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Doing Decon

There have been several instances in late 2009 and early 2010 that highlight the need for emergency decontamination at health care facilities. People contaminated with a hazardous material showing up at random to emergency departments or other health care location poses untold risks to the health care provider, the facility, other patients, and the community. A recent such event at a walk-in urgent care clinic underscored these risks. With the number of walk-in care, urgent care and retail health clinics growing, the issue of emergency decontamination needs to be revisited.

Lets start with the understanding that there is a difference between chemical, biological, and radiological contamination. Chemicals and radiological material is perhaps the most concerning as the longer the material remains in contact with the person, the greater the exposure and subsequent effects will be. Also, if externally contaminated the person may be able to "off gas" or spread the contamination. With chemical materials off-gassing can cause serious inhalation and mucous membrane irritation and secondary contamination in other people. The facility can likewise become contaminated. The spread of radiological contamination has a higher risk of secondary contamination...although the onset of effects will most likely be delayed...and the possibility for occult contamination and extended cleanup measures will be needed. Biological contamination can take the form of a person ill with a disease (flu) or the presence of disease containing solid anthrax in a powder. We should point out here that a difference exists between exposure, contamination and reasonable risk. Exposure simply means you've come in contact with something and may or may not suffer from it. When we talk about exposure we usually are not overly concerned with decontamination unless visible product remains on the person or clothing. Contamination commonly indicates that a residue or material remains on the victim and that material is able to be spread. Contamination comes in two forms...external - able to be spread and internal - not able to be spread. A person who ingests a radiological source most likely would not be capable of spreading that contamination nor would a victim exposed to vapor or gases unless the vapors permiated the clothing. The point is that once a material is inside the body the risk of secondary contamination is much less as is the need for decontamination. Reasonable risk exists when a person has been in an area and, with or without symptoms, is anticipated to have been exposed or contaminated...prophylactic decontamination is warranted.

So, the big question is; who should do decon? At an emergency scene the issue is clear that the jurisdiction having authority in a chem/bio/rad event (most often the fire department) should provide or cause to provide decontamination. The use of low pressure, high volume water streams and improvised shelters may be used in emergency mass decontamination, while specially trained hazardous materials teams may provide a more refined and specific decontamination. The problems begin to arise when victims begin to self-refer to emergency departments or clinics... that is they leave the scene prior to the arrival of traditional responders. This poses a major issue as these victims will likely arrive a health care sites with no warning and no clue as to what they may have been exposed to or contaminated with. When this occurs and goes unrecognized, the health care facility, civilians, and health care providers are at risk. Immediate action will be needed to stave off secondary contamination and serious impact.

Now the question becomes; who should do decontamination at a health care facility? This argument has been going on for years and opinions are highly polarized. One opinion often held by health care organizations is that the local responders will not be able to provide decon services at a hospital during such a large event. This camp believes that hospitals must be able to provide decontamination on their own for a period of time. Still others believe that traditional responders will be able to provide protective services to health care sites by way of mutual-aid from surrounding departments. Both points have concerns. First, how do we expect health care providers, security staff, environmental staff, or others to provide decontamination at a health care site? This is often the pool of personnel that is called upon to take training and carry out the functions if needed. The concerns however, loom large. Who will carry out the duties of those assigned to decon? Will the people mentioned above be able to retain the training information and function in protective clothing, including self-contained breathing apparatus? These issues are just the tip of the iceberg.

Second, while many hospitals in the nation have added some type of decontamination shelter or system to meet requirements most, if not all walk-in care, urgent care and retail health care centers have not. As more and more people turn to these clinics rather than emergency departments for routine care, we must realize that the same level of preparedness must exist for these locations. In the non-hospital clinic setting the need for trained traditional responders doing decon operations is even more vital.

Another issue is the logistics of preparedness for decontamination. Tents and shelters must be trained on and practices with. They must be maintained and checked. Self contained breathing apparatus must also be maintained and personnel continually re-familiarized with its use. Other logistical items that are often forgotten are water supply, cleaning solution, lighting, towels, clothing and runoff management. It is simply not enough for a health care facility to purchase a tent and believe they are prepared.

To wrap this up, let me leave you with a few take-home points:
  • Emergency mass decontamination should be done on site of the event whenever possible
  • Hospitals need to be prepared for self-referrals who may be contaminated and that self-referrals can pose a serious risk
  • Traditional and non-traditional responders must be able to recognize the incident indicators of chemical/biological/radiological exposure
  • Keep in mind that simply removing a victims outer clothing can remove 85 to 95% of contamination
  • All victims being transported by ambulance must be decontaminated prior to transport regardless of triage score or severity

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