1. CHEMPACK Field & Hospital Response Procedures for Nerve Agent Incidents

2.  Explain what responders should do when they recognize a potential nerve agent incident  Determine when to request deployment of CHEMPACK assets  Describe notification procedures observed during the response  List steps taken to deploy CHEMPACK assets  Explain required after-action documentation 2

3.  At 5:35 pm on Wednesday, Oct. 8 th, a traveling freight train derails.  26 of the train’s 79 cars are affected. MoDOT placards indicate that four of these cars contain hazardous materials.  The cause of the accident is unknown. 3 Scenario Background

4.  At 5:36 pm, an overturned tank car from the derailed train is struck by a commuter train traveling at 35 miles per hour.  The commuter train is carrying 297 passengers. 4

5.  According to the MoDOT placard, the tank car contains organophosphate pesticides.  The tank is breached, spilling approximately 10,000 gallons of the chemical. 5

6. Scenario Background  A number of passengers and bystanders call 911 from their cell phones  Between 5:37 pm – 6:15 pm, multiple calls are received by the Missouri state and local police. 6

7.  The first patrol car arrives on scene at 5:44 pm.  As of 6:05 pm, most passengers have been able to evacuate the train on their own, though as many as 40 passengers in the first three cars have sustained serious injuries. 7

8. What should be the initial action of a first responder upon arriving at the scene? 8

9. 9 NERVE AGENT INCIDENT OCCURS First responder on scene calls associated dispatch (Police/Fire/EMS) to report suspected nerve agent incident Dispatch informs Command staff

10.  Information about the incident ◦ Hazardous material ◦ Severity of exposure  Information about the victims ◦ Estimated number of victims ◦ Common medical needs  Information about the response efforts ◦ Updates on decontamination efforts ◦ Location of stating area at the incident scene ◦ Information regarding access, best route for approach 10

11.  As of 6:10 pm, the extent of potential nerve agent exposure is unknown.  Several passengers evacuated from the train are vomiting and complaining of nausea, dizziness and blurred vision. Two passengers are experiencing seizures. 11

12. What should be the initial action of the command personnel when they learn of the size and scope of the incident? 12

13. 13 NERVE AGENT INCIDENT OCCURS First responder on scene calls associated dispatch (Police/Fire/EMS) to report suspected nerve agent incident Dispatch informs Command staff Command Staff commits additional resources, dispatch deploys resources to the scene.

14. 14 Command personnel should commit additional resources to respond to the incident.  Resources may include: ◦ Ambulances ◦ Hazmat teams ◦ Mobile Decontamination Units (MDUs) ◦ Personal Protective Equipment (PPE) ◦ Other personnel and supplies

15. 15 NERVE AGENT INCIDENT OCCURS First responder on scene calls associated dispatch (Police/Fire/EMS) to report suspected nerve agent incident Dispatch informs Command staff Command Staff commits additional resources, dispatch deploys resources to the scene. Alert all area hospitals Prepare CHEMPACK for transport Transportation decisions made

16. Since a suspected nerve agent incident would qualify as a Hazardous Material event, the Incident Commander would most likely be the ___________ ? 16

17. 17 Since a suspected nerve agent incident would qualify as a Hazardous Material event, the Incident Commander would most likely be the Fire Chief or another representative of Fire Services.

18. 18 Initiate Incident Response Incident Commander & Deputy Incident Commander Incident Commander & Deputy Incident Commander Safety Officer Medical Branch HazMat Branch Finance & Administration Section Operations Section Planning & Intelligence Section Logistics Section

19. 19 NERVE AGENT INCIDENT OCCURS First responder on scene calls associated dispatch (Police/Fire/EMS) to report suspected nerve agent incident Dispatch informs Command staff Command Staff commits additional resources, dispatch deploys resources to the scene. Additional responders arrive on scene, initiate incident response: Establish ICS Don appropriate PPE Establish staging area Establish decon area

