EMERGENCY RESPONSE (left-to-right)


HAZMAT-trained EMS at the Advanced Life Support (ALS) level (EMT-Paramedics) must be available for HAZMAT entry teams and be able to provide pre- and post-entry medical screening, on-site monitoring, rehabilitation and emergency medical treatment, including toxic exposures.


Vapour-proof (gas-tight) Level A ensemble must be worn in the hot zone when hazards are not known. PPE can be downgraded later with the approval of the on-scene Safety Offi cer.


Specialised military assets such as National Guard Civil Support Teams (CSTs) offer extensive expertise to civil authorities in CBRN incidents, including defi nitive agent characterisation, decontamination, medical and preventive health services.


WMD-CBRNE events will pose multiple challenges and hazards for EMS and rescue personnel.


Thorough and methodical decontamination must be performed to reduce secondary contamination and exposures.


Hazmat room.


EASY AS A-B-C-D-E


Airway - and antidotal drug therapy (atropine, 2-PAM Cl for nerve agent toxicity) Breathing - may need assisted ventilation Circulatory - cardiovascular/cardiac action, blood pressure Disability and decontamination (neurological/mental status, decontamination to reduce/eliminate absorption) Environmental and exposure (environmental exposure history, exposing body for examination)


This is particularly important in that a CBRN release may involve novel, unknown agents, or perpetrators may have disseminated combined agents, set secondary devices or deploy sniper or other armed teams. Depending the type of explosive and yield


of a RDD, substantial infrastructure damage can occur at the blast site, creating secondary hazards such as structural collapse and secondary fi res. As safety of responders is of paramount importance and supersedes all response actions, a thorough and methodical scene assessment (size-up) and on-going situational awareness and re-assessment are essential to safe response practices. Staging of EMS resources must be done in a safe and eff ective manner. Emergency medical operations must be conducted upwind and uphill of the hot zone. Airborne hazards, meteorological conditions, topography, time of day, safe access and egress routes must be assessed and monitored.


Patient care issues Normally, scene medical operations stage in the Cold Zone (clean zone). Earlier interventions - airway management and antidote administration - are time-critical, especially true for certain chemical agents


that induce life-threatening toxidromes, such as nerve agents and organophosphates - which are acetylcholinesterase inhibitors - and systemic asphyxiants such as hydrogen cyanide, which disrupts mitochondrial electron transport and oxygen utilisation. Time-critical medical or rescue


interventions will not await the arrival of a Hazmat team. The exposure of a patient to a nerve agent may require airway clearance and assisted ventilation, even if defi nitive medical countermeasures are not immediately available. For example, would it be prudent to call for additional resources, don PPE such as self-contained breathing apparatus (SCBA) and turn-out gear, make rapid entry, and extract viable patients in the face of a vapour release inside a structure? The rapid extraction would be done prior to defi nitive agent identifi cation.


Recommendations Greater citizen awareness and preparedness is needed. In the US the Ready.gov and national Citizen Corps’ Community Emergency Response Team (CERT), the Medical Reserve Corps, and FEMA’s Independent Study Program provide free training to enhance community preparedness. We also need greater standardisation of training


programmes for EMS, health and public health providers and uniform interoperability of equipment and supplies – including better protective equipment for responders and increased resources for medical monitoring and surveillance. Major issues surrounding the R&D of medical countermeasures and their application to CBRN events exist and have not been resolved. Stockpiles of crucial pharmaceuticals and vaccines are still inadequate, and those approaching expiration must be replaced. The failure rate to develop novel drugs, vaccines and diagnostic aids has exceeded 80% percent in the US, according to offi cial sources. Therefore, the provision of safe and effi cacious medical countermeasures in the face of unconventional health threats has been severely hampered. We must work collectively to enhance medical readiness and response capabilities to protect lives should the worst happen.


Frank G. Rando is a clinician, trainer and fi rst responder in disaster, tactical and operational medicine, healthcare and public health emergency management, Hazmat, toxicology and emergency response, environmental safety and CBRN defence.


CHEMICAL, BIOLOGICAL & NUCLEAR WARFARE | 2012/02 | 79


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