1. Decontamination Public Health CBRN course Daniel Kollek, MD, FRCPC
Questions
You would wear your highest level of PPE in:
1- the hot zone (correct answer)
2- the warm zone
3- the cold zone
4- your local bar
Patient otherwise well but needing decontamination should flow
1- cold>warm>hot>release patient
2- warm>hot>cold>release patient
3- hot>warm>cold>release patient (correct answer)
4- order is irrelevant as long as all zones are crossed once
Which of the following is not a decontamination method?
1- Mechanical
2- Ventilation (correct answer)
3- Absorption
4- Degradation

2. To provide an overview of Decontamination and PPE
Goals of session
To provide an overview of
Decontamination and PPE

3. Outline of session Erroneous assumptions Decontamination concepts
Biological vs Chemo/Radiation
People vs. Places & Objects
Hot/Warm/Cold zones
Decontamination methods
Streaming by acuity
PPE levels

4. Common erroneous assumptions
All contaminated victims will be decontaminated at the scene
Patients will only go to designated hospitals
Victims will arrive via the EMS system
Victims at a non designated hospital can be safely transported to the appropriate site
Ideally you want to decontaminate on site but in a 6 year review in the US covering 72 incidents not one was decontaminated at the scene.
Tokyo experience showed that incoming patient flow was unpredictable
“Hazardous Materials” Levitin& Siegelson, Emerg. Med. Clin. Of N.Am. Vol 14 No2, May 1996,

5. Reasons for Decontamination
Prevent the spread of chemicals or biological agents from the area of initial release
Remove chemicals or radionucleides from the patient to terminate their exposure
Reduce the need for PPE among those providing care
Prevent accidental exposure to responder/receiver while removing PPE ensembles
Simply defined, decontamination is the process of removing or neutralizing hazardous substances from persons, equipment, supplies or facilities. The purpose of decontamination as it is performed during a HazMat incident response is to confine contamination to areas already contaminated, rather than spreading it to clean areas. For hospital personnel, the decontamination process is a necessary step in HazMat patient care because 1) removing toxic substances from patients limits their exposure to the poison, and 2) a contaminated patient can cause toxic exposure injury to hospital personnel and spread the poison throughout the facility. In addition, decontamination of those wearing protective ensembles during a HazMat incident provides insurance against transferring the hazardous material from the outside of the suit to the person wearing it.

6. Key concept # 1 - Biohazards
Staff treating biological (infected) patients need appropriate PPE only (as determined by routine practice & additional precautions)
Need for isolation of patients depends on pathogen and or syndrome
Infected patients do not need formal decontamination

7. Key concept # 2 Contaminated objects or sites
Need to decide if area should be closed
Need to decide if people should be isolated or decontaminated

8. Close the site?

9. Decontaminate the people?
Leave clothes
on site if possible

10. Key concept # 3 Methods of decontamination
Mechanical
Dilution
Absorption
Degradation

11. Mechanical: Clothing Removal
First step in patient decontamination
Removes majority of contaminant
Only form of decon necessary in
vapor/aerosol exposure
Should be performed outside of treatment areas
Privacy/personal space essential
Clothing may need containment

12. Dilution: Soap & Water Shower
Necessary for liquid or solid contamination
Dilutes the offending agent
Washes away the toxin
Decreases the rate of chemical reaction
Restores normal skin pH
Can usually be self-administered
Consider run-off containment

13. Key concept # 4 Hot, Warm and Cold zones
Personnel must be prepared to conduct emergency decontamination and to set up a decontamination corridor.
Select and secure a large area upwind and uphill of the hot zone. Provide protection for and be able to accommodate the decontamination of large numbers of victims. Base an emergency decontamination operation on speed rather than on neatness.
The decontamination process has the potential of creating a hazard. Notify the proper authorities downstream if personnel cannot confine runoff to the incident scene. To reduce this hazard, personnel must:
Control decontamination runoff as best as possible. Know where it is going and ensure that it will not flow into clean areas. Coordinate with local environmental management officials if possible. Confinement may be critical if radiological materials are involved. Establish measures for decontamination of fatalities. One method is the establishment of an additional lane within the decontamination corridor. Consider the psychological implications of co-location with living victims and the potential need for autopsy for evidence as factors in determining where to establish decontamination facilities for fatalities.
Hot Zone
Contaminated area
Need PPE
Warm Zone
Contamination reduction
Cold Zone
Normal function

