Decontamination

Detail basic management procedures, including decontamination of a chemical agent attack on a health care facility.

A chemical event, whether it happened outside the hospital or where the hospital was the primary target would essentially be handled the same except within the hospital itself; adjustments would have to be made, since part of the hospital would be contaminated along with the personnel in contact with the agent.

Decontamination would have to be done internally along with on-going treatment in another area of the hospital, or moved to other facilities. If the contamination was confined to a portion of the hospital, the A/C and vacuum system would have to be shut down and the area closed. If the entire facilities was affected, as with a gas attack, the entire facilities would have to be evacuated and patients moved to another facilities and decontamination set up as described in the following discussion.

If the event was within the confines of the hospital then this would also present a security issue, since the perpetrator (s) may still be in the immediate area and could cause more problems unless identifies and apprehended. They could be planning a secondary attack so it probably would be better to evacuate the facilities and set up in another area.

Decontamination is the removal or reduction of chemical agents on an object or person. This may be done by physical means, chemical neutralization or detoxification. In the civilian sector it most probably would be by physical means, i.e. clothing removal and washing with soap/water or flour followed by wet tissue wipes.

Decontamination basically accomplishes two purposes: 1.Removes the contaminant from the person to prevent further damage. 2. Prevents chemical contamination of the hospital, therefore keeping the hospital “clean “for patient care.

Decontamination of chemical casualties is an enormous task. The process requires dedication of both a large number of personnel and a large amount of time. Even with appropriate planning and training, decontamination demands a significant amount of resources. The critical resources are PPE equipment, linen, multitude of staff to relieve on the various positions on the decontamination line, and security to protect the hospital and control the perimeter.

The most important and effective decontamination of any chemical exposure occurs within the first minute or two post-exposure. This is self- decontamination (probably not possible in the civilian sector). The military are trained in this procedure and have specific kits (M291) to accomplish this. In the civilian sector decontamination would have to be handled in the field by first responders or in a designated, equipped decontamination area near the treatment facilities or hospital. Because of the time frame it is almost impossible to do decontamination at the site of the event. By the time the first responders arrive and setup, those patients that can walk will self refer to the hospital and only the severely injured will be on-site for the first responders to treat.

I will assume that the first responders and hospital personnel have been trained in decontamination (hospital having had the FEMA course HERT) and have available equipment to accomplish this task when the event occurs.

The chemical used in the event could be pulmonary, cyanide, vesicants, nerve agents or incapacitating agents. The basic decontamination method for any of the above is irrigation with water and removal of clothing (removing clothing will in itself remove about 90-95% of contaminant). If the first responders arrive early on, a decontamination area, using two fire pumper trucks, can be set up parallel with tarp over the top to create a passage way, where patients can be directed and sprayed with water. This is not as good as if they were disrobed (which is not going to happen in the field) but it is better than nothing and will remove some of the contaminant.

Hopefully, the EMS system had practiced this scenario and have called the hospital and alerted them to the event and type of chemical, if known. The hospital should immediately lock down the facility, notify the HERT team, set up the preplanned decontamination protocol, and activate the HICS team’s CP with the necessary equipment.

The primary purpose of the decontamination at the hospital is to remove the contaminant from the patient prior to the patient entering the emergency room for treatment, thus keeping the hospital free from contamination (chemical).

All casualties coming to the hospital after a chemical event are assumed to be contaminated, even if decontaminated in the field, until certified to be ‘clean’ after passing through the decontamination tent. They are then checked by CAM (chemical agent monitor) and only if “clean” are they allowed into the ER. If found to still be contaminated they will be sent back through the decontamination line or spot cleaned and rechecked.

Of the possible chemicals used in a terrorist event, only vesicants and nerve gas might present a hazard problem within any open wound present on the patient.

The ideal decontamination set up at the hospital is listed in bullet format.

1. First responders to scene, decontaminating the patients with water, if possible. Assess the scene as to what happened, number of casualties, type symptoms, describe the event (fire, explosives, gas release, etc., inform the hospital what type injuries to expect), number of survivors and deaths, agent used, if possible, severity of injuries, and start triage. I assume the first responders will be fire, police and EMS, so the appropriate authorities will be notified and disaster plan put into effect.

