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- Herausgeber: John Wiley & Sons
- Kategorie: Wissenschaft und neue Technologien
- Sprache: Englisch
Hazardous Materials Medicine Complete background on chemical exposures that create illnesses, including assessment, diagnosis, and treatment protocols Written on a level that can be understood by field practitioners and/or first responders, Hazardous Materials Medicine: Treating the Chemically Injured Patient provides an in-depth understanding of how to diagnose and treat toxic chemical exposures in a prehospital or emergency department setting. The protocols used in this book conform to the guidelines set forth in the NFPA 470 standard, and the medical guidance developed by FEMA for Type I, II & III Deployable Hazmat Response Teams. The hazardous materials medical protocols in this book have been fully vetted by three poison control toxicologists, multiple emergency physicians, and paramedics. Hazardous Materials Medicine: Treating the Chemically Injured Patient covers sample topics such as: * Scene assessment, to help determine the cause of the exposure, and exposure assessment, to determine what physiologic systems are affected * Toxic syndromes/toxidromes to appropriately treat the exposed patient, including corrosive and irritant, asphyxiant, cholinergic, and hydrocarbon and derivative toxidromes * Science behind a chemical exposure, to allow for a complete understanding of both the chemistry and physiology of what is occurring because of the exposure * Interfacing between the on-scene response team and the hospital, to ensure consistency and continuity of care from the field into the hospital Enabling public safety and health professionals to administer effective care while retaining their own personal safety, Hazardous Materials Medicine: Treating the Chemically Injured Patient is a must-have resource for emergency medical technicians, paramedics, hazmat technicians, and emergency physicians and nurses working in high-risk field situations with chemically injured patients.
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Veröffentlichungsjahr: 2023
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Table of Contents
Cover
Title Page
Copyright Page
Author Biographies and Acknowledgments
Foreword
Preface
1 HazMat Medicine and the HazMat Medic
Introduction
Situational Assessment Continuum
Summary
2 Exposures
Introduction
Patient Presentation
Respiratory System
Chemical and Physical Form of Respiratory Exposure
Types of Injuries Resulting from Chemical Exposure
Types of Chemicals that Injure the Respiratory System
Respiratory System Injury Recognition (Assessment) and Diagnostics
Cardiovascular Abnormalities Related to Exposure
Neurological Abnormalities Related to Exposure
Integumentary System (Skin)
Ocular Exposure and Injury
Gastrointestinal Exposure to Toxic Materials
Environmental Exposures
Summary
3 Toxidromes
Introduction
Assessment Capabilities
Toxidromes
Asphyxiant Toxidromes
Simple Asphyxiants
Chemical Asphyxiants
Cholinergic Toxidrome
Hydrocarbons and Derivatives Toxidrome
Etiological Toxidrome
Radiological Toxidrome
Associated Toxic Conditions
Summary
Reference
4 Event Conditions
Introduction
Summary
5 Hazard Identification
Introduction
States of Matter
Standards, Guidelines, and Acts Regulating Hazardous Materials
Basic Toxicology Definitions
Detoxification
Determining the Level of Medical Surveillance
Summary
6 Team Capabilities
Introduction
Technician Operational Considerations
Rehabilitation
Decontamination
Factors to Consider During Decontamination
The System of Detection
Detection and Monitoring Responses
Mass Causality Incidents
Mass Decontamination
Hospital Decontamination Considerations
Summary
7 HazMat Safety Officer
Introduction
Medical Assessment
Medical Surveillance
Team Exit and Retirement Physicals
ADA, Civil Rights, and Health Insurance Portability and Accountability Act (HIPAA)
Critical Incident Stress Debriefing
Developing a Medical Surveillance Program
Summary
8 Terrorism
Introduction
Terrorism Using Chemical Warfare Agents
Terrorism Using Biological Agents
Explosives and Incendiary Devices
Summary
Epilogue
Index
End User License Agreement
List of Illustrations
Chapter 1
Figure 1.1 All emergency responders/receivers should understand the conseque...
Figure 1.2 The hazardous materials medical technician program emblem has cha...
Figure 1.3 The Situational Assessment Continuum includes the evaluation of t...
Chapter 2
Figure 2.1 The routes of exposure (entry) include inhalation, ingestion, inj...
Figure 2.2 The toxidrome exam is a detailed physical assessment concentratin...
Figure 2.3 Movement of air from the nose and mouth to the alveoli. Various p...
Figure 2.4 Filtration of air from entry to the alveoli. Water‐soluble mucous...
Figure 2.5 The movement of oxygen and carbon dioxide into and out of the blo...
Figure 2.6 Oxygen is primarily carried on the red blood cell. Some oxygen is...
Figure 2.7 Respiration is required to produce cellular metabolism/combustion...
Figure 2.8 Comparison of particle size.
Figure 2.9 A high dose of a chemical over a short amount of time can cause t...
Figure 2.10 Inhalation of a chemical irritant causes swelling of the bronchi...
Figure 2.11 “CO
2
is the smoke from the flames of metabolism.” Ray Fowler, MD...
Figure 2.12 The waveform (capnogram) indicates the level of CO
2
found in exh...
Figure 2.13 The shark fin pattern on the capnogram indicates constriction of...
Figure 2.14 Skin represents the largest organ of the body by weight. Skin ex...
Figure 2.15 Skin acid/alkali injuries.
Figure 2.16 The eye is 1 in. in diameter with only one‐sixth exposed to the ...
Figure 2.17 A healthy eye is wet, has a clear iris with easily seen iris det...
Figure 2.18 Morgan lenses are easy to use and are the only way to provide tr...
Figure 2.19 Simplified example of the liver’s detoxification process. Other ...
Figure 2.20 Rehydration fluid is held in the stomach by the pyloric valve un...