14. Key concept # 4 Hot, Warm and Cold zones
You will be here. Public Health does not usually decontaminate or function in the hot zone
Personnel must be prepared to conduct emergency decontamination and to set up a decontamination corridor.
Select and secure a large area upwind and uphill of the hot zone. Provide protection for and be able to accommodate the decontamination of large numbers of victims. Base an emergency decontamination operation on speed rather than on neatness.
The decontamination process has the potential of creating a hazard. Notify the proper authorities downstream if personnel cannot confine runoff to the incident scene. To reduce this hazard, personnel must:
Control decontamination runoff as best as possible. Know where it is going and ensure that it will not flow into clean areas. Coordinate with local environmental management officials if possible. Confinement may be critical if radiological materials are involved. Establish measures for decontamination of fatalities. One method is the establishment of an additional lane within the decontamination corridor. Consider the psychological implications of co-location with living victims and the potential need for autopsy for evidence as factors in determining where to establish decontamination facilities for fatalities.
Hot Zone
Contaminated area
Need PPE
Warm Zone
Contamination reduction
Cold Zone
Normal function

15. Zone rules Isolate cadavers
Very limited treatment before decontamination
Control access to zones
Temporary
Morgue
Decontamination direction No back flow!!
Personnel must be prepared to conduct emergency decontamination and to set up a decontamination corridor.
Select and secure a large area upwind and uphill of the hot zone. Provide protection for and be able to accommodate the decontamination of large numbers of victims. Base an emergency decontamination operation on speed rather than on neatness.
The decontamination process has the potential of creating a hazard. Notify the proper authorities downstream if personnel cannot confine runoff to the incident scene. To reduce this hazard, personnel must:
Control decontamination runoff as best as possible. Know where it is going and ensure that it will not flow into clean areas. Coordinate with local environmental management officials if possible. Confinement may be critical if radiological materials are involved. Establish measures for decontamination of fatalities. One method is the establishment of an additional lane within the decontamination corridor. Consider the psychological implications of co-location with living victims and the potential need for autopsy for evidence as factors in determining where to establish decontamination facilities for fatalities.
Hot Zone
Contaminated area
Need PPE
Warm Zone
Contamination reduction
Cold Zone
Normal function

16. Clean / Dirty Line

17. Key concept # 5 Minor incident vs. MCI
Not everyone needs formal decontamination
Decontamination should be streamed by acuity or ambulatory ability

18. Decontamination Triage
Serious medical/chemical signs and symptoms get urgent decontamination
Moderate signs or symptoms, or confirmed liquid exposure- delayed decontamination
Minimal signs and symptoms, or vapor exposure will follow the delayed patients
No signs and symptoms, or potential for exposure, but remain significantly concerned re contamination will be processed last- “psychological decontamination”
Decontamination triage utilizes the same principles as the RPM method in assessing clinical signs and symptoms, with the additional feature of assessing the type and risk of exposure to decide on the urgency for decontamination.
Liquid exposure due to its persistency poses a greater ongoing risk to the patient than vapour exposure therefore they are triaged for more urgent decontamination
Following assessment of the ABCs, and having already tagged black, green and red patients, the remainder of the algorithm focuses on which yellow patients should proceed through the decontamination process first. Any patients displaying serious signs and symptoms, either chemical or medical, will be the first patients to be decontaminated. These patients will require rapid decontamination. Patients exhibiting moderate signs or symptoms, or have a confirmed liquid exposure, will be processed once the rapid patients are completed, and will be completed in a normal decontamination fashion.
The National Chemical Stockpile Emergency Preparedness Program (CSEPP) Medical Curriculum 2002
Those with minimal signs and symptoms, or vapor exposure will follow the moderate personnel, and processed in a normal fashion.
As with non-ambulatory patients, ambulatory patients tagged minimal can be prioritized for the decontamination process. It is possible that these patients may decompensate while waiting for decontamination, so signs and symptoms must be monitored carefully. However, it is more likely that these patients will be prioritized by the level of exposure that may have been contacted.
Those patients who have no signs and symptoms, and have no potential for exposure, but still remain significantly concerned regarding exposure will require “psychological decon”, which is removing the outer clothing layer, and a quick shower. Many of these patients may not have been anywhere near the release, however may fear that they will have ill effects. These people may decide not to go through the process once they discover that they must remove clothing and personal belonging, and as long as it can be confirmed that the patient was truly not exposed.