2. Notify the hospitals as to findings in #1. Notify the command center and declare a MCI alert

3. Hospital locks down with security at each entrance; one controlled entrance for patients and one entrance for call- in staff.

4. CP set up in hospital. HICS operational–operations, planning, logistics, and finance/records.

5. The Safety Officer, a part of the command staff and reports to the IC, is a key player in the decontamination process. He should monitor the entire process to insure safety for the hospital personnel as well as the patients. He has the authority to stop or change any unsafe operations.

6. Hospital Emergency Response Team (HERT) activated and begins setting up decontamination equipment in the ER area, about 30 meters from the entrance.

7. Check the weather and set up decontamination tent downwind from ER entrance if possible.

8. Maintenance sets up traffic barriers to have one way entrance to ER. Egress routes established-one way in and one way out. Routes are needed for both vehicles and foot traffic.

9. Notify wrecker service (previously arranged by mutual agreement) to stand by to move any vehicle that blocks the roadway.

10. Perimeter established around hospital to keep on-lookers and the “worried well” outside the area.

11. Security (armed with live ammunition) where ambulances and people enter to check for weapons or explosives. (Hospital is good secondary target.) At this point have barriers arranged in a manner that patients will be funneled into the registration area. Ideally, the entrance where security is checking the patients and ambulances should be at least 50 meters from decontamination area.

The patients will then be triages into immediate, delayed (walking wounding), non ambulatory, and green (no decontamination needed). From here they will proceed to the disrobing area and segreated by gender.

12. The decontamination tent is set up about 30 meters from ER entrance. There will be three separate lanes through the tent.

· Patients with ALS needs. They will be taken immediately to a special room in ER for ALS care and decontamination

· Patients that can walk through the decontamination line and soap and wash themselves

· Non ambulatory patients that requiring direct assistance for decontamination by hospital personnel.

13. All personnel on the decontamination line would have PPE level C, which consist of:

· PAPR with loose fitting hood and appropriate filter cartiage.

· Full face shield

· Chemical resistant suit

· Waterproof, chemical-resistant boots.

14. At the decontamination entrance point there would be personnel to:

· Register patients

· Take all personal items from patients and secure with I.D. tags.

· Geiger counter to check for radiation

· All clothing removed, bagged and labeled “contaminated”

· All children under 6 Y.A. stay with mother regardless of sex. All above 6 years old go through the appropriate line.

· Ambulatory patients can use soap and water in showers

to wash, under the direction of hospital personnel.

· All non- ambulatory patients will be disrobed and placed on a conveyer line that will have six personnel to scrub bodies with soap and water along with pressure showers with a rate of one person/ seven (7) minutes.

· At the end of the decontamination line personnel will check each patient to assure decontamination is complete. This will be done with M-8 paper, M-9 tape and CAM (Chemical Agent Monitor). Placed in hospital gowns and if certified “clean” moved into the ER for treatment, and if not, spot cleaned or returned to the decontamination tent for re- showering.

· Although OSHA will give some leeway on disposal of contaminated waste water during an emergency, it is critical that the hospital develop decontamination and waste water containment plans.

· All reasonable measures must be taken by the hospital to capture waste water runoff.

15. As any time in the above process there is an ALS problem with the patient, it is taken care of at that time. If necessary, to address life threatening problems, transfer to an isolation unit in the ER for treatment.

16. The personnel on the decontamination line cannot stay in the PPEs, depending on the temperature, over 30-45 min. The planning section in CP should be setting up a relief schedule with the personnel for rotation on the decontamination line.

17. Logistics should be inventorying linen and if they do not have enough for the event start calling supplies since this is a “choke” point in the process.

18. At the entrance point it is always prudent to have a psychologist and/or social worker to meet the patients, and if necessary, address emotional problems with disrobing. (It is said “why would anyone complain about disrobing if the decontamination will save their life”. This is a flash point, when you separate families and you ask a wife to disrobe with her husband there. Be prepared address the problem or the line will stop there.)