Figure 2.21 A chemically exposed person who is also dehydrated is at greater...
Figure 2.22 During physical activity, heat is rapidly rising in the body. He...
Chapter 3
Figure 3.1 The quick reference cards are used to provide a rapid reference t...
Figure 3.2 Corrosives and irritants can be found in both industry and in the...
Figure 3.3 Corrosives and irritants will attack the skin and eyes. If vapori...
Figure 3.4 Simple asphyxiants can occur in any confined space where a gas re...
Figure 3.5 Hypoxia initially causes fast breathing and deep breathing.
Figure 3.6 Reflex bradycardia is a complex process that occurs when there is...
Figure 3.7 Rick’s hypoxic syndrome occurs when there is an exposure to a che...
Figure 3.8 Hypoxic syndrome signs and symptoms.
Figure 3.9 Asphyxiation causes cyanosis, shortness of breath, high blood pre...
Figure 3.10 Although every person reacts slightly differently, these are the...
Figure 3.11 Although every person reacts slightly differently, these are the...
Figure 3.12 Organophosphates and carbamates are used in farming and home pes...
Figure 3.13 Organophosphate poisoning is commonly displayed by several obvio...
Figure 3.14 The killer Bee’s of organophosphate poisoning are bradycardia, b...
Figure 3.15 Fuels and solvents fit into the hydrocarbon and derivatives toxi...
Figure 3.16 Hydrocarbons are CNS depressants displaying symptoms similar to ...
Figure 3.17 Etiologic agents causing infections are a concern for emergency ...
Figure 3.18 Responders need to understand the difference between bacterial a...
Figure 3.19 The process of pathogen invasion to infection is a multistep pro...
Figure 3.20 Radioactive sources are used in industry for a variety of reason...
Figure 3.21 Although signs and symptoms of radiation exposure rarely show im...
Figure 3.22 This image demonstrates the types of internal and external injur...
Figure 3.23 Every fire situation is different and the toxicity of each fire ...
Chapter 4
Figure 4.1 Container shape and design are intended to safely maintain the ma...
Figure 4.2 The Emergency Response Guidebook provides pictograms to assist re...
Figure 4.3 The DOT Emergency Response Guidebook provides guidance to all eme...
Figure 4.4 When placards are required on a vehicle, they must be placed on t...
Figure 4.5 Responders can access information by chemical name or United Nati...
Figure 4.6 The Emergency Response Guidebook provides placard clusters that w...
Figure 4.7 The NFPA 704 Marking System for alerting emergency responders to ...
Figure 4.8 The Emergency Response Guide is a quick reference that can provid...
Figure 4.9 The NIOSH Pocket Guide gives more detailed information than the E...
Chapter 5
Figure 5.1 Phosgene quick reference card.
Figure 5.2 Molecule activity in a solid, liquid, and gas.
Figure 5.3 Quick reference card for paradichlorobenzene.
Figure 5.4 The elements combining to make a compound with different chemical...
Figure 5.5 Calculating the vapor density of a gas when exposed to high humid...
Figure 5.6 When a chemical goes from a compressed (or cryogenic) liquified g...
Figure 5.7 Depending on the molecular weight of a chemical, the vapor pressu...
Figure 5.8 Exposure limits comparison.
Figure 5.9 Comparison between actue exposure guideline levels, emergency res...
Figure 5.10 Race and Gender as well as age and size can alter the intensity ...
Figure 5.11 This logarithmic curve represents the comparison between the NOA...
Figure 5.12 Dose response curve.
Figure 5.13 A ChemLine is established with the left side, at the dot indicat...
Figure 5.14 This ChemLine for acetone indicates the location of known chemic...
Figure 5.15 Adding more chemical property components the division between sa...
Figure 5.16 The areas of harm can be easily seen by color coding the ChemLin...
Figure 5.17 Naming sequence for cytochrome P450.
Figure 5.18 Liver metabolism is one form of detoxification and represents a ...
Figure 5.19 Using a hazmat risk spectrum is an efficient means of evaluating...
Figure 5.20 Acetone ChemLine for comparison.
Figure 5.21 Cyanide ChemLine for comparison.
Figure 5.22 By placing both hydrogen cyanide and acetone on the HazMat risk ...
Chapter 6
Figure 6.1 Team capabilities are generally related to funding, staffing, lea...
Figure 6.2 Physiological and environmental stressors are the two most overlo...
Figure 6.3 OSHA Chemical protective suit level designation.
Figure 6.4 Chemical suit comparison between NFPA 1991, 1992, and 1994.
Figure 6.5 Gross decontamination is the quick removal of the majority of a c...
Figure 6.6 Secondary decontamination includes chemical neutralization, disin...
Figure 6.7 When providing air monitoring, a detection strategy must be put i...
Figure 6.8 Quick reference of available technology for hazardous materials r...
Figure 6.9 The SB triage system is based on chemical influences on the body ...
Figure 6.10 As with STEMI, stroke, and trauma alerts, the HazMat alert gives...
Figure 6.11 In most communities, hospitals have the ability to set up mass d...
Figure 6.12 Alternate/Temporary Medical Care Facilities can be set up anywhe...
Chapter 7
Figure 7.1 Utilization of a medical history form will ensure that all pertin...
Chapter 8
Figure 8.1 FBI's shelter and evacuation chart based on the size of the suspe...
Figure 8.2 FBI's evacuation chart based on an improvised explosive device in...
Guide
Cover Page
Title Page
Copyright Page
Author Biographies and Acknowledgments
Foreword
Preface
Table of Contents
Begin Reading
Epilogue
Index
WILEY END USER LICENSE AGREEMENT
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Hazardous Materials Medicine
Treating the Chemically Injured Patient
Richard Stilp
Armando Bevelacqua
Copyright © 2023 by John Wiley & Sons Inc. All rights reserved.
