Explosions and Unknown Hazards: Medical Advice From Inside a Hazmat Suit

Michael T. Hilton, MD, MPH; Eric A. Pohl, BS, NRP

Disclosures

November 19, 2019

Within 1 week, a destructive tornado hit Dallas, wildfires ravaged Southern California, and a second typhoon encroached on Japan. Increasingly common extreme weather events and other disasters can cause significant property damage and possible exposure to hazardous materials (hazmats). To contain the release of hazardous substances, a specially trained emergency response team is called into action.

What is it like to be on a hazmat team? Michael T. Hilton, MD, MPH, interviews Eric Pohl, BS, NRP, to learn more.

What was your role at the New York City Department of Environmental Protection (NYC DEP) Hazardous Material Response Team?

I investigated, assessed, and mitigated spills, releases, and discharges of petroleum and hazmats within the City of New York. In that role, we would respond to incidents and determine whether there was a particular health or environmental threat and what needed to happen to control that. We had to ensure it didn't get worse. That could involve a minor cleanup that we would do ourselves, or working with whoever released the material to perform a cleanup through voluntary effort or via enforcement action if needed. The priority was always to protect public safety.

We also responded to such things as building explosions, stolen tractor-trailers with unknown substances, Hurricane Sandy, and terrorism incidents (such as suspicious white powders). We assisted police in criminal investigations and assisted the New York City Fire Department and New York City Office of Emergency Management on responses.

With a population as large as New York City's, we were very busy. We handled 4000 calls for assistance a year. I always laughed at the fact that we were the only scientists and engineers in the city driving around with lights and sirens.

What real or potential hazmats did you manage when working with the DEP?

One that everyone is aware of, but is often overlooked, is carbon monoxide. I think this is especially true in New York City, which has lots of underground buried electrical cables that burn. It's a source of carbon monoxide that first responders outside of dense urban environments might not be aware of.

The other common one is the use and mixing of materials, such as cleaning products or pesticides in the home. I've responded to incidents where residents have set off a bug bomb in their house according to the manufacturer's directions, leading to acute pulmonary edema and respiratory distress. Someone exhibiting respiratory symptoms after a known use of a pesticide is concerning and often causes some panic for receiving facilities and emergency medical services (EMS) providers, who may be unsure about management.

Aside from these, we ran the gamut of hazmat responses and emergencies, from handling large and small oil spills to drums of chemicals left out on the sidewalk by bad actors. One of my unit's chief capabilities was the identification of unknown substances. I've been fortunate to have gained experience in responding to chemical, biological, radiologic, nuclear, and explosives (CBRNE) incidents over the years—if you can consider that fortunate.

Did you personally ever witness any health hazards on a scene?

The bug bomb thing was interesting. The first failure I noticed was that EMS and fire department crews did not have the resources needed for a contaminated patient. I think for EMS personnel, the concept of upgrading to a level of protection with a respirator or self-contained breathing apparatus for purposes of transporting a patient is somewhat foreign.

But how else do you transport a patient who is contaminated with a respiratory irritant? Unless you decontaminate the patient on scene first—which, in this case, the responding agencies weren't well equipped to handle.

The best thing to do is to remove clothes and do a "wet decon" of the patient if appropriate—which is to shower the patient and wipe them down. Clothes should be placed in sealed plastic bags or, even better, left on scene.

The second failure I noticed was at the receiving hospital. Many hospitals have plans for receiving contaminated patients but a reluctance to implement the plans. This hospital had a decontamination room and had plans in place for chemical gowns and respirators and everything. The whole plan was bypassed. Luckily, it ended up not being a chemical that could cause cross-contamination of the ambulance, EMS providers, the hospital and hospital staff, and patients and visitors. But if it had been, the hospital wasn't really prepared to do that from a decontamination perspective.

Third, the emergency physician who took charge of the case observed respiratory distress and deterioration with worsening pulmonary edema. He heard "pesticide," saw respiratory distress, and immediately assumed organophosphate. It's a good thought clinically; however, in this case, it was not applicable because the patient wasn't exposed to an organophosphate. We had a can of the material with us and brought it to the hospital to show the physician, and we discussed its contents and family of substance with the medical care team, but the physician proceeded to manage the case as an organophosphate exposure—which it wasn't.

Advice for Medical Personnel: Hazmat Scenes

What errors have you seen by first responders on hazmat scenes?

I've seen professional fire departments with hazmat teams underestimate the hazards of the scene they were making an entry to. In one case, I saw a fire department hazmat team attempt a hot zone entry in level B personal protective equipment (that is, a self-contained breathing apparatus and a chemical splash garment). Because they entered a corrosive vapor atmosphere, even though they taped all seams in their garments, they had to retreat and evacuate the hot zone because of chemical burns from the vapor cloud.

I think it is important, except in a true emergency, to have a good understanding of what material is being dealt with and double- and triple-check to make sure you are consulting with expert professionals and other resources to ensure responder safety. The Environmental Protection Agency has on-scene coordinators that can be technical consultants or can respond to scenes to help fire departments and other response agencies.

