HAZMATand fire department teams may not receive medicalcare for 30 minutes or more after their exposure. 23 Asequence of events similar to this occurred after passiverelease of dilute sarin nerve agent in the 1995 Tokyoattack. 17 Authors such as Okumura who studiedthis event closely believe that a more forward medicalpresence, as incorporated by the military, may savemore lives in the event of a chemical release creatingmass casualties, particularly if a potent warfare agentis used in the attack. 17Currently, many larger metropolitan fire departmentsare training their emergency medical technicians(EMTs) to provide life saving medical care in thecontaminated area or at its periphery. This training stilldoes not occur in many smaller rural departments, orin most private emergency services, which providecare only after patient decontamination. Withoutadequate first responder training in the provisionof medical care while wearing PPE, first responderEMTs are relegated to the contamination-free area; inthis situation medical intervention will be too late formany victims. 26 The Department of Health and HumanServices is considering policy and recommendationsto encourage appropriately trained and equipped firstresponders from all agencies to provide medical carein contaminated areas. The National Fire ProtectionAssociation has published standards for the professionalcompetence of EMS responders in hazardousmaterials incidents. 25 Hospitals that receive contaminatedpatients now have guidance through the OSHABest Practices for Hospital-Based First Receivers of Victimsfrom Mass Casualty Incidents Involving the Release ofHazardous Substances, released in January 2005. Thisdocument establishes the baseline for medical facilityresponse to the arrival of contaminated casualties.Its purpose is to insure that the triage, stabilization,decontamination, and treatment of contaminated casualtiesis successfully conducted while first receiversafety is maintained. 27INTEGRATION OF MILITARY SUPPORT INTO CIVILIAN HOMELAND RESPONSEThe role of the US military in national strategies fordefense and homeland security is undergoing rapiddevelopment. Specific capabilities within the Departmentof Defense (DoD) are driven by doctrine andpolicy promulgated from the Office of the Secretary ofDefense and operational orders from regional combatantcommanders. These directives shape the forces thatare organized, trained, and equipped by the servicesto support national strategic policies.The primary role of military medicine, to preservethe fighting force, provides a robust, capable, HSS infrastructurethat is mobile, responsive, and trained andequipped for operations in austere environments. Thisforce, which during peacetime provides routine healthcare for its DoD beneficiaries, must also incorporatethe needs and requirements for the post–September 11homeland defense, the global war on terrorism strategies,and response to requests through the NRP emergencysupport functions. As the policy and doctrinedrives development of specific capabilities, a balance isrequired between the goal of smaller, leaner forces withincreased operational tempos engaged in supportingthe strategies, and a repository of medical response inthe homeland for CBRN mass casualty incidents.Currently, military installations are required to developand implement CBRN capabilities for responseand recovery from terrorist incidents involving weaponsof mass destruction (DoD Instruction 2000.18). 28Capabilities developed for these requirements includedetectors; warning and reporting technologies;decontamination equipment; triage and treatmentprocedures; and command, control, and communicationoperations. Multiple programs with overlappingcapability requirements, including force protection, antiterrorism,and “all hazards” emergency managementdetermine specific capabilities. As all military hospitalssubscribe to the Joint Commission for Accreditationof Healthcare Organizations, local coordination for493