Published by John Wiley & Sons, Inc., Hoboken, New Jersey.Published simultaneously in Canada.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per‐copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, (978) 750‐8400, fax (978) 750‐4470, or on the web at www.copyright.com. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, (201) 748‐6011, fax (201) 748‐6008, or online at http://www.wiley.com/go/permission.
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Library of Congress Cataloging‐in‐Publication Data applied for:
Hardback ISBN: 9781119663928
Cover Design: WileyCover Image: Courtesy of Chris Hawley
Author Biographies and Acknowledgments
Richard’s Biographical Information
Richard Stilp, PM, RN, MA. Richard completed his fire service career in April of 2018 as the Fire Chief of St Cloud Fire Rescue in Central Florida. He began his career in the fire service in 1976 on Orlando Fire Department where he rose in rank to District Chief and served as a paramedic from 1978 until his retirement. During his tenure on Orlando Fire Department, he worked on his off‐duty days as an Emergency Department Registered Nurse at several hospitals in Central Florida and taught Paramedic School at Valencia College. Currently, he is the owner of Emergency Management Systems, Inc. consulting company, serves as the Vice President of the Florida HazMat Symposium, and a member of the NFPA Hazardous Materials Technical Committee.
After retirement from Orlando FD in 1999, he served as the Corporate Director for Safety and Security for Orlando Regional Healthcare Hospitals, Executive Director of the Central Florida Fire Academy, and Regional Hazardous Materials Coordinator for the Urban Area Security Initiative for Region V.
As an author, Richard has authored a number of technical/text books related to hazardous materials response and terrorism preparedness. In addition, he has published a number of articles for both fire and nursing professional publications.
Richard holds an Associate in Arts, an Associate in Science in Nursing, a Bachelors of Arts in Business, and a Masters of Arts in Management. He is a Fire Instructor III and a Master Exercise Practitioner (MEP) through FEMA.
Acknowledgments
After a lifelong career in the fire service, it is difficult to thank every person who had a significant impact in my work life and the completion of this project.
First and foremost, to my writing partner and friend Armando “Toby” Bevelacqua. From the day we were put together on Orlando Rescue One, we immediately began collaborating on different projects. Those projects have continued for 40 or so years. Although technically my friend, Toby is more like my brother. We may disagree and even fight over our differing thoughts or styles but in the end, we come to neutral ground. I will always love this guy. Thank you for being a great friend and fellow collaborator.
Lieutenant Gary Bass, my first real lieutenant who showed me the importance of continuous training to be the best I could be. “Don’t just practice until you get it right, practice until you can’t get it wrong!”
District Chief Leo Wright who always stood up for the firefighter paramedics in the early days when they were viewed more like a red‐headed step child instead of part of the team. He always saw the value in the concept of a heavy rescue that was specially equipped and staffed with well‐trained firefighter/paramedics who were dedicated to all special operations within the department. Leo was never afraid to make a decision and his command presence was second to none.
Joe Landerville, a friend from a different department, who directed me to the first IAFF hazmat train the trainer program and started my career in hazardous materials training that has carried me across the country and beyond. The IAFF hazmat leadership recognized the value of the medical side of hazmat response and provided me the opportunity to both develop and teach hazmat programs across the county. It is also the only job that I was ever fired from, but that is another story. Politics makes strange bedfellow, and destroys them as well.
Doctor Robert Duplis who supported some crazy ideas and backed the hazmat medical project from the beginning. Although you are gone, you will never be forgotten.
Doctor Todd Husty who authored the foreword for this book. Dr. Husty has always kept the health and safety of his paramedics above all. He supports all aspects of this program and has been a friend for many years. As a medical director, there is no one finer!
Although I love the field of hazardous materials response, I have always focused on the medical aspects of hazardous materials. This is different than most of the other hazmat instructors teaching on a national level. Many of those who teach other hazmat subjects have embraced my focus and supported me along the way. They have always had the insight to recognize that a knowledgeable hazmat technician with medical/toxicological background is an asset to any team. Those friends and great hazmat instructors include (in alphabetical order):
Bob Bradley
Chris Hawley
Mike Hildebrand
Joe Leonard
Greg Noll
John O’Gorman
Bob Royal
Greg Socks
Jason Waterfield
And finally, to Rick Edinger who had the confidence to place me on the NFPA Hazardous Materials Committee so I can participate in the development of national hazardous materials standards and continue to participate in the advancement of this field on a national level.
Armando’s Biographical Information
Armando Bevelacqua PM, BS, is a 37 plus year veteran of the fire service. He is the recipient of the 2010 “In the Zone Award,” the “Level A Award” for leadership service and support in education of the hazardous materials first response community, and the “Dieter Heinz 2016 Instructor of the Year Award.” He retired from the City of Orlando Fire Department, Florida, where he served as the Chief of Special Operations, Homeland Security, and Emergency Medical Service Transport. Armando also teaches at local colleges, instructing Fire and EMS classes. He writes freelance, publishing articles and educational textbooks. He has published with topics on report writing for EMS responders and a chemistry book geared for the first responder. He has presented nationally on several issues in the disciplines of technical rescue, EMS, hazardous materials, and management. Armando lectures to fire departments throughout North America and Europe. He is an adjunct instructor through the Department of Defense as well as with several federal agencies involved with force protection.
Chief Bevelacqua serves on several federal, state, and local committees. He held membership to the Inter‐Agency Board (IAB) for training and exercise development discussing issues affecting USAR and HazMat deployment, and training as it relates to terrorism. He serves as a member of the NFPA 470 (472, 1072, 473) and 475 Technical Committees and the ASTM standards development committee for emergency response. Chief Bevelacqua has assisted in the development of standards and protocols such as the Rocky Mountain Poison Control for the development of standardized medical protocol for the WMD event and for the State Department for WMD training embassy delegates.
