1. ED preparation for mass contamination Jaco Slabbert 18 February 2009

2. Introduction Types of contamination Preparation Equipment Decontamination Security and Traffic control Media Cape Town perspective

3. Mass casualty events – ER challenges High impact, low-probability events Delayed notification Self presenting patients Convergence of medical staff Convergence of the media Convergence of family, friends Lack of supplies Less than 20% of victims receive decon on scene High index of suspicion

4. Types of contamination Chemical Biological Radiological Nuclear

5. Chemical contamination Peloponnesian war 429 BC – Spartans and Thebans created a hot fire, and added brimstone and pitch Henry III – finely pulverized lime used by English sailors 1899 Boer War – picric acid WW I – Mustard gas

6. Tokyo subway sarin attack 5510 people seeked medical attention 640 chemically contaminated patients arrived at a single hc facility, using private transport 23% ED staff contaminated In one instance 11 doctors were affected treating 2 patients

7. Preparation Planning – ER layout, hospital’s capacity, outdoor decontamination area. Table top exercise Full-scale, live exercise Virtual live exercise (VLE)

8. VLE University of Alberta Hospital,Edmonton,Ca 136 simulated patients created,using data from actual pt. encounters 15 physicians and 18 nurses MD-delay / Workup-delay Results:↓ pt flow, under-triage Conclusions:inexpensive,discovery of new approaches,triage accuracy

9. Equipment Protection of staff Decontamination of casualties Specialist medical supplies

10. Personal protective equipment Levels A – D A:fully encapsulating chemical-resistant+SCBA Protect head, face and eyes, the ears, the body, the hands and feet. Protect against unknown chemicals B:splash protection,chemical-resistant,SCBA C:full-faced,air-purifying respirator Filter change times monitored D:standard work uniform,gloves,mask

11. Decontamination equipment Scissors Clean, warm or tepid water Buckets (10 litre capacity) Decontaminent/liquid soap : 10 ml added to a 10 litre bucket Sponges/ soft brushes/ wash cloths Disposable towels,gowns,slippers. Blankets Plastic bags and plastic bins Nsaline and drip sets for eye and wound irrigation

12. Specialist medical supplies Medical equipment may become contaminated(wheelchairs, stretchers) Antidotes

13. Decontamination ↓absorption and ↓ spread of contamination Remove clothing : 80-90% of contamination. Rinse affected areas Wipe with a sponge or soft brush Rinse for a second time 3-5 minutes

14. Limitations to decontamination PPE suits require filter change – takes time Staff needs to be rotated: fatique,heat PPE suits are cumbersome Space in decon tents are limited Decon units can clear 2 ambulatory pts every 10 minutes

15. Questions about decontamination that await further scientific evaluation Will victims remove their clothing? How long will victims remain at the scene awaiting decontamination? What impact does modesty or inclement weather have on clothing removal? How long should victims be showered and what water volume is required? Can victims be effectively managed and communicated to by staff in PPE?

16. Security and Traffic control “Lockdown” Difficulty containing contaminated patients Family Media Ambulances – “clean and dirty”circuits Nonessential vehicles

17. Case Report Singapore – chlorine gas released from pump room at a local swimming pool 54 pts seeking treatment – 36 presented to Singapore General Hospital over 90 minutes Hospital Decontamination Station outside of ED ED Staff donned Level-C protective gear Entrances to ED were secured

18. Disaster plan activated ED re-organized to triage, treat and evacuate victims as well as manage existing patients HAZMAT incident, not causing severe injuries Well executed Valuable lessons learned

19. Hospital decontamination and the Paediatric patient Psychosocial needs Communication Chaperones Removal of clothing Holding infants Process of decontamination

20. Cape Town perspective Fire Service 7 Medical Battallion – Simonstown Dilution is the solution Fire hoses at hospitals TBH Pharmacy – 160 ampules Atropine in Disaster cupboard in F1, 896 ampules in main pharmacy

21. Tygerberg Hospital

22. Groote Schuur Hospital

23. G.F.Jooste Hospital