Response to emergency incidents involving hazardous materials (hazmat) and weapons of mass destruction (WMD) places public safety responders at greater risk of morbidity and mortality than the general public.1Incidents involving hazmat can cause physical harm to both the public and first responders,2 necessitating the delivery of medical care during treatment and transport.3
EMS providers must be prepared for the challenges hazmat/WMD incidents present from chemical, biological, radiological, thermal, mechanical and asphyxiation hazards.4 This article details the latest National Fire Protection Association (NFPA) standard for EMS hazmat professionals.
THE NFPA STANDARD
NFPA 473, “Competencies for Emergency Medical Services Personnel Responding to Hazardous Materials/Weapons of Mass Destruction Incidents,” was written in 1992 as a companion standard to NFPA 472, “Standard for Competence of Responders to Hazardous Materials/Weapons of Mass Destruction Incidents.”5
The NFPA Technical Committee on Hazardous Materials Response Personnel originally developed NFPA 473 because of the absence of existing guidance for the roles and responsibilities of EMS personnel at hazmat incidents and the recognition that hazmat incidents present unique challenges for EMS.
Although NFPA 473 has existed for more than 20 years, it’s often overlooked in the presence of its predecessor, NFPA 472.6 For the 2008 and 2013 editions, the Technical Committee felt it was time to breathe new life into NFPA 473, matching NFPA 472’s format and content by clarifying the roles of BLS and ALS responders during hazmat incidents, as well as introducing new mission-specific competencies for ALS responders.
NFPA 473 defines a BLS responder as an EMS responder functioning at a level defined by the medical authority having jurisdiction either as an emergency care first responder (ECFR) or as an EMT-ambulance/basic (EMT-A/B).5
The goal of the competencies in NFPA 473 at the BLS responder level is to define the knowledge and skills necessary to safely deliver BLS medical care at hazmat/ WMD incidents.
The competencies defined for a BLS responder include:
>> Analysis of a hazmat/WMD incident to determine potential health hazards;
>> Development of a plan to deliver BLS to any exposed patient within the scope of practice; and
>> Implementation of the prehospital treatment plan within the scope of practice by determining the nature of the hazmat/WMD incident.
NFPA 473 defines the ALS responder as an EMS responder functioning at a level beyond the BLS level as defined by the medical authority having jurisdiction, either as an EMT-intermediate (EMTI); paramedic (EMT-P), medical director or as a medical team specialist such as a nurse, nurse practitioner, physician assistant or physician.5
The competencies defined for an ALS responder include all competencies required of a BLS responder, plus:
>> A more detailed analysis of a hazmat/ WMD incident to determine the potential health hazards, including an assessment of health risks and identification of patients who may be candidates for advanced clinical care;
>> The development of a plan to deliver ALS to any exposed patient within the responder’s scope of practice, including identification of supplemental regional and national resources; and
>> Implementation of an enhanced prehospital treatment plan within the responder’s scope of practice by determining the nature of the hazmat/WMD incident, including an assessment of available equipment and evaluation of the need for advanced clinical care.
ALS responders wishing to specialize in specific skill areas have mission-critical competencies outlined in the new NFPA 473.
ADDITIONS TO THE 2013 EDITION
Following the release of the 2008 edition of NFPA 473, the NFPA Technical Committee focused on bringing the document more in line with the philosophies of NFPA 472, in particular by defining mission-specific competencies for ALS responders who wish to specialize in specific skill areas.
For the 2013 edition of NFPA 473, competencies were incorporated for the ALS providers assigned to:
1. A hazmat team;
2. Provide clinical interventions at a hazmat/WMD incident; and
3. Treatment of smoke inhalation victims.5
The specialty areas are designed to provide guidance for EMS agencies that have a desire to integrate with a hazmat team, perform hazmat clinical procedures in the prehospital environment or protect response personnel from the hazards of smoke inhalation.
There’s no requirement for agencies meeting the competencies for BLS and ALS responders in NFPA 473 to train to the new mission-specific competencies, as the specialties are an optional enhancement to existing ALS response capabilities.
ALS RESPONDERS ASSIGNED TO HAZMAT TEAMS
Medical support to hazmat teams can present complex problems for ALS providers who aren’t aware of the procedures and responsibilities surrounding hazmat response operations.
Assigning dedicated ALS providers to participate with the hazmat team on training and response operations allows them to become advocates for the health and safety of hazmat team personnel.
The mission-specific competency for ALS responders assigned to a hazmat team is designed to provide guidance for hazmat teams that choose to integrally include ALS providers.
The competency defines the assigned ALS responder as “that person assigned to provide direct medical support and intervention to the members of an established hazardous materials team.”5
The competency is organized into three primary areas:
1. Plan a response within the authority of the agency having jurisdiction (AHJ) to support hazmat team operations;
2. Implement the planned response consistent with the standard operating procedures of the AHJ to support hazmat team operations; and
3. Terminate the incident consistent with the standard operating procedures of the AHJ to document hazmat team operations.