His latest endeavor is to create educational videos and comics for the first response community. Educating new and seasoned responders to the ever‐advancing technologies that are entering the first response arena.
Acknowledgments
It has been a long while since I have thought about the day that I stepped into my first emergency responder‐related course. I truly did not understand the ramifications of what would become a lifelong career. Not sure what draws individuals into this journey but I am so glad to have been a part of the early days of EMS and my career as a firefighter and eventually as a chief officer.
We sometimes do not consider those that came before us, or stood shoulder to shoulder with us, how they have had an impact on our lives and career, and to that end is a short list of those that have had strong influences on my career. These are just a few because there have been so many: Dr Eugene Nagel who taught segments of my then EMT II class, Dr. Armando Garcia ACLS Instructor, and emergency room physician, Dr. Barth Green who taught us how to properly support a spinal injury, Captain Randy Boaz City of Miami Fire, Chief Bernie Tillson Boca Raton Fire, Chief Ed Hesse Orlando Fire, Terry McGowan, John “Sal” Saltalamacchia, and Oscar Grimes to name a few. But what these individuals did for me is they made me not only want to be a better medic and in some cases forced me to be a better responder as a whole.
I would also like to thank some of my HazMat brothers and sisters that over the years have made me think about responses in a different light. Many responders have influenced some of my work over the years or have contributed to the work contained herein such as Kristina “Krissy” Kreutzer PhD. Her work with Risk Assessment and how to look at hazards made it simple to “see” toxicity. She would often challenge me in the classroom, until I told her that she should be in the front of the classroom. A few years later she was and delivered her concepts of hazard assessment to the fire service. Thank you Krissy for your work and service. We lost Krissy a few years ago may you RIP my friend. I miss your response challenge questions.
Another hazmat friend was Ludwig Benner. Often, I would call or email Ludie, to give me his thoughts on a subject. Although he would always remind me that he was not a responder, he always had an interesting twist on a process, concept, or idea, many hours where spend talking about hazmat with him. During the writing of this book, I would discuss concepts and ideas about basic hazmat principles and concepts of response. Ludwig passed during the editing process of this manuscript; I miss our discussions tremendously my friend.
Thank you, Chris Hawley, for helping me with writer’s block, our discussion in the hallway at the Florida conference was exceedingly valuable. Chief Bob Royall for his support on just about anything I come up with (just do not call him out when you are the key note – although the deer in the headlight look was priceless). Mike Hildebrand and Greg Noll for their inspiration to write and get involved. Thank you for the friendship. Christina Baxter for her work on PPE and contribution to this book in Chapter 7. I think she learns from us as much as we have from her. Mike Callan for his down to earth approach to hazmat response, his concept of safe, unsafe, and dangerous inspired the chemical time line, thanks Mike for all you do and all your help over the years! Robert Cruthis thank you sir for your additions to the Triage piece and your review of the SOP and of course Al Valerioti for his CAMEO contributions. Thank you sir.
Over the years countless responders have called, emailed, approached me at conferences and during class, asking questions. All these questions have been much appreciated, as many times my response to the responder was “I don’t know but let me find out.” To all of these people a sincere thank you as you also helped me learn and grow within this discipline. To all the responders that have actually used the information contained herein, thank you for learning a new approach toward prehospital care. Continue your learning, keep asking questions!
Of course, Rick Stilp my partner on Heavy Rescue 1 during this journey from the beginning to date and the coauthor of this book and many other works. Our conflicts and discourse on many topics along with the heated discussions have definitely made me consider other methods and approaches to different problems and ideas. Thank you for the lifelong friendship.
And lastly, my wife Mary Michelle she puts up with some of my most esoteric discussions (which has in some cases led to some very interesting projects), but most important her support on this project. The long nights of research while writing this edition, sometimes during a vacation which would occur because of something I would read or a dot I wanted to connect, thank you for allowing me to think through the process. Additionally, thanks for allowing me to verbalize my frustration at times, but most important allowing to do my work as a whole.
Additional Recognition
Jointly, the authors would like to thank those who have played a big part in this particular project:
Thanks to Chris Pfaff for supplying excellent hazardous materials related photographs for this text.
Thanks Chris Hawley, our good friend for his contribution for the cover photo and so much more over the years.
Butch Loudermilk who has always been a behind the scene supporter. He always has something great to say and has provided the authors with great review of the subjects in this book.
Robert Cruthis who has, on many occasions, taught with the authors and has continuously provided great insight and enthusiasm for this project and many more.
Don Guillette, the most talented paramedic instructors we have ever met. Don is known in Florida as the “Capnography King.” He is a great cheerleader for this program and has attended more of the authors’ classes than any other student over the years.
Foreword
I teach a lot and have done so for a long time. Emergencies, including prehospital emergency medicine, is my specialty. But sometimes what I teach is more basic.
I teach that a true professional knows what they know and knows what they do not know. A true professional embrace that concept without shame but actually, with pride. That is because a true professional may not know everything but we know where to find the answers.
And I can say with authority that I do not know enough about hazmat! I mean, I really do not know enough about hazmat!! But I know where to find out!!! Right here in this book!
But it is more than just a resource. This book should be a reminder that although, we who practice emergency medicine in a prehospital or in‐hospital setting may not know everything there is to know about hazmat. We need to recognize and remember that our patients and the scenes we run on may have a toxic source.
I teach all levels of practitioners to the concept of a differential diagnosis. After the chief complaint/presentation, the history of the present problem or illness (OPQRST, etc.), and some observation and/or physical examination, we should have a list of likely suspected conditions that are causing our patient's difficulties. That is how we will ultimately arrive at a final diagnosis. And yes, paramedics make presumptive diagnoses or else you cannot use any medications in your drug box. The problem is, in the heat of battle or in the middle of the night, or with highly anxious and distraught family members around, we sometimes forget those things that should be on our list, on our differential.
