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

Medical Aspects of Chemical Warfaresequently reduce the incidence of cross contaminationto others. Early removal of the hazardous substanceis key to significantly reducing the dose of agent anindividual is exposed to. When early removal (withinthe first 15 minutes—ideally within the first 2 minutes)is not possible, later removal can reduce the effectsfrom a chemical agent but to a lesser degree. Removalat any time reduces the threat that others may be crosscontaminated.Patient thorough decontamination, performedbefore allowing a contaminated patient insidethe confines of a hospital, provides two benefits. First,it can potentially reduce the dose the patient receives,and, second, it protects hospital staff from exposure tothe hazardous agent and its vapors.In the United States, healthcare workers are the 11thmost common group injured in hazardous materialsincidents, but injury to emergency department workersis even more infrequent, only 0.2% of some 2,562events from 1995 to 2001 documented in the Agencyfor Toxic Substances and Disease Registry HazardousSubstance Emergency Events Surveillance System. 44 Inthese instances, the injured workers were not wearingrespiratory protection and suffered eye and respiratorytract irritation. 62Several studies and reports illustrate the need for thethorough decontamination of patients before hospitaladmission. Okumura et al 63 published a survey of thestaff of Saint Luke’s International Hospital in Tokyo.This facility was closest to the Tokyo subway sarinrelease and received 640 patients, the largest numberof victims from the event. The study indicated that 110staff members, 23% of the 472 medical personnel in thehospital at the time, reported acute poisoning symptomsincluding headache, blurred vision, dyspnea,nausea, and dizziness. None of the staff at this facilitywore respiratory protection, and none of the patientswere decontaminated in any way. Particularly affectedwere staff working in the hospital temporary triagearea, which was located in the poorly ventilated hospitalchapel, and those in the intensive care unit. 63Nozaki et al 64 conducted a retrospective studyof care providers at another facility, the UniversityHospital of Metropolitan Japan, who also attended tosubway victims. Of the 15 physicians who worked inthe emergency room, none wore any protective equipment;13 became aware of symptoms of exposure whileresuscitating two of the casualties. Eleven of thesedoctors complained of dim vision lasting several days,and eight showed significant miosis (pupils < 2 mm).Eight had rhinorrhea (runny nose), four had dyspnea(shortness of breath or tightness of the chest), and twohad a cough. Six of the symptomatic care providerswere given atropine sulfate, and one, who had morepredominant dim vision than the others, was alsogiven pralidoxime methiodide. Subsequent removal ofthe patients’ contaminated clothing and ventilation ofthe emergency room helped reduce exposure. 64 Table16-3 summarizes the signs and symptoms displayedby medical personnel at St Luke’s and Universityhospitals.Similarly, reports by Foroutan 65 indicate that unprotectedmedical staff caring for contaminated Iranianvictims of an Iraqi poison chemical gas bombardmentalso became ill. In one instance, a doctor and a nurseproviding patient resuscitation in a busy treatment areabecame dizzy, were short of breath, and had severeheadaches and cough. Within 5 minutes the remainderof the medical staff in the emergency room developedthe same symptoms, could no longer stand up, and hadto sit on the floor. The staff was evacuated to anotherhospital and the emergency room closed and ventilatedfor 3 hours. In this case both cyanide antidotes andlater atropine were administered, which reduced theproviders’ symptoms. 65Another documented relevant example took placein 2001 in the emergency room of a hospital in an agriculturalarea of Great Britain. Pesticides are among thetop choices for those committing suicide and homicide,particularly in agricultural regions of the world. 66 Aman who attempted suicide by ingesting an organophosphatepesticide was brought into the emergencyroom, where he vomited, causing a chemical spill. Theincident caused 25 hospital workers to seek medicalattention, and 10 complained of symptoms indicativeof toxic exposure. 67 These events illustrate the importanceof thorough decontamination for contaminatedpatients, prompt clean-up of pesticide-tainted vomit,and adequate protection, particularly respiratory protection,for hospital workers when vapor hazard fromcontamination exists.PersonnelPatient thorough decontamination operations arepersonnel intensive. Typically from 7 to 20 personnelare needed to staff decontamination teams, notincluding medical treatment personnel. In the military,with the exception of the US Air Force and someship-based units that deploy trained patient decontaminationteams composed of medical personnel, themilitary patient decontamination process is carriedout by nonmedical augmentees supervised by trainedmedical personnel. 3 In the civilian sector gross decontaminationis often performed by fire departments orhazardous materials (HAZMAT) teams, and thoroughdecontamination at medical facilities is carried out byhospital personnel assigned to perform the job as anadditional duty. 2,68540