19. Chemical MCI - Ambulatory

20. Chemical MCI – Non-ambulatory

21. Key decon. concepts Protect yourself and your staff
Containment of people & contaminants
Appropriate PPE (& know how to use it!)
Define the Hot and Cold zones
Triage in or before Hot zone
Secure the perimeter
Very limited care (if at all) in Hot zone
Stream patients by acuity
Integrate the decontamination plan into the general disaster plan
Not everyone needs a shower

22. PPE levels
When response activities are conducted where atmospheric contamination is known or suspected to exist, personal protective equipment (PPE) must be worn. Personal protective equipment is designed to prevent/reduce skin and mucous membrane contact as well as inhalation or ingestion of the chemical substance. Protective equipment to protect the body against contact with known or anticipated chemical hazards has been divided into four categories, levels A-D.
Level A - To be selected when the greatest level of skin, respiratory, and eye protection is required.  The following constitute Level A equipment:
1. Positive pressure, full face-piece self-contained breathing apparatus (SCBA), or positive pressure supplied air respirator with escape SCBA, approved by the National Institute for Occupational Safety and Health (NIOSH).
2. Totally-encapsulating chemical-protective suit.
3. Coveralls.  (as needed)
4. Long underwear.  (as needed)
5. Gloves, outer, chemical-resistant.
6. Gloves, inner, chemical-resistant.
7. Boots, chemical-resistant, steel toe and shank.
8. Hard hat (under suit).  (as needed)
9. Disposable protective suit, gloves and boots (depending on suit construction, may be worn over totally-encapsulating suit).
EPA
Level "A" Response Personal Protective Equipment -required when the greatest potential for exposure to hazards exists, and when the greatest level of skin, respiratory and eye protection is required. These fully encapsulating suits afford protection against petroleum products and halogenated hydrocarbons, as well as against nerve and blister agents.
OSHA Level B - The highest level of respiratory protection is necessary but a lesser level of skin protection is needed.  The following constitute Level B equipment:
1. Positive pressure, full-facepiece self-contained breathing apparatus (SCBA), or positive pressure supplied air respirator with escape SCBA (NIOSH approved).
2. Hooded chemical-resistant clothing (overalls and long-sleeved jacket; coveralls; one or two-piece chemical-splash suit; disposable chemical-resistant overalls).
3. Coveralls.(as needed)
4. Gloves, outer, chemical-resistant.
5. Gloves, inner, chemical-resistant.
6. Boots, outer, chemical-resistant steel toe and shank.
7. Boot-covers, outer, chemical-resistant (disposable).  (as needed)
8. Hard hat.  (as needed)
9. [Reserved]
10. Face shield.  (as needed)
Level "B" Personal Protective Equipment - required under circumstances requiring the highest level of respiratory protection, with a lesser level of skin protection. EPA's ERT has both fully encapsulating suits that provide for additional splash protection and coveralls that are used in situations where splash hazards are not anticipated or expected.
OSHA
Level C - The concentration(s) and type(s) of airborne substance(s) is known and the criteria for using air purifying respirators are met.  The following constitute Level C equipment:
1. Full-face or half-mask, air purifying respirators (NIOSH approved). 
2. Hooded chemical-resistant clothing (overalls; two-piece chemical-splash suit; disposable chemical-resistant overalls).
6. Boots (outer), chemical-resistant steel toe and shank.  (as needed)
9. Escape mask.  (as needed)
From --
Additional OSHA Notes
Support Function Protective Garment (meets NFPA 1993)              
Full-facepiece, air-purifying, canister-equipped respirator              
Chemical resistant gloves and safety boots              
Two-way communications system, hard hat
From --
Level "C" Personal Protective Equipment - used when the concentration and type of airborne substances is known, and the criteria for using air-purifying respirators are met.
Level D - A work uniform affording minimal protection: used for nuisance contamination only.  The following constitute Level D equipment:
1. Coveralls.
2. Gloves.  (as needed)
3. Boots/shoes, chemical-resistant steel toe and shank.
4. Boots, outer, chemical-resistant (disposable).  (as needed)
5. Safety glasses or chemical splash goggles.  (as needed)
6. Hard hat.  (as needed)
