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Bioterrorism Preparedness: The Basics For America’s Ambulance Providers By Chuck Kearns, MBA, Paramedic The events of September 11, 2001, changed our world forever. For those of us in the ambulance industry our concerns go beyond what many Americans are experiencing. We not only have to worry about our day to day personal lives and families, but we now also have to worry about what we may encounter in our professional lives as the first line providers of public health services. This of course includes our paramount concern, the health and safety of our workforce. The world of weapons of mass destruction (WMD) and bioterrorism preparedness is far too vast for complete explanation in an article of this nature. It is my intention to give you some basics on preparedness for your agency, your crews, and to direct you to some valuable web sites where additional, in-depth information may be retrieved. Weapons of mass destruction include a variety of methods that can be used to destroy physical structures, human beings, or even the sense of security that individuals have for themselves. Weapons of mass destruction can include biological elements, industrial and militarized chemicals, explosives, radioactive elements or other poisonous substances, some of which we come in contact with on a routine basis, such as mercury in thermometers. Whereas, there are a lot of moving pieces to be concerned with in this arena, there are some basic strategies to employ through the use of protocols to mitigate damage that can be done by such destructive forces. On one end of the spectrum is the non-emergency interfacility ambulance service, which may get recruited into a serious public health and safety threat, such as the World Trade Center attack. On the other end of the spectrum is the ambulance service who provides first line of public safety for a community through their own EMS-based HAZMAT team. Clearly, the service with HAZMAT responsibilities is going to be better prepared for terrorist threats than many other agencies, but an awareness and plan can be effective protection for non-HAZMAT, ambulance workforce and assets. If your agency does not provide HAZMAT services, you need to work closely with the HAZMAT public safety agency in your service area to coordinate responses to WMD incidents. Setting up response protocols prior to an event will prove beneficial but it's also important to inform your workforce and train them in what will be expected of them in such an event. Another important aspect of coordinating these situations is to recognize that in most cases of biological agents being used as a weapon, the state and local public health department will, in many instances, be one of the lead agencies in charge, and should be responding early in a bioterrorism incident to help determine what the threat element is. The minimum training for your workforce should include the Department of Justice four-hour, Domestic Preparedness Training course on bioterrorism awareness. All members of your staff should receive this training and increase their understanding of the different threats our industry may face. The Department of Justice makes the training available for free on a CD-ROM, (Version 8.1, is most current). To go along with the training, different levels of personal protective equipment should be provided by your agency to your workforce, depending on the scope of your agency's responsibilities in these situations. These range from Level "A" (most protection), to Level "D" (primary work uniform and safety shoes). There are a couple of principles to bear in mind when dealing with biological weapon scenes or chemical weapon disbursements. The operation area is generally divided into three zones: the Hot zone (Contaminated), the Warm zone (Decontamination Area), and the Cold (Safe) zone. Only those people who are specially trained in hazardous material handling or decontamination should enter the Hot or Warm zones. The highest personal protective equipment needed for them is called a Level "A" suit, which includes vapor barriers and self-contained breathing apparatus. Level "A" suits provide significant protection for the respiratory system, eyes and mucous membranes, by having self-contained breathing apparatus and no exposed skin. This is mandatory equipment for HAZMAT teams but not usually provided or needed, for ambulance services. The next zone is called the Warm zone. In the Warm zone, contamination is still present. Any patients who were in the Hot zone will be removed from the immediate area of exposure to a place where they can be decontaminated. Decontamination takes place in the Warm zone. Generally, there should be two levels of patient decontamination; primary (gross) and secondary, which take place in the Warm zone. The decontamination procedures are usually accomplished by the hazardous materials expert who entered the Hot zone to retrieve patients. Most ambulance services should never have their employees enter a Hot or a Warm zone. Decontaminated patients should be brought to medical treatment sectors and ambulances, which are established in what is called the Cold zone. After a patient is decontaminated twice (which may include their clothing being removed) in the Warm zone, they should be brought to the ambulance personnel in the Cold zone by the HAZMAT technicians. The Cold zone is where most ambulance services need to take special precautions to protect their crews and equipment from any further exposure. It is recommended that medical treatment personnel should have Level "C" suits supplied for their use. Level "C" protection is used when the HAZMAT substance and its concentration is known, respiratory requirements are met by using respirator masks and problematic eye and skin exposure is unlikely. Level "C" suits are made of a paper-like substance called Tyvek, coated with vapor barrier and cost around $30-$50 each. Eye protection, gloves, booties and respirator masks must be worn with Level “C” suits. HEPA masks do not meet the requirements of Level “C” respiratory protective equipment. The interior of your ambulances themselves should also be protected when a decontaminated patient is going to be transferred to a medical facility. The easiest and most basic method to protect the ambulance is to use rolls of visqueen-type plastic and duct tape to completely cover the interior of the ambulance. This will protect the patient compartment so that foreign substances do not render the ambulance an unhealthy environment and possibly eliminate its future use. Having your crews protect the interior of the ambulance is essential because some substances may be so hazardous to human health, the ambulance may have to be decommissioned and never used again. Crews should protect the ambulance while in the staging area and awaiting their patient(s). There are other associated caveats to consider when dealing with WMD situations, such as what type of element was used. In the case of a biological agent, the contaminated area may be as small as a room in a building. However, if a nerve agent such as sarin or VX gas is used as a weapon, the Hot zone could span an area of several miles. These are the reasons I stress a coordinated approach to staging areas with local HAZMAT authorities. It cannot be stressed enough, that unless your crews normally provide HAZMAT services, they must stay away from these areas. Another caution to consider is when an explosion occurs. Rescue workers must be forever mindful that there may be a secondary device that is specifically timed to occur after rescuers arrive in the area, such as the Planned Parenthood clinic bombing in Atlanta, Georgia several years ago. The key aspects of dealing with weapons of mass destruction include coordinating your agency response with the established HAZMAT provider. If there is no HAZMAT provider in your area, consider developing your own HAZMEDIC (hazardous materials paramedic) program. Provide awareness training and Level "C" exposure suits to your employees. Along with the training and suits, equip your ambulances with an appropriate amount of rolled plastic and duct tape to protect the interior of what is essentially a confined space, the patient care compartment. In all events, try to avoid having your agency transport patients who have not been decontaminated. Otherwise, your crew, your ambulance, citizens and the receiving hospital may all be subjected to the same threatening elements. This is called secondary contamination. It is sad that people have died over the envelopes containing anthrax. However, citizens calling 9-1-1, because they received suspicious envelopes should not necessarily receive an ambulance response, unless it is determined that the patient has had a significant exposure and has other medical complaints. The good news, if there is any good news in this attack, is anthrax was probably one of the easier biological elements to control that could have been used against our country. The situation would be much worse today had the terrorists used biological elements that were more communicable and more deadly, such as smallpox or plague. In a sense, using anthrax gave our nation and our industry a "wake up call" that we are able to respond and adapt to. It also raised our awareness of where our preparedness deficiencies are. This article is not intended to be all-inclusive but more of a primer for ambulance agencies responding to WMD events. For further information, please refer to the list of web sites below. In all cases, have your crews be prepared, provide them with the appropriate training and exposure clothing and equipment and remind them to always be cautious. Center for Disease Control
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