What should an EMT or paramedic do to prepare for a hazmat situation?

I think EMS personnel should take a hazmat awareness class as part of their training. It is very important. It's maybe a 4- to 8-hour class. It will help EMS providers to maintain a continual sense of awareness; recognize early that something is out of the ordinary; and that it's time to back away, establish a safe zone, and reassess and, if necessary, call in additional resources and experts.

Often, hazmat scenes aren't readily identifiable as such, at least at first. This is particularly challenging for the first responders. Patients often present with symptoms that mimic those of many other pathologies. The responders walking in might not realize that there's a potential exposure, and by the time they do, they have been affected. Once a provider or responder is exposed and might be experiencing adverse health effects, it greatly complicates the scene and impairs patient care.

What should emergency medical staff do when responding to known or potential hazmat situations?

For all scenes, again, maintain awareness, back off, set up a safe zone, and call in additional resources.

If it's a confirmed hazmat scene, know what material is in play. Contact incident command or the dispatcher, ask bystanders, or look for a Material Safety Data Sheet. Use the "Orange Book," the emergency response guidebook published by the US Department of Transportation. The initial steps to take are listed there. Always stage vehicles and personnel uphill and upwind. Try to ensure that responder safety is the number-one concern. Continue monitoring weather conditions and if they change, be flexible and reposition.

Larger organizations may train EMS providers to be hazmat technicians so that they can enter a hot zone and start providing care early. An example of this is the Haz-Tac program in New York City.

Advice for Medical Personnel: Decontamination

EMS providers must ensure that patients are properly decontaminated before receiving them. You don't want to transport contaminated patients and contaminate the ambulance, healthcare providers, and the emergency department.

Are patients typically decontaminated on the scene or at the hospital? How is decontamination performed?

It's driven by local protocols, so it's a bit different everywhere. The best thing to do is a two-step decontamination. On-scene decon will make patients safe for transport, and that should be followed by a more detailed decon at the hospital.

However, "decontamination" is a broad term. Decon really needs to occur with an understanding of what the material is. If a patient is contaminated with a solid caustic material, don't add water! Don't rinse it off. Water will react and cause exothermic reactions and burns. This would need to be a dry decon (that is, brushing off powder and removing clothes). A good hazmat team would do a dry decon with confirmation techniques to ensure that all of the chemical is removed. But not all hazmat teams do this. It's important to consult people who can bring expertise to the scene and the hospital. The local poison control center is often a good first step if a talented technical hazmat team isn't well versed in the chemical at hand.

I have heard the phrase "dilution is the solution to pollution," meaning that diluting a hazardous material with lots of water is how hazmat contamination is managed. Is this true?

For managing people, that actually is not bad, particularly if you have no other options and it's an emergency situation. Even with the example of the caustic powder that is water-reactive, deluging a person with copious amounts of water will most likely be in the patient's best interest, barring any other available options. I am talking large volumes of water. A shower is not enough; a deluge from a fire hose for several minutes is what you want.

The major exception to this is contamination from persistent organic materials, such as the chemical warfare agents. Nerve agents such as VX and organophosphates are oil-based. Even with a deluge of water, the oil may remain on skin. There are conflicting data with varying levels of evidence on how to decontaminate a nerve agent on the skin. If you insufficiently deluge a VX-exposed patient with water, you might assume the patient is sufficiently safe to transfer to an ambulance and hospital. But VX can remain on the skin. Even minute quantities of these agents cause a health hazard, so transferring the patient to a hospital may cause issues. The same is true for many organophosphate pesticides too, but they will elicit symptoms only in larger quantities than the chemical warfare agents.

Hazmat Training

You have since left the NYC DEP. What are you doing now?

I am a federal on-scene coordinator for the US Environmental Protection Agency. The perspective has changed, but the hazards remain the same as when I was with the NYC DEP. When I was a local responder, it was boots on the ground every day, jumping from one job to the next. With this new role, I am now more of a backstop. We offer support to other agencies. There is a usually a buffer before an incident reaches a threshold to involve the federal government.

Do you have any recommendations for additional training in hazmats?

The Federal Emergency Management Agency (FEMA) offers an online hazmat course. Texas A&M Engineering Extension Service provides hazmat courses as well.

For more hands-on training, there is a 40-hour Hazardous Waste Operations and Emergency Response (HAZWOPER) course, available to public sector employees. For really advanced training, especially in terorrism-related incidents, there is the FEMA Center for Domestic Preparedness.

Michael T. Hilton, MD, MPH, an assistant medical director of Sollis Health, is double board-certified in emergency medicine and emergency medical services. He has served as associate medical director of EMS and Disaster Preparedness at Mount Sinai and medical director of EMS systems in Pittsburgh.

Eric Pohl, BS, NRP, is an on-scene coordinator for the US Environmental Protection Agency, Region 5 Emergency Response Branch, based in Cleveland, Ohio. Previously, he was a supervisory hazardous materials specialist for the Bureau of Police & Security of the New York City Department of Environmental Protection, where he was responsible for managing a breadth of emergencies, including toxic chemical releases and CBRNE/weapons of mass destruction incidents.

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