7. Escape mask.  (as needed)
8. Face shield.  (as needed)
Coveralls, safety boots/shoes, safety glasses or chemical splash goggles
No danger of chemical exposure exists.  Current recommendations for PPE to be used in situations of radiation contamination suggest only Level D type protection plus a dust filter for respiratory protection.
EPA Levels of Protection
When response activities are conducted where atmospheric contamination is known or suspected to exist, personal protective equipment must be worn. Personal protective equipment is designed to prevent/reduce skin and eye contact as well as inhalation or ingestion of the chemical substance. Protective equipment to protect the body against contact with known or anticipated chemical hazards has been divided into four categories.
LEVEL A
Level A protection should be worn when the highest level of respiratory, skin, eye and mucous membrane protection is needed.
Personal Protective Equipment
Positive pressure (pressure demand), self contained breathing apparatus (NIOSH approved), or positive-pressure supplied air respirator with escape SCBA. Fully encapsulating chemical protective suit. Gloves, inner, chemical resistant. Gloves, outer, chemical resistant. Boots, chemical resistant, steel toe and shank; (depending on suit boot construction, worn over or under suit boot.) Underwear, cotton, long-john type.* Hard hat (under suit).* Coveralls (under suit).* Two-way radio communications (intrinsically safe/non-sparking).* * Optional
LEVEL B
Level B protection should be selected when the highest level of respiratory protection is needed, but a lesser level of skin and eye protection. Level B protection is the minimum level recommended on initial site entries until the hazards have been further identified and defined by monitoring, sampling, and other reliable methods of analysis, and equipment corresponding with those findings utilized.
Positive-pressure (pressure-demand), self-contained breathing apparatus (NIOSH approved), or positive-pressure supplied air respirator with escape SCBA. Chemical resistant clothing (overalls and long-sleeved jacket, coveralls, hooded two-piece chemical splash suit, disposable chemical resistant coveralls.) Coveralls (under splash suit).* Gloves, outer, chemical resistant. Gloves, inner, chemical resistant. Boots, outer, chemical resistant, steel toe and shank. Boot-covers, chemical resistant (disposable).* Two-way radio communications (intrinsically safe).* Hard hat. * Faceshield.*
* Optional
LEVEL C
Level C protection should be selected when the type of airborne substance is known, concentration measured, criteria for using air-purifying respirators met, and skin and eye exposure is unlikely. Periodic monitoring of the air must be performed.
Full-face or half-mask, air-purifying respirator (NIOSH approved). Chemical resistant clothing (one piece coverall, hooded two piece chemical splash suit, chemical resistant hood and apron, disposable chemical resistant coveralls.) Gloves, outer, chemical resistant. Gloves, inner, chemical resistant. Boots, steel toe and shank, chemical resistant. Boot-covers, chemical resistant.* Cloth coveralls (inside chemical protective clothing).* Two-way radio communications (intrinsically safe).* Hard hat. * Escape mask. * Faceshield.*
LEVEL D
Level D is primarily a work uniform and is used for nuisance contamination only. It requires only coveralls and safety shoes/boots. Other PPE is based upon the situation (types of gloves, etc.). It should not be worn on any site where respiratory or skin hazards exist. Refer to The Office of Emergency and Remedial Response. Environmental Response, Division. See "Interim Standard Operating Safety Procedures" for full details.
The type of environment and the overall level of protection should be reevaluated periodically as the amount of information about the site increases and as workers are required to perform different tasks.
Reasons to upgrade to a higher level (D is lowest, A is highest)
Known or suspected presence of dermal hazards Occurrence or likely occurrence of gas or vapor emission Change in work task that will increase contact or potential contact with hazardous materials Request of the individual performing the task
Reasons to downgrade:
New information indicating that the situation is less hazardous than was originally thought Change in site conditions that decreases the hazard Change in work task that will reduce contact with hazardous materials