An important basic medical concept is that if a patient is exhibiting signs and symptoms that are not consistent with diseases and conditions that we are familiar with, we should investigate what substance may be causing the problem. Frequently, these are side effects of medications. I have made a lot of house payments based on side effects of medications! But this is how we also spot that toxic problem. Someone who is turning blue and cannot breathe for apparently no reason is pretty suspicious.
But it is more than that. I am always impressed with how complicated it gets out there doing prehospital emergency medicine in uncontrolled environments. It can be dangerous. It worries me for everyone but it is even worse since my middle kid became one of my paramedic firefighters. When you have skills testing/scenarios, the first words out of your mouth is “scene safety.” But are you really thinking that as you are absorbing the pesticide through your own skin or you are running into a subway filled with sarin? Do we really check our situational awareness at each scene and with each patient? Your world is dangerous enough. Please be careful and remember your hazmat lessons.
I am so sure that I do not know everything about hazmat, that one of my assistant medical directors is an occupational medicine and a hazmat specialist, Dr. Stan Haimes. As good as he is, he still does not know everything! That is why we have protocols that include calling the poison center and that is why we need Rick and Armando. Thank you for the resource that you have created but thank you even more for the reminder of the importance of hazardous materials in our profession.
Todd M. Husty, DO
Office of the Medical Director
City of Lake Mary, City of Longwood,
City of Maitland, Orlando/Sanford Airport,
City of Oviedo, City of Sanford,
County of Seminole,
Seminole County SWAT, City of Winter Springs SWAT
Preface
There is a never‐ending argument concerning the provision of medical care. Is the practice of medicine an art or a science? Physicians have argued this for over a century. And of course, there is no real answer. Both can be debated. What is apparent is that the provision of medical care at all levels, from basic EMT to skilled surgeons requires the learning and understanding of anatomy and even more importantly, physiology. It takes both understanding the science to comprehend the intricate workings of the body systems combined with the art of intuition to know when a patient is in medical trouble. The field of Hazardous Materials Medicine is no different.
Unfortunately, there are numerous reports and case studies that have revealed that a healthcare provider failed to understand the seriousness of a chemical exposure only to see the patient’s condition deteriorate. Victims have been misdiagnosed and not treated with the care necessary to make them well or to reduce the physiologic damage that will continue if the treatment is not effective. Many times, these exposures and the resulting injuries require the initial care of first responders who are dispatched to the scene of the incident. These field EMTs and Paramedics are generally very well trained in the recognition of medical, cardiac, and trauma‐related issues. But their training and experience is lacking when it comes to chemical exposures. Then, to make matters worse, emergency department providers also may lack the knowledge and experience to quickly and efficiently treat the victims of chemical exposures.
This book is a culmination of over 40 years of effort by the authors. Upon development of fire department‐based hazardous materials response teams in the 1980s, the authors realized the need for additional education and training in case one of the hazardous materials team members inadvertently got exposed during an emergency response. The effort started by developing training that was specific to the chemicals found within their city, especially in industry. This initial list of chemicals was somewhat short.
It did not take long to realize two important factors that would change the overall objective. First, the main interstate highway and a major railroad, both going east and west through their city carried almost every imaginable chemical used in the state and that interstate highway has a long history of being the most dangerous highway in the state. This broadened the list substantially. Second, and possibly more importantly, realizing that the majority of chemical exposures were not taking place at hazardous materials emergency scenes. Instead, they were taking place in homes and small businesses within the community. These exposures normally did not cause injuries to a group of people but, most of the time, it involved only one or two victims.
The goal of the initial training was to teach not only the recognition of various signs and symptoms associated with chemical exposures, but also to educate the medical responders about the physiology associated with the exposure. When specific treatments were taught, the students also had to understand the physiology of the therapy involved. With buy‐in from the department and the medical director, a program was developed and presented. Word of this new program reached outside of the authors’ department and soon surrounding departments were requesting the training. The program grew from there. To the author’s knowledge, it was the first hazardous materials medical program offered in the United States and today, the longest standing program in the country. All other programs in the country were based on the work previously done by these authors.
An earlier book, Emergency Medical Response to Hazardous Materials Incidents, was published to place the hazardous materials medical program in a more formal package. Although this book was basic, it was well ahead of its time. Many paramedics stated that they had never heard of a program to teach prehospital responders how to treat chemical exposures. Unfortunately, many did not care. These exposures did not happen often and some paramedics were very happy only treating the symptoms that were initially noticed without understanding why they were occurring. But times have changed and now the thirst for knowledge has increased and the occurrences of chemical exposures have multiplied.
Although there have been other publications on this subject, none contain the depth and detail this text contains. It has always been the desire of the authors to present information that is complete and detailed but in a format that is understandable to the reader. This has always been a challenge but one that has been taken very seriously. This text represents a body of work that is relevant, understandable, important, and ready for those eager to expand their knowledge and skills in providing medical care to those exposed to hazardous agents.
1HazMat Medicine and the HazMat Medic
Introduction
The late 1950s and into the early 1960s brought innovation to prehospital care as we know it today. These were the “wild west” days of a new concept called EMS (Emergency Medical Services). Many early pioneers of EMS had the vision to recognize that the lifesaving efforts typically done in the hospital setting could be accomplished in the field.
Because of the death of his daughter, Dr. Safar trained and organized one of the first prehospital EMS services in the country. While working in Pittsburg, he rigorously trained a group of ambulance attendants over nine months and in 1968, put these highly trained prehospital care providers to work. These ambulance attendants operated out of Pittsburgh's Presbyterian and Mercy Hospitals. They were instructed to manage airways, start IVs, deliver babies, and interpreted EKGs. They were known as the Freedom House Ambulance Crew. They were indeed the first civilian‐trained paramedics in the country.
