In both rural and urban settings, the potential to respond to an incident in which one or more patients requires hazmat decontamination mandates that EMS providers be taught the theory behind decontamination, with a focus on keeping providers and patients safe from exposure and contamination by toxic substances. Unless providers are part of the local hazmat response group, those without hazmat certification shouldn’t attempt to act in this capacity.
Instructors should ensure all providers know that even when the decontamination is for a single patient, it’s necessary to establish hot, warm and cold zones as if it were a larger hazmat release. This should be accomplished by the first-arriving units. Before beginning the process of decontamination, providers should attempt to identify the products involved and/or the toxidromes present in the patients, establish an incident command system (ICS) and transmit this information to dispatch.
The Theory
To understand the decontamination process, students must understand the concepts of contamination and exposure, two terms many first responders and medical professionals often confuse. Decontamination is the physical or chemical process of reducing and preventing the spread of contaminants from persons and equipment at a hazmat incident.1
Contamination is hazardous material (e.g., solid, liquid or gaseous vapor) that physically remains on a person, animal or object. Direct contamination results from direct contact with a contaminant or through cross contamination. Cross contamination occurs when a “clean” person is contaminated by a “dirty” object or individual. Of particular concern to first responders is whether the patient was exposed to a vapor or gas, because their clothing and hair retains vapors. Known as “off-gassing,” this poses a serious hazard, and the situation can be worsened when providers examine and treat a patient in the confined space of an ambulance.
Beyond being “dirty,” exposure is the term used when a person is subjected to a toxic or harmful substance through any route into the body (e.g., injection, open wound, absorption, inhalation or ingestion). Exposure can produce immediate injury or illness or can have a delayed presentation reaching years into the future. So it’s possible to be contaminated without being exposed.
To demonstrate this key difference in the classroom, instructors can sprinkle scented baby powder on a desktop. It teaches us on-scene isolation, especially in weapon of mass destruction (WMD) or biological terror (BT) agent events. Strike the desktop with your hand, or blow a small amount in the air and watch as it lingers and moves with air currents. This exercise demonstrates the need to isolate contaminated individuals. Although it isn’t a perfect model of a BT agent, it emphasizes how little effort is needed to send a product throughout an area.
The powder spreads (product release and surface contamination); its vapors announce its presence (inhalation exposure hazard), and inevitably, someone gets it on their hands and clothes (direct contamination). Others will experience cross contamination.
Decontamination Types
Students should learn the four types of decontamination and that each should be implemented according to local protocol.
Emergency gross decontamination: This is the physical process of immediately reducing contamination on patients in potentially life-threatening situations with or without formally establishing a decontamination corridor. Although this is the quickest method, be careful not to become contaminated in the process. Generally, over-spray and water runoff isn’t contained and poses a danger to others operating on scene.
Technical decontamination: This operation generally supports a hazmat incident with established corridors for ambulatory and non-ambulatory personnel to operate in chemical protective clothing. There’s also an area for tools and meters to be “dropped” from decontamination.
Mass gross decontamination: This process involves decontaminating large numbers of people quickly with firefighting fog nozzles to reduce surface contamination. This protocol is generally reserved for WMD, toxic industrial chemical or radiological releases. Mass gross decontamination operations have many problems associated with them, most notably, families with children. They should be kept together as a unit, if possible, during the decontamination process to reduce the stress and ensure better compliance.
Non-ambulatory patient decontamination: This process of decontamination is for patients who are unconscious, unresponsive or unable to move without assistance. This is a multi-step process of clothing removal, rinsing and washing with soft sponges, and appropriately monitoring the chemical or radiological agent. The process is personnel- and material-intensive, and it requires different equipment types. Providers should use stretchers that don’t retain contaminants and roller systems and saw horses to raise patients to a workable height to preclude the need to kneel down into the contamination.
The Practice
For students to understand that decontamination can begin with the patient removing their outer layer of clothing. A U.S. Army study indicates this can remove at least 80% of the contamination.2 Garments shouldn’t be removed over the head, or you risk introducing more contaminants to the head and face, thus risking further inhalation exposure.
