Contaminated patients pose a special difficulty to hospitals because the contamination poses risks not only to the patient but also to those around the patient. Whether the contamination is from something relatively innocuous such as cooking oil, or from one of the extremely dangerous industrial chemicals now prevalent throughout the world, or from a chemical weapon, the problems are much the same.
Like many businesses, hospitals are under considerable economic pressure to cut costs to maintain their operating margins and stay within whatever funding levels have been established. Their staffing schedules seldom if ever permit them to have large numbers of medical providers available for “just in case” situations, even in the emergency room (ER). In any event, it can be assumed that any “supernumerary” staff in the ER at the time of a major incident would be immediately put to work in that ER. (See supporting article.)
Despite the budgetary constraints, it can be safely assumed that the central functions of most hospitals still will be accomplished until they have to close their doors, but a shrinking cash flow may in any case necessitate a cutback in services seen as non-essential. In some cases, unfortunately, the struggle for financial survival has become so dire that any function not central to the mission of the hospital is seen as expendable. Many hospitals have stopped providing obstetric services, for example, or have had to farm out their non-emergency imaging and/or laboratory-analysis work. One result of these trends and new ways of thinking is that it is now uncertain how many, if any, of a hospital’s non-central functions can be accomplished during a major emergency.
Often, what is not recognized is that efforts to develop a “good name” for the hospital, thus raising the hospital’s name recognition in the local market, guarantee that many patients will automatically look to that hospital for help during an emergency. In spite of the desire on the hospital’s part, however well founded, to stay within the citadel of the hospital itself during an emergency, it must be recognized that some incidents require a much more proactive stance.
Establishment of Priorities
The First Priority. During a HAZMAT (hazardous materials) incident that results in a large number of contaminated patients, the hospital cannot afford to become contaminated itself or it will no longer be able to treat those patients effectively and safely, and might even cease to function entirely. The first and most important rule, therefore, is that – starting with the emergency room and continuing through various specialized hospital spaces such as the ICU and surgical suites – the hospital must maintain its ability to function.
Maintaining the ability to function applies to people as well as to hospital spaces. One staff member can treat a large number of patients in a 12-hour shift. However, if the staff member becomes ill – from exposure to a contaminated patient, in this instance – he or she probably would be able to treat only that patient and then will need care from the hospital’s other providers, becoming part of the patient load.
Meeting the first priority requires, therefore: (1) protection of the hospital’s own personnel and equipment; and (2) maintaining the continued ability to provide a clean safe work environment. Care providers who are becoming ill from exposure to a contaminated patient cannot continue to treat that patient. Moreover, the hospital’s patients – whether they are contaminated patients from the HAZMAT incident, or other patients suffering from “routine” illnesses or injuries – cannot and should not be treated in a contaminated clinical setting. In medicine, continuity of operations is much more than a simple business concept.
The Second Priority. After maintaining the ability to continue operations – and, by extension, ensuring the safety of the staff and other (i.e., non-contaminated) patients already at the hospital – the next priority must be providing lifesaving care. That life-saving care is both for those affected by the incident and those unrelated patients, this should be followed, of course, by the provision of high-quality non-lifesaving care, as needed.
A Change of Paradigms
In the pre-hospital phases of an incident, contaminated patients pose another significant problem – namely, that they should not be transported in ambulances until they have been decontaminated. The only exception to this rule is that patients may be transported while contaminated if the ambulance carries the special equipment required (and is staffed by the specially trained personnel also needed), and the receiving hospital has the capacity to decontaminate the patients.
Most EMS (Emergency Medical Services) agencies or units do not possess such specially equipped ambulances in any great number. As a result, the general planning assumption has been that patients who come to the ER by regular ambulance are probably “clean.” This is based in part on the policy of most EMS services that patients should not be transported until they are decontaminated.
This works as long as the patient arrives in an ambulance, however, real-world experience – in the Tokyo subway attack, for example, in the attacks on the World Trade Center, and in similar incidents – has shown that victims who can leave the scene of a terrorist attack or other disaster under their own power will almost always do so. And they will then show up very quickly at the doorstep of the nearest ER.