As part of the planning process, the competency guides the ALS responder to become a medical advocate for the team, including organizing team medical records, encouraging team fitness, ensuring appropriate team medical surveillance and establishing liaison with medical facilities that may potentially receive injured or ill team members.The competency also guides implementation of the planned response, including functioning in medical capacities within the incident command system, coordinating medical support to the team, ensuring rehabilitation is established and becoming a patient care advocate in the event of team member injury or illness.
ALS RESPONDERS PROVIDING CLINICAL INTERVENTIONS
There are numerous clinical interventions available to ALS medical providers who respond to hazmat/WMD incidents, based upon approved protocols from the AHJ’s medical director. The delivery of clinical interventions, such as antidotes for chemical exposure and associated clinical techniques, may provide improved patient outcomes, especially during extended transport times to definitive care.7
The provision of ALS clinical interventions should be viewed as a “tool in the toolbox,” utilized as necessary following an analysis of patient treatment and transport options. The ALS responder should base that analysis on existing AHJ treatment protocols, impact on favorable patient outcomes, available toxicological information and overall safety concerns.
Implementation of ALS clinical interventions within the exclusion or “hot” zone must be considered cautiously from the perspectives of responder safety, patient exposure times and available medical resources.
The mission-specific competency defines the ALS responder assigned to provide clinical interventions as “that person who is assigned to provide antidotes, antibiotics, and/or radiological countermeasures to persons contaminated by hazardous materials.”8
The competency is organized into two primary task areas:
1. Plan a response within the authority of the AHJ to provide advanced clinical interventions; and
2. Implement the planned response consistent with the medical protocols of the AHJ to provide advanced clinical interventions.
Three competency areas are included to guide the ALS responder assigned to provide clinical interventions:
1. Toxidromes for chemical, biological, and radiological materials;
2. Clinical intervention pharmaceuticals; and
3. Clinical intervention skills.
The mission-specific competency is designed to be flexible to fit the AHJ’s approved protocols for the delivery of clinical interventions; the AHJ utilizes competencies only for authorized interventions.
ALS RESPONDERS TREATING SMOKE INHALATION VICTIMS
Smoke products released during structural, vehicle, aircraft and hazmat fire incidents present challenges for EMS responders. The presence of carbon monoxide, cyanide and other smoke products are sources of potential exposure for both victims and responders at every fire incident.
The competency is designed to provide guidance for the knowledge and skills of ALS providers treating smoke inhalation patients.5
The mission-specific competency identifies the considerations for ALS responders assigned to treatment of smoke inhalation victims and is organized into three major areas:
1. Analysis of the incident, including a survey of the incident and collection of information from potential victims and responders to determine if smoke inhalation has occurred;
2. Development of a plan to deliver ALS care to victims of smoke inhalation, including the availability of antidotes and identification of local treatment facilities; and
3. Implementation of a treatment plan for smoke inhalation victims, including decontamination, treatment of burns or other trauma, complete patient assessment including carbon monoxide levels, delivery of antidotes, and transport to an appropriate treatment facility.
The competency emphasizes the location, method of transport and routes of travel to appropriate treatment facilities such as trauma centers, burn centers, hyperbaric chambers and hospitals prepared for antidotal treatment of cyanide toxicity.
EMS responders to hazmat incidents face significant challenges; however, integration of medical care providers into the planning process for hazmat incidents can facilitate a more efficient response. The competencies found in NFPA 473 provide thorough guidance for EMS professionals during planning, preparation and response to hazmat/ WMD incidents.
1. Suyama J, Rittenburger JC, Patterson PD, et al. Comparison of public safety provider injury rates.Prehosp Emerg Care. 2009;13(4):451–455.
2. Maquire BJ, Hunting KL, Smith GS, et al. Occupational fatalities in emergency medical services: A hidden crisis. Ann Emerg Med. 2002;40(6):625–632.
3. Occupational Safety and Health Administration: Best practices for protecting EMS responders during treatment and transport of victims of hazardous substance releases. U.S. Department of Labor: Washington, DC, 2009.
4. Noll GG, Hildebrand MS: Hazardous materials: Managing the incident, 4th edition. Jones & Bartlett Publishers: Burlington, Mass., p. 270, 2012.
5. National Fire Protection Association: NFPA 473: Competencies for emergency medical services personnel responding to hazardous materials/weapons of mass destruction incidents. NFPA Publications: Batterymarch Park, Mass., 2013.
6. Schnepp R. EMS at haz-mat/WMD incidents? Well it depends… Fire Engineering. 2005;158(11):S21–S22.
7. Managing hazardous material incidents, vol. 1. (July 3, 2013.) Agency for Toxic Substances and Disease Registry. Retrieved on Jan. 15, 2014, from www.atsdr.cdc.gov/MHMI/mhmi-v1-2.pdf.
8. Emergency medical services: A planning guide for the management of contaminated patients. Centers for Disease Control Printing: Atlanta, Ga., 2000.