20. 20

21.  25 responders are on the scene, helping to evacuate the last victims from the train.  Over 100 victims are complaining of headache, blurred vision, and tightness in chest. A dozen people are experiencing seizures. 21

22. One configuration ◦ EMS 22

23. 23 EMS CHEMPACK Configuration (454 Casualties) Unit PackCasesQuantity Mark-1 auto-injector kit24051200 Atropine Sulfate 0.4 mg/ml 20 ml1001 Pralidoxine 1 Gm inj. 20 ml2761 Atropen 0.5 mg1441 Atropen 1.0 mg1441 Diazepam 5 mg/ml auto-injector1502300 Diazepam 5 mg/ml vial, 10 ml25250 Sterile water for injection 20cc vials1002200 CHEMPACK Configurations: EMS

24. 1. Unlock the padlock 2. Break the plastic seal across the container door 3. Slide open the deadbolts on either side of the container 4. Use the canvas strap to pull the front door panel upwards 5. Pull the door panel out from the bottom of the container and remove 24

25. 25

26.  The host hospital received the request for CHEMPACK assets at 5:51 pm.  CHEMPACK assets were ready for transfer by 6:12 pm. 26

27. 27 Designated personnel open CHEMPACK container, remove and sort contents, prepare material for transfer Transport of CHEMPACK antidotes from host facility to field and treatment hospital (if needed) CHEMPACK assets delivered to the incident scene CHEMPACK assets delivered to receiving hospitals.

28. What organization picks up the CHEMPACK assets and transports them to the incident scene and to the nearby non-host hospitals? 28

29. 29 EMS or Law Enforcement will pick up the CHEMPACK assets and transport them to the incident scene and to the nearby treating hospital.

30. 30 Transport of CHEMPACK antidotes from host hospital to field and treating hospital (if needed) EMS/ LE arrives to pick up antidotes for transport to incident scene Local 911 dispatch works with EMS and hospitals to coordinate transport of patients to area hospitals CHEMPACK assets delivered, first responder takes custody of material Field responders triage and treat patients using CHEMPACK antidotes Field responders transport patients to area hospitals

31. 31 Administer one auto-injector to patients demonstrating the signs and symptoms of mild nerve agent exposure.

32.  CHEMPACK assets were delivered to the incident scene.  All victims have been evacuated, and gross decontamination is underway.  Over 150 victims are complaining of headaches, blurred vision, and tightness in chest.  3 victims are in acute respiratory distress. 32

33.  CHEMPACK assets were delivered to the non-host hospital at 6:37 pm.  30 victims of the crash left the scene and went directly to the two closest hospitals.  An additional 150 area residents have presented to area hospitals with complaints of nausea and shortness of breath. None were within 500 yards of the crash. 33

34. Host Hospital Facility Additional Treating Hospital 34 Determined quantity of antidotes needed for the Emergency Room (ER) ER Personnel treat patients transported via ambulance ER Personnel Decon patients self-presenting from scene Determined quantity of antidotes needed for Emergency Room (ER) at an additional treating hospital ER Personnel treat patients transported via ambulance ER Personnel Decon patients self-presenting from scene ER Personnel treat patients

35.  At 10:07 pm, the last of the 297 victims were treated and transported to area hospitals.  33 patients showed the signs and symptoms of severe nerve agent exposure. One of these patients died at the scene.  64 patients showed the signs and symptoms moderate nerve agent exposure.  200 patients were treated for mild nerve agent exposure. 35

36.  Collaborative process, involving incident commander, dispatchers and CHEMPACK host facility  Describe incident, including timeline, location and agencies involved  Critique effectiveness of CHEMPACK deployment  Inventory used and unused CHEMPACK material 36

37.  38 CHEMPACKs strategically located across Missouri 37

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39.  What should responders do when they recognize a potential nerve incident?  When should responders request deployment of CHEMPACK assets?  What notification procedures should be observed during the response?  What steps should be taken to deploy CHEMPACK assets?  What kind of after-action documentation is required? 39