Same problem – different solutions
1Magen David Adom, Israel, State of; 2Frankfurt city Health Department Germany; 3SAMUR-Protección Civil. Madrid. Spain
The chemical attack in the subway system of Tokyo in 1995 draw the international assistance to the risk of chemical terrorist attacks. Since 1995 most of the countries are preparing to respond to a major chemical attack. Different countries have developed different response concepts for the response to a chemical terrorist attacks. These concepts are with regards to the type of personal protective equipment to be used by the medical personnel and their tasks.
The objective of the session it to present and discuss the different approaches to medical chemical response in: (1) Germany – Frankfurt: the victims are removed by fire-fighters from the contaminated area; go through "technical decontamination" by fire-fighters. EMS personnel treat and transport only decontaminated patients. (2) Spain – Madrid: EMS personnel wearing Level A protection will enter the contaminated area and remove the patients. EMS is responsible for the decontamination site, where medical treatment will commence. The team working with PPE is a specially trained team. The "normal" EMS teams treat and transport only decontaminated patients.(3) UK: specially trained teams (HART) using Level A protection enter the contaminated area, decontamination is performed by HART teams, "normal EMS" teams treat and transport only decontaminated patients. (4) Israel – all EMS personnel are trained and expected to perform in a contaminated area (staff and volunteers) and carry PPE as part of the regular ambulance equipment. The personnel wearing a powered PAPR and splash suit will enter the contaminated area and transport contaminated patients to the hospital. The only decontamination measure in the field is disrobing. Wet decontamination will be performed at the hospitals gate.
Session concept: 4 presentations of 10 minutes each, followed by 5 minutes of questions for each presentation. 30 minutes will be dedicated to an interactive session with the audience discussing the pros and cons of EMS personnel working in a contaminated zone.
Initial medical care of Chemical patients
Frankfurt City Health Department
Due to the international threat situation an event with terrorist background cannot be ruled out in a city of Frankfurt.
Considering this particular situation, a conflict of interest arises between fast and effective assistance on the one side and the self-protection on the other side. Therefore the units will be downsized to a minimum, for their own safety.
In a normal chemical accident but even in case of a terror backround it’s allways the firebrigade who controls the scene. Only a small group of firefighters in protective cloth will be send into the scene for primary evaluation.
At this stage, there will be no medical treatment/care of victims. In comparison to other countries or even other German cities, the EMS personal is not equipped with protective clothing/equipment like rebreathes. Therefore it is the responsibility of the firefighters to remove victims/patients out of the danger zone which is primarily set at approx. 100 meters. At the borders of this zone, the EMS will be waiting.
According to the agent used, the firefighters will make a decision if they (still in protective clothing) will have to remove clothing and start cleaning the patient before they will hand over the patient to EMS personal.
In general, no antidotes will be used without a physician present. According to the medical status (green, yellow, red) the patient will be minimally treated, stabilization for the transport is primary care.
Immediately after stabilization the patient is transported to a hospital. Not every hospital in Frankfurt is equipped with showers on the outside premises. This restricts the availability of treatment for this kind of patients.
MDA Response to a Mass Casualty Toxicological Accident
Magen David Adom, Israel
The chemical attack in Tokyo 1995 raised the awareness to the possibility of a mass casualty toxicological incident caused by an accident, deliberate release or natural disaster.
These are the main concepts leading to MDA chemical procedure:
In a MCTA the exposure is to vapors. This enables reducing the level of skin protection of responders.
If victims exposed to the toxic substance still show signs of life by the time rescue units arrive to the scene, the concentration of oxygen is high enough to sustain life, and the concentration of the contaminant is rather low. These facts enable reducing the respiratory protection of responders.
Since the exposure is to vapors, disrobing will provide initial sufficient decontamination, and the risk of long term contamination of the ambulances is minimal.
A MCTA could occur any time anywhere all over the country.
These concepts lead to the following operational procedures:
All ambulances carry personal protective equipment and antidotes. MCTA procedures are part of the training programs for all team members at their various levels.
EMS personnel wearing PPE will assist in the fast removal of patients from the contaminated area.
Patients that have been disrobed will be transported to the hospitals, by EMS personnel wearing PPE. If there is a need for, wet decontamination will be performed at hospital's gate.
Diagnosis of Oregano Phosphate will be based on clinical criteria. Following the decision of Paramedic / Physician on organophosphate intoxication, all EMT are authorized to use antidote auto injectors.
Several small scale operations have demonstrated that this procedure is well incorporated and understood by MDA staff and volunteers. An ongoing learning process is essential to creating this level of knowledge by the personnel.
Same problem – different solutions: Spanish Model
SAMUR-Protección Civil. Madrid. Spain
Since the terrorist attacks on March 11th 2004, SAMUR PC Madrid is preparing for a possible CBRN attack and not only to an explosives one. The reponsibility to respond to a CBRN incident has shifted from the military to civiliyan institutions, that have different structures, but will support thus cooperation is required. Some important points about the pre-hospital CRBN incident planning are: The pre-hospital emergency medical services work in coordination with the Fire Department, Police and others National Security Forces. Decontamination and medical management of the victims are performed also by these pre-hospital emergency medical systems. Teams must have personal protective equipment and the training to use it. Rapid deployment of the nesecarry resources is key. Training is essential. No hospital in Spain has a CBRN system in place although worl is being done. This specific Procedure of performance For CBRN, the following aspects are considered:
Personal protection equipment in all units.
Staff teaching and training on a regular basis given by specialists in the subjet.
Work Procedure coordinated and training on a monthly basis.
CBRN response is incorporated into daily activities:
1. Rapid deployment vehicle on duty 24/7.
2. On duty detection expert.
3. Personal Protective Equipment on all vehicles.
Designatedbackpack ( “TURTLE BACKPACK”) that includes:
3 full masks with vapour and particles filters.
3 semi-masks with vapour and particle combine filter for sprinklings of non-agresive liquids and or particles to mucous areas.
3 autofilter elements for particles FFP-3
3 pairs of chemical protection glove
3 pairs of shoe covers
1 roll of tape to seal
3 isolating protective anti-splashing garments (level I)
Training consists of theory and practical excersise. Monthly inter-institutional drill is conducted. Destection equipment is used in fires. Detection capacity for - CO, O2, HCN and explosive content.