The assumption that patients arriving by ambulance are therefore clean has affected decisions about the types and quantities of resources a hospital needs to deal with contaminated patients. There was a time when it was reasonably assumed that a single shower room was all that was needed, and when a patient “decontamination” simply meant the washing off of body dirt – or, perhaps, delousing. In such situations the patient could receive life-saving treatment first, if need be, because what he or she was contaminated with would not kill or injure anyone else. Further, decontamination usually involved only one patient, not the large numbers that would be expected from a major HAZMAT incident.
Typically, the hospital shower room could be reached only by moving the patient through other spaces in the ER. That was an inconvenience, perhaps, but usually nothing more than that. However, a patient contaminated with a hazardous material is not just an irritant to the staff and to other patients, but a potentially deadly hazard to them.
The cost of building a multi-position decontamination shower structure adjacent to the emergency room is so high some hospitals have made the investment needed, but most have not. Instead, many hospitals have opted to purchase a portable shelter or tent for decontamination purposes. One result – based on years of experience with first-responder agencies buying such systems – is that manufacturers have developed some very sophisticated but easy-to-use units that are effective both in taking large numbers of contaminated patients from the street and in feeding them, as clean patients, into the ER.
Issues Still to Be Resolved
Many forward-looking hospitals have invested a great deal of money and effort into acquiring the material resources needed for a mass-decontamination emergency. They also have purchased or built decontamination areas or shelters and have stocked up on the supplies needed for the decontamination of a large number of patients.
In addition, they have carried out the development and training process required for their staff to successfully operate a decontamination line. They have written plans for the deployment of the decontamination shelters, and have trained staff personnel on the intricacies of those plans. Finally, many have exercised and evaluated the effectiveness of the plans, and have used the evaluations to further refine the plans, if necessary. Additional training and staff development starts the next cycle of what should be a continuing process.
Even with the best and most detailed preparations for decontaminating large numbers of people, many hospitals still have a problem with staffing. They usually plan to increase their staffing levels during a crisis, but the question that must always be asked is if the hospital can maintain an effective decontamination line outside and at the same time continue to provide effective care inside.
Many hospitals envision sending just a few staff members outside to oversee the decontamination process, and expect that most patients will wash themselves. As with any emergency process that deals with large numbers of patients, well-trained and well-qualified staff people will be needed to shepherd the patients through the process. Additional staff will be needed to help stretcher patients who must be decontaminated, because those patients may not only be incapable of washing themselves but also, as a result of their physical condition, may be in urgent need of decontamination so they can be treated immediately.
Solutions for the Future
A number of private and public sector organizations have been working on programs to solve the hospitals staffing issue by forming partnerships with hospitals. Several hospitals in Massachusetts, for example have already taken the first necessary steps of properly equipping and training its staffs to deal with major emergencies. They’ve taken the additional step of fostering a partnership between the hospital and the local fire department.
Following this model a hospital would have a single point of contact (or they simply have to call 911) when they are facing a significant flow of contaminated patients. Theoretically, that one call should trigger a dispatched response of FDs to staff the decontamination line.
The staffs of these fire department(s) already have been trained in HAZMAT decontamination and would work using the hospital’s equipment.eally, and to make the program more effective, the FD(s) would be closely involved in the hospital’s planning, drills, and training. It is important to remember that this plan is envisioned as a true partnership between the hospital and the field responders. In its purest form the hospital and the fire department(s) would work together through the entire emergency planning cycle – planning, training, exercising, and ensuring that their respective plans are and remain complementary to one another. Implementation of the plan would allow the hospital’s personnel to work at their primary functions, rather than having to choose between manning a decontamination line or operating an emergency room.
In the new post-9/11 world the emergency community can no longer afford the luxury of compartmentalization. Hospitals can no longer be just hospitals, the exclusive province of doctors and nurses. Emergency-services personnel can no longer afford to be fire fighters only, or EMTs, or police officers – or first responders.
To be successful in the future, first responders and hospital communities must join together and be what they were always intended to be: the bulwark protecting the average citizen from an unpredictable world (See supporting article.) – a world that today has been made even more unpredictable, and infinitely more dangerous, by terrorists and others who wish to do harm to the United States and other nations of the Free World.
Joseph Cahill is a medicolegal investigator for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Prior to that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s Paramedic Program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.