In 1974, the University of Pittsburg received a grant from the U.S. Department of Transportation to create a curriculum for nationwide emergency medical services. Dr. Safar and Dr. Nancy Caroline developed the standards for education, training, ambulance design, and specialized equipment.
A few innovations that occurred simultaneously contributed to a new standard for prehospital medical care. Dr. Karl Edmark perfected the heart defibrillator, giving rise to the Seattle Fire Department Medic One, a rescue program in 1970. At the same time, the revolutionary “LifePac” was being developed by Dr. Peter Safar from Pittsburg. Dr. Safar and Dr. James Elam developed the understanding and application of what was called the ABCs (Airway, Breathing, and Circulation) of CPR (Cardiopulmonary Resuscitation). All of these developments contributed to the foundations of EMS and the new emerging field of prehospital care.
Meanwhile in Florida, an electrical engineer‐turned anesthesiologist, Dr. Eugene Nagel was looking at the fire department as a community resource to provide initial prehospital care. He convinced the Miami Fire Department, because of their strategic locations within the community, to have specially trained firefighters with these new lifesaving techniques and equipment to respond to medical emergencies. Radio communication equipment was provided so that the field providers could talk directly to a physician in the hospital and receive critical guidance at a medical emergency. In 1964, Dr. Nagel became the medical control officer (Medical Director) for the City of Miami Fire Department.
Other leaders in this field were Walt Stoy, PhD, for his contribution of education materials and systems design, and Fire Chief Jim Page, a Battalion Chief with the Los Angeles County Fire Department and founder of JEMS (Journal of Emergency Medical Services) Magazine. Chief Page paved the way for development of EMS as a discipline. He also served as a technical consultant to the TV show “Emergency.” All had a hand in developing field personnel providing advanced prehospital care that later held the title of “paramedic.”
In the 1970s, the television show named “Emergency” started to play on Saturday evenings. The show featured emergency calls of all types but focused on emergency medical calls. The two lead actors portrayed the paramedic/firefighters Jonny Gage and Roy Desoto. These two treated everything from trauma patients involved in a car accident and rattle snake bites to cardiac arrest. This show was a great propelling force to bring advanced prehospital life support to every community in the United States. The viewing audience witnessed what could be accomplished by well‐trained and skilled paramedics. The public's expectation that ambulance attendants could save lives before the patient reached the hospital increased across the nation and raised the bar for prehospital medical care.
Both of the authors of this book became paramedics in the 1970s. In the early days of EMS, many agencies struggled to get enough paramedics trained to provide these advanced skills. Training standards were not consistent across the nation and largely depended on what the local physicians wanted their prehospital providers to know and what skills to perform. A paramedic in the City of Chicago was different than a paramedic trained in Miami. In fact, in some areas of the country, paramedics were called EMT IIs and not paramedics at all.
As this medical specialty grew in popularity, new radio systems were being introduced that allowed prehospital providers the opportunity to talk to an emergency room physician and send an EKG tracing over the radio waves. Cardiac defibrillators became more portable. Suddenly, the role of the advanced life support provider became more technical and required more knowledge to provide the best prehospital care possible.
At almost the same time, the field of hazardous materials response began to take root. There were more and more industrial accidents involving chemicals occurring both in facilities and along transportation routes. Highway crashes and train derailments often made the news because of the fires, explosions, injuries, and deaths that they caused related to the hazardous cargo.
Just as fire departments welcomed the new field of emergency medicine, they also embraced the field of hazardous materials emergency response. It would seem logical that there would be a blending between the two specialties that had found their way into the fire service. But that has not been true in the past. Seldom was there a focus of hazardous materials exposures being a subject of emergency medical training.
The paramedic curriculum has always included exposure to carbon monoxide and sometimes even went as far as teaching the pathophysiology of pesticide poisoning, but that was about it. Those EMS agencies, whether they are fire department based or not, found themselves responding to industrial, farm, highway, and railroad incidents where victims were contaminated and sick from chemical exposures. Many times, these victims were being swept up from their location and transported to the hospital without the thought of decontamination, causing injury to both the prehospital care providers and the hospital staff.
But worse than that was the injury suffered by the victim. Even today, there existed a great lack of knowledge of chemical exposure injury by both the prehospital providers and the emergency department staff. This has led to victims suffering and even dying because of a lack of appropriate care. None of these providers received adequate training to treat a victim suffering from acute chemical exposure and the resulting injury. Instead of embracing this field, it was pushed aside because it was either too technical, required too much training, or just did not happen enough to be concerned about.
The regional poison control centers across the nation were put in place to assist with these situations. They are fairly quick to respond and will send critical information to the hospitals to assist in the care of these patients. Many times, the centers are contacted by the emergency physicians, but unfortunately, too often this important step is missed by the physician, and needed information is not obtained.
Rapidly identifying the injury and providing appropriate treatment for the chemical injury will reduce the recovery time and will save lives but is often an afterthought. Although the regional poison control centers provide factual and detailed information, any expected delays in the information will ultimately delay the treatment and may lead to a poor outcome or long recovery time. Basic knowledge of chemical exposures and an understanding of how physiology may be affected is critical to providing quick and efficient treatment.
The premise for this book and the subject of chemical exposure and injury has been a career‐long venture for the authors. The field of hazmat medicine has been their passion for many years. Their focus has always been to train both prehospital personnel and hospital care providers to a level where they can confidently assess and treat the victims of chemical exposure. The authors have learned from real‐life experience, reviewing case studies, and conducting research to train health care providers to a level of care expected by their customers (see Figure 1.1).
