Ease of access to deadly chemicals may be the greatest threat to hospital readiness
How close is your hospital to a railroad track?
Though biological agents have dominated recent terrorism discussions, ease of access to deadly chemicals may make them a greater threat to hospital readiness, experts emphasized recently at the University of Georgia in Athens. "Eighty new chemicals a day are patented in America, and most of them will kill you," said Jon W. Watson, special agent in the FBI’s joint task force on bioterrorism. Watson joined other experts in a conference on preparing hospital clinicians for mass casualty situations. The underappreciated threat of chemical weapons was a recurrent theme throughout the Dec. 5, 2001 meeting.
"Most people do not realize that the chlorine — the substance we put in our swimming pools — will kill you," Watson said. "Yet tanker carloads of it are railed through the middle of Atlanta every day. A [munitions] charge placed on the side of that tanker would blow a hole in it, the chlorine would escape, form a flue, and move across the city."
A potent irritant to the eyes and skin, chlorine can cause severe pulmonary irritation that may result in death. Yet chlorine exposure is difficult to diagnose, and there is no specific antidote. (See "Signs and symptoms of chemical exposures" in this issue.) "That is not sexy; that’s not going to make the news," Watson said. "We would much rather talk about Ebola and anthrax."
The chemical agent deployed by a terrorist could include an industrial hazardous material or a traditional militarized agent such as nerve gas. While many nations still have stores of chemical weapons, in 1997, the United States and some 80 other countries signed a treaty banning their use. As a result of that legislation and prior actions, the United States is in the process of destroying its stocks of chemical weapons through incineration. One such storage site is the Noble Training Center in Anniston, AL.
"We are privileged to store 2,100 tons of sarin, mustard [gas], and VX derivation," said John Hoyle, MHA, LFACHE, director of the Noble Training Center and an employee of the U.S. Public Health Service. A $1 billion incinerator has been built to destroy the chemical stocks, but people in the surrounding communities have expressed concern about the public health threat of the incineration process, he said at the conference. "There is a lot of concern in the citizenry about those chemical weapons, but the Army has been storing and handling them for 50 years," Hoyle said. "I have toured the incinerator three times. I am very convinced they know exactly what they are doing."
However, while confident in the safety of the incineration program, he expressed concern about the amount of chemicals that are railed through that area and other parts of the country. "I live but a mile from a train track, and we are the main route between Atlanta and Birmingham," Hoyle said. "Chlorine cars, World War I warfare chemicals go through our town all of the time. [But] nobody worries about a rail-car accident, much less terrorism [involving] a rail car," he added.
A reality in Tokyo
As with bioterrorism and anthrax, the threat of chemical attacks on citizens is no longer theoretical. While the use of chemicals is well documented in warfare, the incident that drove the terrorist threat home was the release of the nerve agent sarin in the subways of Tokyo in 1995. Twelve people were killed and 5,000 injured in the attack by the Aum Shinrykyo cult. It could have been worse. The group reportedly had little problem getting scientific assistance in developing the chemical, but never really came up an adequate delivery system.
"[Terrorists don’t] have to hire a bunch of PhDs and spend millions to try and create some sarin — not when you’ve got rail cars full of the stuff going through our towns everyday," Hoyle warned.
Lessons learned from the Tokyo sarin attack include the fact that a significant number of exposed individuals may find their own means of transportation to the health care facility after a chemical attack. "The vast majority of casualties in any disaster will get to your hospital without the benefit of EMS," Hoyle said. "They simply don’t wait around for EMS to organize, set up a triage, casualty collecting points, and all that."
In addition, "worried well" patients who have experienced very little or no exposure will go to a hospital. Many may still require decontamination because it may be difficult to rule out exposure. Any real symptoms of a chemical agent will occur in conjunction with anxiety and confusion. All the while, residual chemical agents on those exposed may pose a risk of secondary spread to workers, as evidenced by pesticide patients presenting at emergency rooms.
Indeed, three health care workers — one who was subsequently hospitalized for nine days — fell ill after a patient who had ingested pesticide came into an emergency room in a South Georgia hospital in 2000. As a result of the case, the Centers for Disease Control and Prevention (CDC) recommended staff take personal protection measures beyond standard infection control precautions. Depending on the extent of the contamination, health care workers caring for chemically contaminated patients should use level C protection (i.e., full face mask and powered/nonpowered canister/cartridge filtration respirator) or level B protection (i.e., supplied air respirator or self-contained breathing apparatus). The type of canister/cartridge should be appropriate to the agent. If the agent cannot be identified, use an organic vapor/HEPA filter, the CDC recommended.
Self-reliance a must
Other practical considerations are the availability of heavier gloves, because thin latex medical gloves are of little protection against many chemicals. In addition to the need for surface decontamination of patients, body fluids also must be contained to prevent skin and inhalation exposure. To limit spread of the contaminant, the emergency room’s ventilation exhaust should be directed away from the hospital’s main ventilation system. A less-expensive alternative is to set up an outdoor shower decontamination area. (See "Triage, decontamination after chemical exposures" in this issue. )
Such preparations may be critical because local officials will be too busy at the scene of exposure to assist hospitals with incoming patients, Hoyle warned. "Hazmat people will not show up at the hospital emergency room and decontaminate patients for you, because they are still going to be in the area of the exposure. You have to think self-containment. You’re going to have to direct your own traffic and decon your own patients."
Moreover, it is actually a regulatory requirement that hospitals are prepared to deal with chemically contaminated patients, added Henry Siegelson, MD, FACEP, a consultant with Disaster Planning Intentional Inc. in Atlanta. The Occupational Safety and Health Administration (OSHA) requires such preparation as part of its regulations on hazardous wastes, he told conference attendees. "[OSHA] rules require employers — including hospital CEOs — to plan for Hazmat if they expect their employees to handle an emergency involving chemicals," he said.
In complying with OSHA, the preparedness plan will also meet requirements of the Joint Commission on Accreditation of Healthcare Facilities, Siegelson added. Despite the risk of accreditation problems or OSHA fines, the response to the regulations has been historically lackluster, he said. "Prior to Sept. 11, some people said, [OK] fine me. I don’t care.’" he said. "Really, I ran in into that all over the country. Before [the 11th] we were called to train hospitals by safety committees, nurses, security professionals. Now we are being called by hospital CEOs."
In general, the OSHA requirements include that all employees — including affiliated personnel, physicians, and nurses — who may be involved in chemical emergency response must be familiar with the plan. By the same token, facilities must plan for emergency treatment of noncontaminated patients, he noted. "What are you going to do if someone comes in with a heart attack or a broken hip while you are dealing with this decon event?" Siegelson asked.
1. Centers for Disease Control and Prevention. Nosocomial poisoning associated with emergency department treatment of organophosphate toxicity — Georgia, 2000. MMWR 2001; 49:1,156-1,158.