23. PPE level A
This is the level you are most likely to see in the Hot Zone of a significant event.
It is entirely self contained with SCBA and fully encapsulated.
Level A - To be selected when the greatest level of skin, respiratory, and eye protection is required.  The following constitute Level A equipment:
1. Positive pressure, full face-piece self-contained breathing apparatus (SCBA), or positive pressure supplied air respirator with escape SCBA, approved by the National Institute for Occupational Safety and Health (NIOSH).
2. Totally-encapsulating chemical-protective suit.
3. Coveralls.  (as needed)
4. Long underwear.  (as needed)
5. Gloves, outer, chemical-resistant.
6. Gloves, inner, chemical-resistant.
7. Boots, chemical-resistant, steel toe and shank.
8. Hard hat (under suit).  (as needed)
9. Disposable protective suit, gloves and boots (depending on suit construction, may be worn over totally-encapsulating suit).
EPA
Level "A" Response Personal Protective Equipment -required when the greatest potential for exposure to hazards exists, and when the greatest level of skin, respiratory and eye protection is required. These fully encapsulating suits afford protection against petroleum products and halogenated hydrocarbons, as well as against nerve and blister agents.
LEVEL A
Level A protection should be worn when the highest level of respiratory, skin, eye and mucous membrane protection is needed.
Personal Protective Equipment
Positive pressure (pressure demand), self contained breathing apparatus (NIOSH approved), or positive-pressure supplied air respirator with escape SCBA. Fully encapsulating chemical protective suit. Gloves, inner, chemical resistant. Gloves, outer, chemical resistant. Boots, chemical resistant, steel toe and shank; (depending on suit boot construction, worn over or under suit boot.) Underwear, cotton, long-john type.* Hard hat (under suit).* Coveralls (under suit).* Two-way radio communications (intrinsically safe/non-sparking).* * Optional
LEVEL B
Level B protection should be selected when the highest level of respiratory protection is needed, but a lesser level of skin and eye protection. Level B protection is the minimum level recommended on initial site entries until the hazards have been further identified and defined by monitoring, sampling, and other reliable methods of analysis, and equipment corresponding with those findings utilized.
Positive-pressure (pressure-demand), self-contained breathing apparatus (NIOSH approved), or positive-pressure supplied air respirator with escape SCBA. Chemical resistant clothing (overalls and long-sleeved jacket, coveralls, hooded two-piece chemical splash suit, disposable chemical resistant coveralls.) Coveralls (under splash suit).* Gloves, outer, chemical resistant. Gloves, inner, chemical resistant. Boots, outer, chemical resistant, steel toe and shank. Boot-covers, chemical resistant (disposable).* Two-way radio communications (intrinsically safe).* Hard hat. * Faceshield.*
* Optional
LEVEL C
Level C protection should be selected when the type of airborne substance is known, concentration measured, criteria for using air-purifying respirators met, and skin and eye exposure is unlikely. Periodic monitoring of the air must be performed.
Full-face or half-mask, air-purifying respirator (NIOSH approved). Chemical resistant clothing (one piece coverall, hooded two piece chemical splash suit, chemical resistant hood and apron, disposable chemical resistant coveralls.) Gloves, outer, chemical resistant. Gloves, inner, chemical resistant. Boots, steel toe and shank, chemical resistant. Boot-covers, chemical resistant.* Cloth coveralls (inside chemical protective clothing).* Two-way radio communications (intrinsically safe).* Hard hat. * Escape mask. * Faceshield.*
LEVEL D
Level D is primarily a work uniform and is used for nuisance contamination only. It requires only coveralls and safety shoes/boots. Other PPE is based upon the situation (types of gloves, etc.). It should not be worn on any site where respiratory or skin hazards exist. Refer to The Office of Emergency and Remedial Response. Environmental Response, Division. See "Interim Standard Operating Safety Procedures" for full details.
The type of environment and the overall level of protection should be reevaluated periodically as the amount of information about the site increases and as workers are required to perform different tasks.
Reasons to upgrade to a higher level (D is lowest, A is highest)
Known or suspected presence of dermal hazards Occurrence or likely occurrence of gas or vapor emission Change in work task that will increase contact or potential contact with hazardous materials Request of the individual performing the task
Reasons to downgrade:
New information indicating that the situation is less hazardous than was originally thought Change in site conditions that decreases the hazard Change in work task that will reduce contact with hazardous materials