19. If the chemical event happened in the hospital the same procedure for decontamination would take place but the facilities would have to be rearranged. The areas that were contaminated would have to be closed off or cleaned. The contaminated personnel would have to go through the decontamination line set up at the ER entrance.

20. If a patient has an imbedded object or an open wound, the area should be irrigated and covered with a marking to indicate imbedded object. Only a doctor should remove the object, either in the decontamination line or in the hospital.

21. When the event is declared over, the decontamination equipment and the decontamination area must be decontaminated and this is usually done from the clean area to the dirty area.

22. The event is not closed until all personnel in the HICS CP concur.

23. An AAR should be held at some point after the event.

24. Algorithm for Chemical Decontamination In a Hospital Setting. This setting can be changed to fit the geography of the hospital.

25.A recommended list of equipment for patient decontamination is attached:

· Staff PPE

Full face shield

Hood or hair covering

Gloves

Water repelling gown

Rubber boots

· Equipment list

Waterproof triage tags

Sealable plastic bags, size small & large to accommodate belongings and clothing

Paper bags

Labels

Permanent marker

Mild soap

Sponges

Long handle brushes

Buckets

Hoses with gentle flow, controlled nozzles with hot and cold water

Showers—multiple heads

Plastic pallets to prevent slippage (minimum of three)

Water contamination/collection system

Gowns and /or suits for patients to don post decontamination

Towels and blankets

Self Decon “trash bag” kits

Tents or pre-fabricated decon tents

Modesty screens, portable screens

Rope and tarps, barrier tape

Duct tape, scissors, traffic cones, megaphones, plastic totes for hospital equipment

Laminated decon instructions in different languages ( community specific)

References:

1).Medical Management of Chemical Casualties Handbook U.S. Army Medical Research Institute of Chemical Defense (USAMRICD) Aberdeen Proving Ground, MD. 3^rd ed. 2000

2.) Textbook of Military Medicine: Medical Aspects of Chemical and Biological Warfare Office of Surgeon General 2005

3.) Hospital Emergency Response Team (HERT) FEMA Ft. McClellan, Ala. 2006

4. ) Hospital and Healthcare Systems Disaster Interest Group. Califormia Emergency Medical Services Authority 9/2004

www.emsa.ca.gov/dms2/recommendations.doc

Nuclear Terrorism

1. How readily do you feel terrorist can acquire nuclear weapons?

Ferguson writes in his book, “The Four Faces of Nuclear Terrorism”, maintains “that there is a greater likelihood today than at any time in the past three decades that nuclear weapons will actually be used”. Acquiring high risk radioactive material is a certainty, therefore a radiological attack appears to be all but certain within the coming years.

The acquisition and use of a nuclear weapon depends on the type and the chances of a nuclear even occurring are from highly possible with minimum effect to highly improbable with devastating effect.

My personal feeling is that the USA will be hit by a nuclear device in the form of a “dirty bomb”, delivered with a conventional explosive within two years or less.

There are four possibilities:

· Nuclear device with plutonium and/or uranium (nuclear bomb).

There are two types: 1. Simple “gun type” as used in Hiroshima, killing over 100,000 people. This device is simple and reliable and easy to make, but requires approximately 100 pounds of HEU, which is very abundant on the world market. There is an unknown amount in Russia, mostly unsecured.

During the Manhattan Project the scientist were so confident that the bomb would work that it was not pretested prior to dropping over Hiroshima. A knowledgeable terrorist could build this type and “drop it” without pretesting.

The device is a 76. 2 MM anti-craft barrel, 6.6” wide, 6 feet long, weighting about 1000#. Cordless power can be used to propel a 56 # HEU bullet into a 85# HEU target. The down side is that, with all the regulations and detective devices in place, HEU is hard to obtain in the required purity to make a bomb. One needs 95% pure HEU for the bomb to work. The probability of making this device is low but the results would be devastating.