Case Study – Sarin Attack in the Tokyo Subway
On March 20, 1995, the religious‐based terrorist organization call the Aum Shinrikyo, under the direction of their leader Shoko Asahara, conducted an attack in the political district of Tokyo. Plastic bags filled with Sarin (a viscous liquid that vaporizes) were used to deploy the nerve agent poison that affected 15 different subway stations and trains. At the time, this was the largest terrorist attack ever carried out. In total, over 6000 victims were affected and 19 died.
Shortly after the Sarin was released into the subway cars, emergency calls began to come into the call center. In total, 1364 EMTs and 131 ambulances responded to 15 different subway stations. At the time, the EMTs working in Tokyo were advanced practice EMTs and were trained in advanced airways and IV therapy but were required to receive direct orders from a physician to do either. Because of the ongoing disaster, physicians were not available to provide those orders and as a result, only one patient received an advanced airway and IV. No other advanced life support was conducted outside of the hospital.
Figure 1.1 All emergency responders/receivers should understand the consequences of chemical exposure and injury. Rapid diagnosis and treatment is necessary for positive outcome and rapid recovery.
Although some of the victims died or had more serious signs and symptoms that required care in the hospital, most of the 6000 only complained of eye pain, dim vision, and headache related to miosis caused from low‐level exposure. Those treated in the hospital were related to breathing, somatic, and cardiac issues.
The hazardous materials response team was managed within the Tokyo Metropolitan Fire Department (TMFD). The team had advanced capabilities including infrared gas analyzer and gas chromatograph‐mass spectrometer (GCMS). The police department has similar equipment but only had select individuals trained to use the equipment and did not maintain a hazardous materials response team.
The first call for assistance came into the dispatch center at about 8 a.m. At about 10 a.m., the TMFD identified the chemical offender as acetonitrile (methyl cyanide). This analysis was incorrect. At about 11 a.m., the police department correctly identified the material as sarin using their own GCMS.
The after‐action reports completed well after the incident found several major points for concern. First, there was a lack of training and equipment available for a chemical response including the absence of prehospital decontamination which led to the secondary contamination and injury to both emergency responders and hospital staff. 135 EMT alone developed acute symptoms and received medical treatment at the hospital. Second, the EMTs were hindered in the care of the victims because, although they were trained and equipped, the EMTs were unable to provide advanced care unless given direct permission by a physician but all physicians were overwhelmed in the hospital and unable to provide the required permission. Finally, it was determined that triage in chemical disasters, including nerve agents, is of limited use since delayed symptomatology that can be consequential and normal data points were developed for trauma patients.
When this incident took place in 1995, the hazmat medical program provided in this book was well underway. This incident provided the authors with addition motivation to prepare for all kinds of chemical events. In fact, the authors of this book took many lessons learned from terrorist activities around the world and authored the book “Terrorism Handbook for Operational Responders.” This became the first Terrorism‐based book for emergency responders in the United States and was published well before the terrorist attack on September 11, 2001 and the Anthrax incidents that followed. Now, almost 30 years later, this program addresses all of the shortcomings that were found in Tokyo and other significant chemical/biological incidents. Since that time, there have been many chemical incidents that have caused extensive injuries and deaths. All have provided evaluation points to improve the information found in this text. It has always been the author’s goal to prepare and teach hazardous materials medical information so the effects from chemical incidents of all types are reduced.
History
In the 1980s, when we first envisioned this field of study and began developing and presenting coursework to our fellow paramedics, we found that some criticized us, believing that treating chemically injured patients was more of a Ghostbusters operation and there are not enough of these patients to truly make a difference. Others recognized the need for the training, embraced the additional knowledge and skills, and adopted much of what they learned into their responses.
With greater training and knowledge of chemical incidents, prehospital responders began recognizing that there were many more chemically injured patients than they had previously thought. Many of the incidents were reported to dispatch centers as a general illness or injury not as a report of chemical exposure.
The authors found that many incidents that were dispatched as normal EMS responses were really related to chemical exposures. One example involved two different cases involving elderly women who lost consciousness during a hair‐dying procedure. In both of these cases, a hair dye was placed on the victim's head, and after the dying procedure was complete and the victim’s hair was being washed in a salon sink, they lost consciousness. These incidents occurred only three days apart involving the same beautician. When the second incident took place, an investigation revealed that the hair dye, made outside of the United States. contained a high nitrite concentration. The nitrite concentration combined with the elderly patients with poor circulation contributed to the loss of blood pressure and loss of consciousness. After years of presenting these cases to students, many have reported back that they have experienced similar emergency calls involving hair dye.
Another incident that has been misdiagnosed for years, especially in Florida, is the emergency call for assistance to a patient with heat stroke. Typically, when emergency services arrive, they find a patient unconscious after working outside on the lawn. The patient’s skin is not significantly hot, and their blood pressure is abnormally low. In some of these cases, there is evidence of fertilizer stuck on the patient’s legs from the knees to the ankles, which is often ignored. The EMS responder starts treatment for a heat‐related injury not understanding that the loss of consciousness is not related to heat exposure.
Fertilizers are rated according to its content and contain three numbers. The first number is the percentage of Nitrogen, the second is the percentage of Phosphorus, and the third the percentage of Potassium. Those fertilizers with a high first number are especially toxic. For example, 20‐3‐3 contains 20% nitrogen. The nitrogen is often sodium nitrite or similar chemical.
In many of these cases where homeowner have spread high nitrogen fertilizer without protecting their sweaty skin, the exposure causes a complete loss of vascular tone resulting in a loss of blood pressure and consciousness. This is misdiagnosed as a heat‐related injury instead of a chemical exposure leading to mistreatment. The authors have presented these cases during classes over the years. Again, many students have returned to us stating that this scenario has happened to them as well, but because of their recent hazmat education, they have been able to diagnose and treat appropriately.
