It’s 2 a.m. when you’re dispatched to the scene of a suspected overdose in a suicide attempt. There’s a garlic-like odor as you enter the house, where you find an obtunded man in his 40s lying on the floor. It’s obvious he’s been vomiting.
He responds to verbal stimuli with garbled speech and his airway is open. His vitals include a heart rate of 48 beats per minute, respiratory rate of 20 breaths per minute, a blood pressure of 100/45 mmHg, and an O2 saturation of 94%. The patient has secretions from his nose and significant expiratory wheezing.
You see alcohol in the house, but find no pill bottles nearby. However, you do find a bottle of pesticide on the kitchen counter. You place the patient on the stretcher, apply a non-rebreather mask and begin transport to the hospital. While preparing to administer atropine en route, you feel slightly nauseous and have a headache. Just prior to arriving at the ED, the patient begins to vomit profusely.
On arrival, the patient is attended by several nurses and technicians as you transfer him over to a hospital bed. But soon after, several of them begin to feel dizzy, nauseous and lightheaded.
Your nose is now running, your head is pounding, and others in the ED are starting to complain about fumes. After several minutes of resuscitating the patient, one of the nurses gets sick and starts to vomit. The physician and nurse manager move everyone from the surrounding rooms, place the patient in isolation and begin to treat the sick staff members.
At the request of the ED leadership, the hospital administrator places the ED on “Status Black,” essentially closing it to incoming patients, while the staff members are cared for and decontamination takes place. Shutting down this busy ED has a dramatic effect on the regional EMS agencies and surrounding hospitals, causing delays across the entire system.
Is there a way this could have all been avoided?
Understanding the Impact
Hazardous materials (hazmat) are any substance capable of harming people, property or the environment. The United States Department of Transportation publishes a list of all hazmat chemicals, which are classified by the International Hazard Classification System into nine categories: explosives; gases; flammable/combustible liquids; flammable solids; oxidizers and organic peroxides; poisonous material and infectious substances; radioactive substances; corrosive materials; and miscellaneous hazardous materials. Incidents involving hazmat frequently result in complicated scene management, extensive decontamination processes and possibly death or serious injury.
Hazmat exposure can result in both primary contamination (direct contact with the chemical at the scene) and secondary contamination (contact of the patient, rescuers or equipment after leaving the scene).
Secondary contamination is a unique attribute of hazmat scenarios and can dramatically alter the scope of an event. Prevention of secondary contamination is paramount to controlling the scene and avoiding a larger exposure.
The complex nature of these materials, and particular methods for decontamination and treatment, have led to specialized processes created to deal with hazmat exposures, including hazmat fire/rescue squads, advanced hazmat life support (AHLS) certificate courses and expanded regional poison control centers.
Hazmat calls are a complicated part of EMS. Working around and handling hazmat, as well as caring for exposed patients, requires specialized knowledge and equipment. These complex calls involve recognition of the hazmat, identification of toxidromes and treatments, and an understanding of proper decontamination techniques.
Patients can be contagious, with particles transferred on their clothing or skin—and in some cases, via bodily fluids. There are also published reports of widespread contamination from exposure to gastric contents, resulting in a compromised ED after unrecognized organophosphate poisoning.1
Secondary contamination is also potentially devastating to the emergency care system. Exposure to the healthcare team may threaten the overall care of the patient and, as in the case presented earlier, exposure to emergency personnel and ED/hospital staff can cause operational difficulties. Therefore, in order to properly manage a hazmat scenario, trained specialists should be involved at multiple levels of the event.
Special Notification System
The Orange County (Fla.) EMS System has created a specific notification, the Hazmat Alert, to properly indentify risk, better facilitate information exchange and appropriately decontaminate any patient exposed to hazmat. The goal of this multitiered notification system is to improve management of patient care scenarios involving hazmat exposures.
