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

Field Management of Chemical Casualties• providing mental health assets specific tochemical casualties and PPE utilization;• instituting waste recovery plans for decontaminationoperations; and• coordinating with supported and supportingagencies.Postattack, or recovery, measures consist of• practicing medical team recovery and stafftechnical decontamination;• monitoring for chemical contamination;• continuing patient evacuation if needed;• properly disposing of hazardous waste frompatient decontamination operations;• inventorying supplies and equipment andarranging for replacements; and• coordinating with supported and supportingagencies.The key for effective field management of chemicalcasualties is to develop a workable plan and train forthe event using real equipment and realistic scenariosappropriate for the location. In reality, MTFs must assumean influx of mass casualties and develop plansto effectively stabilize patients at smaller facilities andthen promptly evacuate them to larger facilities withgreater resources. Proper preparation for mass casualtyevents will ensure a smaller number of serious casualtiesthrough successful management.Casualties may sustain additional conventionalinjuries; for example, blast injuries may occur when anexplosive device is used to disseminate the chemicalagent. The following key objectives, which also relateto military HHS and FHP, should be the focus of anyfield management process:• Minimize chemical agent injuries.• Prevent aggravation of conventional injuriesduring care and decontamination.• Control the spread of chemical contaminationthrough decontamination.• Continue with the primary mission of caringfor patients not involved with the release.Personnel RequirementsThe process of field management can be personnelintensive, requiring between 12 and 50 workersto operate triage areas, emergency treatment areas,and decontamination lines. Personnel requirementsdepend on a variety of the following factors: ambienttemperature in which field management operations aretaking place, number of casualties, type of chemicalagent, level of fitness of medical and decontaminationpersonnel wearing PPE, and decontaminationequipment used.TemperatureA critical factor in the ability to sustain decontaminationoperations is temperature, ambient temperature,and, most importantly, wet-bulb globe temperature(WBGT). The WBGT is a composite temperature usedto estimate the effect of temperature, humidity, andsolar radiation on humans. It is used by industrialhygienists, athletes, and the military to determine appropriateexposure levels to high temperatures. TheWBGT index combines air temperature, humidity, airflow, and radiant heat data to provide a measure forthe risk of heat stress. Typically WBGT readings arebelow simple thermometer readings. For example, a78.9° F (26.1° C) WBGT could roughly be equivalentto an outdoor temperature of 95° F (35° C) in the sunor 98° F (36.7° C) in the shade. 34 WBGT measures bothradiant and evaporative temperatures. A variety ofWBGT devices can be purchased. Most units are lightweight,easily transportable, and have digital displays.An example of a WBGT is shown in Figure 14-5.Wearing protective ensemble increases the WBGTindex by 10° F (5.6° C). 3,4,33 Body armor (a possible requirementfor the military, but not normally for civilianmedical personnel) increases the index by another 5° F(2.8° C). 3,4,33 Protective clothing increases the heat loadon an individual because sweat from the skin is unableto contact air and dissipate heat through evaporation.The risk of dehydration, heat cramps, heat stroke, andother heat-induced injuries is greatly increased by thehot encapsulating protective gear, and water consumptionwearing a protective mask is cumbersome, if notimpossible. Many civilian protective masks lack anoral rehydration tube.A safety monitor should be appointed to preventinjury, especially heat-related injury, for teams wearingPPEs. 27 Handheld heat stress calculators are commerciallyavailable to assist in calculating the time thatindividuals should remain in PPE. 35,36 Both OSHA andthe military joint manual covering patient decontaminationemphasize the importance of preventing heatinjury. OSHA recommends periodically taking theblood pressure of workers wearing protective gear ormeasuring core body temperature; both are difficultto accomplish while the worker remains adequatelyencapsulated in protective ensemble in a contaminated,or potentially contaminated, area. 27 The militaryincorporates a program of work–rest cycles based onthe WBGT index reading (Table 14-2). During the restcycle, team members wearing PPE rest in a shaded area495