24. PPE level B
This is the level you are most likely to see in the Hot Zone of a less hazardous event or in the warm zone.
It is still fully encapsulated and maybe self contained or not.
OSHA Level B - The highest level of respiratory protection is necessary but a lesser level of skin protection is needed.  The following constitute Level B equipment:
1. Positive pressure, full-facepiece self-contained breathing apparatus (SCBA), or positive pressure supplied air respirator with escape SCBA (NIOSH approved).
2. Hooded chemical-resistant clothing (overalls and long-sleeved jacket; coveralls; one or two-piece chemical-splash suit; disposable chemical-resistant overalls).
3. Coveralls.(as needed)
4. Gloves, outer, chemical-resistant.
5. Gloves, inner, chemical-resistant.
6. Boots, outer, chemical-resistant steel toe and shank.
7. Boot-covers, outer, chemical-resistant (disposable).  (as needed)
8. Hard hat.  (as needed)
9. [Reserved]
10. Face shield.  (as needed)
EPA
Level "B" Personal Protective Equipment - required under circumstances requiring the highest level of respiratory protection, with a lesser level of skin protection. EPA's ERT has both fully encapsulating suits that provide for additional splash protection and coveralls that are used in situations where splash hazards are not anticipated or expected.
LEVEL B
Level B protection should be selected when the highest level of respiratory protection is needed, but a lesser level of skin and eye protection. Level B protection is the minimum level recommended on initial site entries until the hazards have been further identified and defined by monitoring, sampling, and other reliable methods of analysis, and equipment corresponding with those findings utilized.
Personal Protective Equipment
Positive-pressure (pressure-demand), self-contained breathing apparatus (NIOSH approved), or positive-pressure supplied air respirator with escape SCBA. Chemical resistant clothing (overalls and long-sleeved jacket, coveralls, hooded two-piece chemical splash suit, disposable chemical resistant coveralls.) Coveralls (under splash suit).* Gloves, outer, chemical resistant. Gloves, inner, chemical resistant. Boots, outer, chemical resistant, steel toe and shank. Boot-covers, chemical resistant (disposable).* Two-way radio communications (intrinsically safe).* Hard hat. * Faceshield.*
* Optional