The decision to take on the task of developing a hazardous materials toxicology‐based program led us to have many spirited discussions with our medical director, personal conversations with other health care professionals. and evaluating our own experiences. Using our teaching and emergency response experiences, we created a program that would benefit our department, our team, and ultimately brought the approval of our medical director. We knew that we were venturing into an area of study that had not been attempted before in the prehospital community. Little did we know that it would eventually become a national program of study.
We did not enter into this endeavor without appropriate backgrounds. By the late 1980s, both of us already had more than a decade of experience serving as field paramedics. Both instructed paramedic school at the local college and had taught advanced classes in ACLS, pharmacology, pathophysiology, trauma life support, and were serving as hazmat technicians on our department's hazmat team. With the blessing of both our department and our medical director Dr. Robert Duplis, we started down this path of developing the first hazmat Advanced Life Support program and course in the nation.
Over the years of actual scene response, teaching hazmat medicine, writing, and researching, we have had the opportunity to generate many operational procedures. Throughout those years, numerous departments and agencies have requested our policies, procedures, and our medical SOPs to use in their agencies. Even State agencies have incorporated our policies and procedures into their medical systems. In one case, we were requested to participate in the development of a national evidence‐based protocol for response to victims of weapons of mass destruction and become reviewers of national curricula (Figure 1.2).
That leads into the present day and this text. Although there have been several other books published in this area of study, including an earlier book published by the authors of this book, this one is the most complete text available. This text represents lessons learned, years of research, review of many case studies, and years of teaching and guiding other agencies on the development of hazardous materials medical programs. We have always believed that if you want to truly understand and function at a high level then, you must teach. We have learned a lot over the past 40 years of response and instruction. A good deal of this learning, from our perspective, came from our students and their experiences. Through them, we have learned and matured in our thoughts and response concepts.
We understand and teach what we know works, both in the field and in the emergency department. From the beginning, we have focused on what can be accomplished in the field. We begin with a quality assessment to form a differential diagnosis, then follow that with appropriate treatments based on the assessment findings and, when possible, determination of the offending chemical.
Through the response and review of many emergency incidents and exercise design and evaluations, we identified both the extent and limitations of field practice. Of course, the emergency departments will always have the ability to take treatment further than a field paramedic can. For example, many toxidromes could be addressed in this text, but the application of treatment of these toxidromes is beyond the capability of field advanced life support trained personnel and many hospital emergency departments. Some require extensive laboratory testing and long‐term care or chelation therapies. These do not have a place in the field or the emergency department.
Figure 1.2 The hazardous materials medical technician program emblem has changed through the years. These emblems represent the program from 1990 to present.
There exists a fallacy that training for chemically exposed patients should only be provided to those paramedics that support the hazardous materials teams. This is misleading as most chemical exposures take place with individuals not associated with a hazardous materials incident. There also exists the thought that emergency department medical providers do not need the training because resources are at their fingertips to guide them in the treatment process. After several experiences which resulted in unnecessary death, we have found that this is also not true. Both prehospital care providers and hospital emergency department medical providers need training and education on both assessment and treatment for the chemically injured patient.
For example, one of our case studies involves a 12‐year‐old girl who was exposed to 70% hydrofluoric acid. The father had purchased the acid for his pressure cleaning company because of its ability to remove rust stains from the stucco on buildings. His daughter knocked over a 1 gal jug wetting the grass with the acid. The 12‐year‐old then slipped in the wet grass, exposing both legs, buttocks, and back. The injured girl was taken to the hospital, where the father carried her into the hospital in his arms, handed her to a nurse, who subsequently handed her to a physician who placed the girl on the bed. By this time, the young 12‐year‐old was unconscious.
Complaints of burning arms by the father, nurse, and physician soon followed. No one in the Emergency Department understood the effects of hydrogen fluoride. They only understood that it burned their skin and eyes. Unfortunately, a bolus or two of calcium gluconate or calcium chloride may have saved the girl's life. A lack of awareness and training caused the misconception that hydrofluoric acid was similar to hydrochloric acid. Both cause injuries at the site of contact, but one greatly differs from the other in systemic toxicity. This demonstrates the importance of training in chemical exposures at all levels of the emergency medical chain of response.
Events
Although true hazardous material incidents do not occur every day, what is seen frequently is the personal misuse of chemicals both in the household and in the workplace, causing exposures. These are typically not classified as hazardous materials incidents. Most of the patient exposures that are treated by emergency responders do not come from a dispatched hazardous materials incident. Instead, the emergency response was dispatched as some kind of general medical call, and it was not until the EMS providers arrived and found that an exposure to a chemical was responsible for the resulting symptoms.
Unfortunately, most emergency responders do not have appropriate training to deal with these patients. Not only do these patients often present a secondary hazard to the health care provider, but their recovery is dependent on how they are treated immediately after the exposure. Many times, the lack of understanding and the continued tissue damage related to the exposure causes patients to decompensate while in route or while awaiting lab results in the hospital emergency room.
This text was developed to provide both the knowledge and skill necessary to assess, diagnose, and treat an acutely chemically injured patient. In addition, the materials presented in this book will provide background, physiology, and logic to the assessment and treatment process.
In some incidents, it will be easy to determine the chemical and route of exposure to cause the injury. A chlorine leak at a water treatment facility is one of those examples. These are not difficult to determine, and responders are rarely led in the wrong direction. But, when an employee of a chrome plating company is found unconscious in the shop, and there is no clear cause for the incident, a detailed assessment must be completed to determine if the patient’s illness is due to exposure or a medical cause. Today, emergency responders and emergency department nurses, and physicians have equipment immediately available that can help with the determination of the cause. And if not, through a detailed focused assessment, the care provider can be led into a differential diagnosis strategy.