The second type is the implosion type nuclear device. This type of device uses weapon grade plutonium, composed of isotope 239, was dropped on Nagasaki. A shell of WGPU is surrounded with chemical explosives arrayed to produce a symmetrical inward moving (implosion) shock wave that compresses the plutonium enough to be supercritical. This device is very difficult to make and requires experts and many days, plus it has to be tested; making it highly unlikely that a terrorist organization, without the backing of a country could build this type weapon. Also the plutonium required would be extremely difficult to obtain, although it is thought that plutonium is available in Russia, N. Korea, and Pakistan. Plutonium is much easier to detect with radiation sensing instruments since it has “Identity” as opposed to HEU, which gives off very little“identity”.

· Improvised nuclear device (IND). This device would use HEU or Plutonium but not used in the type of mechanism described above. This would be a crude nuclear weapon with less explosive power, but still dispense radiation.

· “Dirty bomb”. Conventional explosives with radioactive material attached. This type devise is the most likely weapon to be used by the terrorist simply because the conventional explosives are readily available and the radiation material is also available all over the world in the medical and commercial sector. The isotope material that is most desired in a “dirty bomb”, due to its radioactivity, half life, and availability is: Cobalt 60- ½ life 5.3 years; Cesium -137 ½ life 30 years; Indium -192 ½ life 74 days; Strontium 90 -½ life 29 years; Americium ½ life -433 years; Plutonium ½ life -88 years; Radium -½ life 1600 years. The most probable one that will be used is cesium chloride (power form) which is very plentiful.

Depending on the area where the devise is used and the element used, an event causing very few deaths could make the area uninhabitable for 5-1600 years. The psychological effect on the population would be devastating.

· Attack or takeover of a nuclear power plant. A nuclear power plant uses less pure HEU for the reactors and with the safeguards build into the operation, even if there was a malfunction it is impossible for the core to reach a supercritical mass which is needed for (fission) a nuclear blast. True, as in Chernobyl, there could be a melt- down in the core and radiation released.

The destruction of a nuclear power plant would cause considerable damage. The loss of the plant itself and permanent or temporary loss of use of any co-located nuclear power reactors would cost billions of dollars. Wide spread radioactive contamination could lead to tens of billions of dollars loss to the economic sector, extensive property damage, and long term physical and psychological health effects.

A report of June 2004 by the National Commission on Terrorist Attacks upon the United States found that even though an attempt by al Qaeda in 1994 to purchase uranium failed, “al Qaeda continues to pursue its strategic objective of obtaining a nuclear weapon”.

Presently there are numerous sources where nuclear material suitable for a nuclear device can be obtained. The resource of greatest concern is Russia. Russia has tons of HEU and weapon grade plutonium, mostly under very thin security.

The Nunn-Luger bill addresses the problem by appropriating monies to help Russia secure and store nuclear material. The US is also hiring or placing, the critical scientist in the program in scientific or commercial establishments to prevent them from selling their knowledge to other rogue countries.

Another concern is Pakistan, which has nuclear capability.If one does a risk analysis; probability of an event multiplied by its consequence. The greater the probability or the greater the consequence, the higher the overall risk.

Nuclear terrorism experts generally agree that the nuclear terror acts with the highest consequence are the least likely to occur because they are the most difficult to accomplish. Conversely, those acts with the least damaging consequence are the most likely to take place because they are the easiest to carry out. Therefore using this analogy and with the information presented, I would say that the risk of a RDD (“dirty bomb”) happening in the USA within the next two years is high.

References:

1. Ferguson, Charles D., Potter, William C. The Face of Nuclear Terrorism Routledge: Taylor & Francis Group 2005.

2. Allison, Graham Nuclear Terrorism Times Books 2004

2. In the eyes of the adversary, assess an operation of such on the homeland. Include tactic, target, damage assessment and casualties, and response expectations by emergency services.

The players: al Qaeda agent (politico-religious); plot over a year time frame; material from Russia; HEU isotope 235 and cesium chloride 137 as secondary REW; HEU 235 very difficult to detect with present sensors if properly shielded; maximum 100#; “gun assembly” weapon, 6 inches in diameter by 6 feet long; placed in ship in Hong Kong with load of toys to US west coast—Los Angeles--; device on manual detonator via remote control from a member of the ship crew (imbedded suicide bomber). The purpose is economic, psychological, and symbolic destruction of an important seaport, along with a large number of deaths, making the area unusable for decades.