25. PPE level C
This is the level you are most likely to see in the cold zone, in transit and the hospital.
Full-face or half-mask or air-purifying respirator
Chemical resistant clothing
Gloves
Not self contained.
OSHA
Level C - The concentration(s) and type(s) of airborne substance(s) is known and the criteria for using air purifying respirators are met.  The following constitute Level C equipment:
1. Full-face or half-mask, air purifying respirators (NIOSH approved). 
2. Hooded chemical-resistant clothing (overalls; two-piece chemical-splash suit; disposable chemical-resistant overalls).
3. Coveralls.  (as needed)
4. Gloves, outer, chemical-resistant.
5. Gloves, inner, chemical-resistant.
6. Boots (outer), chemical-resistant steel toe and shank.  (as needed)
7. Boot-covers, outer, chemical-resistant (disposable).  (as needed)
8. Hard hat.  (as needed)
9. Escape mask.  (as needed)
10. Face shield.  (as needed)
From --
Additional OSHA Notes
Support Function Protective Garment (meets NFPA 1993)              
Full-facepiece, air-purifying, canister-equipped respirator              
Chemical resistant gloves and safety boots              
Two-way communications system, hard hat
From --
EPA
Level "C" Personal Protective Equipment - used when the concentration and type of airborne substances is known, and the criteria for using air-purifying respirators are met.
LEVEL C
Level C protection should be selected when the type of airborne substance is known, concentration measured, criteria for using air-purifying respirators met, and skin and eye exposure is unlikely. Periodic monitoring of the air must be performed.
Personal Protective Equipment
Full-face or half-mask, air-purifying respirator (NIOSH approved). Chemical resistant clothing (one piece coverall, hooded two piece chemical splash suit, chemical resistant hood and apron, disposable chemical resistant coveralls.) Gloves, outer, chemical resistant. Gloves, inner, chemical resistant. Boots, steel toe and shank, chemical resistant. Boot-covers, chemical resistant.* Cloth coveralls (inside chemical protective clothing).* Two-way radio communications (intrinsically safe).* Hard hat. * Escape mask. * Faceshield.*
* Optional

26. PPE level D Used for nuisance contamination only.
It requires only coveralls or equivalent and safety shoes/boots or equivalent.
OSHA
Level D - A work uniform affording minimal protection: used for nuisance contamination only.  The following constitute Level D equipment:
1. Coveralls.
2. Gloves.  (as needed)
3. Boots/shoes, chemical-resistant steel toe and shank.
4. Boots, outer, chemical-resistant (disposable).  (as needed)
5. Safety glasses or chemical splash goggles.  (as needed)
6. Hard hat.  (as needed)
7. Escape mask.  (as needed)
8. Face shield.  (as needed)
From --
Coveralls, safety boots/shoes, safety glasses or chemical splash goggles
From --
No danger of chemical exposure exists.  Current recommendations for PPE to be used in situations of radiation contamination suggest only Level D type protection plus a dust filter for respiratory protection.
LEVEL D
Level D is primarily a work uniform and is used for nuisance contamination only. It requires only coveralls and safety shoes/boots. Other PPE is based upon the situation (types of gloves, etc.). It should not be worn on any site where respiratory or skin hazards exist. Refer to The Office of Emergency and Remedial Response. Environmental Response, Division. See "Interim Standard Operating Safety Procedures" for full details.
The type of environment and the overall level of protection should be reevaluated periodically as the amount of information about the site increases and as workers are required to perform different tasks.

27. PPE levels Reasons to upgrade Reasons to downgrade:
Known or suspected presence of dermal hazards
Occurrence or likely occurrence of gas or vapor emission
Change in work task that will increase contact or potential contact with hazardous materials
Request of the individual performing the task
Reasons to downgrade:
New information indicating that the situation is less hazardous than was originally thought
Change in site conditions that decreases the hazard
Change in work task that will reduce contact with hazardous materials

28. Summary
Receiving facilities all need some form of decontamination plan, assume everyone arrives dirty
Biological, Chemical and Radioactive contamination have different decontamination and isolation requirements
People, Places & Objects have decontamination and isolation protocols
Divide the decontamination area and the impact site into Hot/Warm/Cold zones and stream patients by acuity
PPE levels vary by the agent