This is accomplished by early involvement of hazmat teams in decision making, early involvement of the regional poison control center or linkage to a medical control physician by radio when needed, assignment of an EMS liaison to assist the receiving ED in preparing for arrival of the patient, establishment of unified command between EMS and the hospital, and, when necessary, preparation for the EMS system to redirect EMS transport traffic until the situation has been resolved. The Hazmat Alert involves three steps: notification, on-scene patient care and facilitated transfer of care.
There are several origination points for a Hazmat Alert. It can be initiated at the time of dispatch when a caller reports a medical emergency involving a chemical smell or hazmat exposure.
The first-arriving crew can also initiate a Hazmat Alert when there’s suspicion of a hazmat exposure due to odor, history or other source of information. And, an ED can institute a Hazmat Alert in the event a hazmat exposure is suspected in a walk-in patient and additional resources are needed. Regardless of the point of initiation, the process remains the same.
The Hazmat Alert Process
Once an alert is initiated, EMS units are directed to advise the communications center of the transport destination as soon as it’s determined and employ appropriate protective standards to avoid exposure by the prehospital providers.
The communication center notifies the agency hazmat team, dispatches a unit (EMS liaison) to the receiving hospital to assist in transfer of care, provides a notification to the intended receiving hospital and, if requested, places the ED on Status Black until it’s determined safe to resume EMS transports.
Once notified, the agency hazmat team contacts the on-scene crew to determine the nature of the exposure, advise on personal protective equipment (PPE), provide input on an appropriate decontamination strategy, advise on treatment in coordination with medical control or poison control physicians, and determine when transport can be safely initiated.
Accomplishing these goals may or may not require the hazmat team to respond to the scene. However, the initial responding crews must wait for input from the hazmat team prior to initiating transport. This ensures specially trained individuals are actively involved in patient care, crew safety and decontamination early in the response.
Prior to ED arrival, transporting crews must contact the receiving ED and the EMS liaison to convey pertinent patient information and specific decontamination strategies employed on scene.
The EMS liaison or hospital staff is instructed to meet the arriving crew outside the ED entry door. Before entering, the EMS liaison and hospital staff are allowed to assess need for additional decontamination—this redundant layer of evaluation further decreases the chance of secondary contamination. At that point, patient care is transferred to the hospital staff, with the additional resource of the EMS liaison as needed.
The crew immediately suspected organophosphate poisoning, but took no steps to decontaminate the patient. Furthermore, they entered a busy ED with a patient who hadn’t been appropriately decontaminated, resulting in secondary contamination of rescuers and staff.
The hospital wasn’t prepared to accept a patient in this condition, and neither the crew nor staff were wearing appropriate PPE. Although the crew recognized the toxidrome and the correct treatment, the overall scene wasn’t controlled.
If the Hazmat Alert protocol had been used, the initial crew members would have notified dispatch as soon as they identified the organophosphate exposure. The agency hazmat team would’ve instructed the crew on proper PPE and decontamination of the patient on scene. The receiving ED would’ve been notified a potentially contaminated patient was being transported to their facility and could have arranged for an isolated room. The EMS liaison would’ve coached the hospital staff on appropriate PPE, assessed the patient outside the entrance, and likely directed a second decontamination prior to entering the hospital.
This process could’ve ensured that no secondary contamination occurred, and provided a mechanism to better care for the patient while protecting the rescuers and maintaining the integrity of the overall system.
Since the deployment of the Hazmat Alert notification system, the strategy has significantly improved the safe transition of patient care from a hot zone to the hospital. We’ve seen an increase in the utilization of our hazmat teams to evaluate for potentially serious exposures, and have had several events where secondary decontamination occurred at the direction of the EMS liaison prior to entry into the hospital. Patients exposed to suspicious materials have been evaluated and decontaminated in a manner that allowed the EDs to feel comfortable continuing operations without diversion or risk to their staff.
The Hazmat Alert notifications have also provided a layer of protection against the threat of chemical attack or bioterrorism. This straightforward notification system provides a mechanism to better utilize resources and reduce the possibility of secondary contamination.
1. Stacy R, Morfey D, Payne S. Secondary contamination in organophosphate poisoning: Analysis of an incident. QJM. 2004;97(2):75–80.