The black market in nuclear material is a known and proven fact since Russia split in the early 1990s and with unsecured nuclear weapons and unemployed scientists would help or sell their services to the highest bidder. An al Qaeda working in Russia, via the black market, obtained small amounts of HEU (isotope 235 and cesium chloride 137) from numerous dealers for large sums of money. He was buying in small amounts from many different sellers so he would not attract attention. The HEU was packaged and smuggled out of the country and eventually ended in a warehouse in the New Territory in Hong Kong. Here, technicians with nuclear experience, assembled a “gun assembly type” device, measuring 6’’ in diameter, and 6 feet long with conventional explosives at the end to propel a HEU 235 bullet into another HEU 235 mass at the other end of the tube. Also for backup a cesium chloride 137 REW that will detonate from the initial blast and increase the radiation level in the area. The detonator used was on a specific frequency that could be activated via an external source controlled by another operative (s) that would be an employee of the ship transporting containers of toys, destined for the port of Los Angeles, Ca. The device was placed in a lead box and also filled with toys to cover the device and stored in one of the 300 containers on the container ship. Since only about 2% of containers are checked prior to loading in Hong Kong, the chance of detection is almost impossible. The exact location of the device was unknown to the operatives carrying the detonation controls. In fact the operatives were told that the controls they were carrying were to make contact with other al Qaeda operatives in LA for another operation and the device was used to locate the unknown operatives on arrival in LA Harbor. The control was not to be activated until the ship was secured in the harbor.

If Hong Kong had the new X- Ray or gamma ray devices and scanned the containers, with the protection around the device they most probably would not be detected since only a small per cent of containers are scanned.

The ship sails for LA and on arrival would not be checked until in the harbor and then only when containers are off loaded.

On docking, the operatives would activate the radio device causing the “gun assembly” to detonate, thus atomizing the ship and destroying all within, at least, a one mile radius and killing probably 10,000 to 30,000 people. The cesium chloride 137 REW would be detonated via the initial explosion contaminating the area with cesium 137 (half life 30 years).

The EMT system would be over whelmed immediately and on approaching the site the radiation meters would go off the scale, making the approach, within 1 ½ miles of the scene impossible except for properly attired rescuers and then they would have to work in shifts to reduce the amount of radiation exposure received by each. The entire system would be totally overwhelmed for days.

The psychological effect would be unpredictable and the exit of people from the LA area would clog all the freeways and traffic would come to a standstill.

The economic damage would extend, not only to the US but to all other countries shipping goods into any harbor in the US, since the government would prohibit all container ships from entering any US port for a long time.

The economic effect would spread like falling dominos. Stores like Wal Mart, Target, etc that depend on shipments (China) from the Far East for their merchandise would be cut off, so with no stock, the employees would be furloughed and the economic fall-out on families and businesses would probably cause a recession if not a depression.

Within the last year there was a longshoremen’s strike in the LA shipping areas that almost put stories all over the US in depression stage since a large per cent of their merchandise comes from Asia. Just think what a nuclear event would do to the economy.

After the immediate effect had been controlled it would be very difficult, without foreign intelligence, to point to a specific perpetrator of the event although al Qaeda would probably be high on the list.

References:

1. Ferguson, Charles D., Potter, William C. The Face of Nuclear Terrorism Routledge: Taylor & Francis Group 2005.

2. Medalia, Jonathan Terrorist Nuclear Attack on Seaports: Threat and Response CRS Report For Congress #RS21293 Jan. 24, 2005

3. Stern, Jessica The Ultimate Terrorists Harvard University Press 1999

As promised, I would follow up my inital entry with an actual blog entry. Crazy I know, but alas, here I am. I decided today to write about some of my personal thoughts. As such, the best title for this post and aptly so, is "Living the Dream". It's funny how life is. You often have this vision of your future, you know, the rock star, unique and special snow flake, movie star, whatever it maybe we all have these visions of ourselves down the road. The next thing you know you're in your mid-twenties, wake up and your life is someplace you never even dreamed. For some, it's a train wreck, maybe a kid or two, some minimum wage job, others it's a decent life, married, maybe a kid and in a 9-5. I'll continue this post later...