Patient Decontamination; A Last Line Defense Keeping EDs Open During Disasters
Christopher Wend
Today, we find ourselves in an era of escalating international and domestic tension. International conflicts like the ongoing Russian invasion of Ukraine, and domestic conflicts such as civil unrest have the potential to create situations that bring hazardous materials to the doorsteps of emergency departments (EDs). From chemical weapons and even nuclear weapon threats in Ukraine to significant riot control agent uses in the United States, and the ongoing possibility of accidental hazardous material (hazmat) incidents, ED patient decontamination strategies are becoming increasingly important. When patients present to an ED after being exposed to hazardous chemicals, biological agents, or even radiological threats, proper decontamination can be one of the most important actions taken by staff. Immediate decontamination and casualty management can single-handedly keep an ED open by preventing accidental widespread contamination of patients and personnel inside.
As seen historically, failure to properly decontaminate patients can be disastrous. In 1995, domestic terrorists released Sarin gas, a nerve agent, within the Tokyo subway system. Patients were rapidly transported from the scene without field decontamination. When they arrived at St. Luke’s hospital, only the most seriously ill were decontaminated. The hospital had no pre-planned decontamination areas, and the only personal protective equipment (PPE) staff wore were surgical gloves and masks, which are inadequate to protect against Sarin. As a result, approximately one-quarter of the ED staff showed signs of nerve agent exposure from secondary contamination. Exposures without proper decontamination can cause significant ED disruption even if they are not immediately life-threatening. Riot control agents like tear gas can lead to large numbers of ED patients covered in irritative, but not deadly, substances after usage in cases of civil unrest, which unfortunately has been significantly more common in the last decade.
Competency in field mass decontamination is standard for hazmat responders in the US and should ideally occur at the scene. However, decontamination capabilities are equally important in the hospital setting, as many patients are transported separately from emergency medical services. Most EDs have pre-planned procedures and trained staff to receive potentially contaminated patients but some still rely solely on local hazmat teams or fire departments to provide this service. In the wake of a disaster, when first responders are responding to the scene of incidents, EDs should be able to rapidly implement mass decontamination on their own. The best way to do this successfully is with ongoing training and preparedness. The Occupational Safety and Health Administration (OSHA) mandates those responsible for these tasks to have initial and yearly training. Federally funded training is available at the Center for Domestic Preparedness, but hospitals may need to go beyond once-yearly training to have sufficient proficiency.
In a time of rising hazmat threats, EDs need to be significantly more prepared to decontaminate patients if necessary. Hospitals should train regularly, and staff should have significant proficiency, not just minimum competency, in decontamination techniques. Universally, there needs to be an understanding that even a low index of suspicion may be appropriate to activate mass decontamination protocols to protect healthcare workers alongside the public. Allowing contaminated patients to enter the ED prior to decontamination could exacerbate an already catastrophic situation.