The decontamination process is dependent on the chemical and physical properties, as well as the inherent hazards associated with the agent. You can remove a vast amount of contaminants with the judicious use of high-volume, low-pressure tepid water, and when necessary, use a non-reactive mild soap as a surfactant and a soft sponge. Teach students that a scrub brush should never be used on bare skin. The neutralization of corrosives is never done on live tissue because of the potential to cause further injury.
Instructors need to emphasize that some contaminants can be retained on the patient, an important point to consider when receiving a patient post-decontamination. Hazmat providers can monitor post-decontamination with electronic meters and low-tech test paper strips. Depending on the agent and findings documented, EMS providers should observe the patient when possible for signs of hypothermia, exacerbations of pre-existing medical conditions and resolution or recurrence of the toxidrome.3
Weather Conditions
Students in colder climates should learn that decontamination operations can take place outside in cold environments. The basic methods of decontamination–immediate clothing removal and a high-volume, low-pressure shower–remain the same for temperatures as low as 36º F. Many departments use pop-up tents with hot-air blowers and portable hot-water heaters, or trailer-mounted showers. Wind breaks can also reduce wind chill, if natural shelter isn’t available.
In temperatures below 36º F, alternative methods (i.e., blotting up) or using a resin-type wipe can be utilized as a stop-gap measure until an adequate decontamination can be completed. Finally, staging ambulances should have the patient compartment heater on full blast.
Special Considerations
Decontamination operations pose unique challenges for hazmat and EMS responders alike. Students should learn the special considerations some patient populations require.
Infants and the elderly are susceptible to heat and cold stresses, and mobility issues make decontamination a potential for harm. The elderly also have skin integrity issues that can affect the decontamination process. Patients with implanted ports may need Tegaderm or plastic wrap placed over these sites for protection. Tracheotomy patients will require shielding of the stoma during decontamination and changing of the cloth holders if they’re used. Medical electronic devices should be placed in a bag before decontamination.
Students should decontaminate morbidly obese patients appropriately by gently reflecting and washing the folds and clefts of skin. Those with artificial limbs should be decontaminated with the prosthesis on if possible because removal can be a challenge and could affect the patient’s mobility or ability to execute tasks that will assist in their own care; however, a wheelchair-confined patient may have to leave the wheelchair on scene for technical decontamination.
The hearing impaired may need signs with clear direction, whereas those with impaired vision may require one-on-one care during the process. Those with developmental disorders will need careful attention, guidance and reassurance during the process. Also tell students that the homeless or intoxicated patients who require decontamination can pose a challenge to providers because they’re prone to erratic and sometimes violent behavior.
Patient Refusal
It’s important for students to learn that public health laws give the government power to isolate and quarantine a person who may pose an “unreasonable” risk of harm to the public health and that these laws can also mandate decontamination and treatment. But, how far the law extends to hazmat and EMS isn’t clear in every case. If an official public health emergency is declared, however, law enforcement is empowered to use reasonable force to ensure compliance. Refusal of care after decontamination should be executed per local protocol. Providers should document the agent of exposure, signs and symptoms, symptom resolution and decontamination method.
Conclusion
Decontamination operations are personnel- and material-intensive, even for a single patient, and they’re fraught with danger. When teaching hazmat decontamination to EMS providers, it should be made clear that this in no way certifies the provider in decontaminations operations. As EMS providers, our hazmat and decontamination instruction is meant solely to keep providers safe from contamination and exposure to hazardous substances while providing our patients the best care possible. JEMS
References
1. NFPA 472 Professional Competence of Responders to Hazardous Materials Incidents. National Fire Protection Agency. Quincy, Mass. 2002.
2. Guidelines for mass casualty decontamination during a HAZMAT/weapon of mass destruction incident. www.ecbc.army.mil/downloads/publications/ECBC_SP_024_Lake.pdf
3. Peterson D. Decontamination best practices. Firehouse. 2009;34:50—52.
This article originally appeared in October 2010 JEMS as “Down & Dirty: Debunking Decontamination.”
