Decon doctor on patrol!


vapour pressure, and therefore the physical state of the chemical. If it is 32°F/0°C, then most agents will not transition to the vapour state. This is an easy concept to teach. Would you rather walk past a garbage dumpster in New York City in the summer, or past one in Norway in the winter? Physics doesn’t care if the material is toxic to you. It only has one set of rules. This dynamic is also temporal,


because dose requires both concentration AND time and must be linked to one of the routes of entry. If the wind is blowing at 10 m/sec then concentrations will not accumulate. There is no threat. This thought process, using the


threat assessment to determine when, where and how threats are possible also teaches us when, where and how they are NOT possible. This ability to leverage existing knowledge bases to identify independent variables to eliminate things that are not impossible, simplifies the training regime for this new concept of operations (CONOPS). Paramedics can solve this tactical


dilemma because they use a process that is strikingly similar to the threat assessment process. They triage for the purpose of sort with an eye to eliminating the noncritical so they can prioritise the sickest. The triage process assesses the threat to life and allows us to find the symptomatic sick and the injured so they can be decontaminated first. Threat assessment is always


performed before risk analysis for one simple reason. It would be foolhardy to spend time calculating the risk of events which are not within the realm of the possible. Let’s now apply some basic risk analysis concepts to our scenario. Risk analysis uses that which is


known to determine the probability of that which is knowable. What do we know? Patients will either be ambulatory or they will not. Therefore, we know that the first tactical challenge is to control the flow of ambulatory patients. We also know that the ambulatory patients will either be symptomatic or they will not. Our second tactical challenge is to identify


and collect the symptomatic patients for expedited decon and treatment. What else do we know? We know


that some will be higher risk because of physical frailty or co-morbidities. Our next tactical challenge is to identify and collect these vulnerable populations for specialised decon and treatment Here is an example of how the


incident changes when we prioritise the threat assessment and integrate risk analysis as we perform triage. Again, we are using the known to determine the knowable. Military types will recognise this as basic BOA/COA stuff. We know that the scene will require active crowd control. We know that people will want to move away from the threat, so movement should be controlled, not inhibited. The first paramedic will become


primary triage and will visually sort all ambulatory patients. Any symptomatic patient (evidence of SLUDGE or trauma) gets pulled out for immediate technical decon and treatment (lanes 1- 9). The ambulatory worried well will be directed to secondary triage. The second paramedic will become


secondary triage and takes up a position behind primary triage, providing a second set of eyes on the worried well. They will identify ‘the hat-trick’ (paediatric, geriatric and bariatric), who tend to be physiologically frail and are more challenging, and will be directed into secondary technical decon (lanes 10-19). All others are directed to general gross decon (lanes 20+). The first law enforcement officer


(LEO) will take up a position behind primary triage to ensure the safety of primary triage, and provide additional authority to ensure that instructions are followed. All additional LEOs will deploy on the left flank and on the right flank of triage one, and direct the crowd flow through the triage points into the decon lanes and holding areas. Incident command positions will be


filled as they would in any other response. This modular structure has many benefits. The scene and the responders will be protected. The sickest will be treated first. The physiologically fragile will receive special attention. Follow on responders know that the


lanes should be staffed beginning with the lowest numbers. The personal protective equipment


(PPE) and decon level can be determined by the operations chief and the safety officer based on local knowledge and a tactical/meteorological assessment. For example, bitter cold and windy days equate to a significant reduction in risk as they both inhibit vaporisation and help to dissipate the toxic agent. Less PPE will be required. This system can be deployed without any additional equipment, and responders already have a substantial relevant base of knowledge that simply needs doctrinal redirection. With two paramedics, we have begun to bring order to the chaos. What level of PPE do they need? Let’s do some more risk analysis. We know that the environment is clean enough for people to live without any PPE and therefore it isn’t a low oxygen environment so self- contained breathing apparatus (SCBA) is not warranted. An air purifying respirator should serve them well. We know that they haven’t touched a single patient. They aren’t supposed to touch any patients. They are there to direct traffic. There may be some particulates or aerosols so some dermal protection would be warranted. They certainly do not need a vapour tight ensemble with a dozen layers of gloves. This CONOPS does not solve all our


problems, and it does not get everyone on the same page. There is still a major discrepancy between the UK’s emphasis on dry decon and the US fire service’s insistence on wet. It is intended to create a common operational picture based on common language using common doctrine. While some may legitimately argue that many EMS systems do not maintain a level of operational proficiency in hazmat and would be unlikely to meet the commitment to training and drilling on the new CONOPS, that might not be necessary. The medical knowledge necessary to perform primary or secondary triage is rudimentary. You don’t have to be a seasoned paramedic, and certainly do not need to be the Grim Reaper’s superhero nemesis to do this job. You


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