EMS Hazardous Waste Response

Issues of Concern

Epidemiology

Data from the US Department of Transportation Office of Hazardous Materials Safety indicate that approximately 12,000 to 18,000 events are classified as hazmat events yearly. These events include spills on roadways, industrial leaks, laboratory chemical exposures, naturally occurring toxic exposures, and, rarely, events intended for harm (eg, bioterrorism). Many spills and exposures are addressed on a local level and never reported; therefore, these events are underreported. In 2012, an analysis of prehospital responses to hazmat events was released. The authors studied public data from the National Emergency Medical Services (EMS) Information System and concluded that hazmat events are a rare cause of EMS activation in the US. The authors further explained that most events involving 2 or fewer patients occurred in nonindustrial venues. In patients with reported exposure, cardiac arrest occurred in one-fifth of the patients, supporting the seriousness of these exposures. Mortality rates were not calculated due to the large number of potential agents and their effects on humans.

On-Scene Hazmat Response

As noted, EMS and other emergency personnel must be prepared to handle hazmat exposure adequately, regardless of size. The prehospital response to hazmat exposure is typically complicated by factors such as a potentially dangerous environment, multiple victims, the need to ensure adequate decontamination for both the patient and the responder, and arrival-to-scene delays. The Emergency Planning and Community Right-to-Know Act (EPCRA) was passed in 1986 in response to concerns about the environmental and safety hazards of storing and handling toxic chemicals. This act requires local governments to prepare chemical emergency response plans overseen by state governments. Even so, many hazardous chemicals are stored at various sites, and expecting a detailed plan for each chemical or toxic agent is unreasonable. Instead, hazmat response is guided by general principles. These principles include community assessment, recognition, identification of the substance in question, scene control and isolation, decontamination, and stabilization.

Community assessment involves state and local government response and other available resources, such as EMS, fire departments, and local organizations. In addition, EPCRA requires response plans to be practiced annually. Once community plans are in place, a hazmat event must be recognized. Industrial facilities are typically well equipped with monitoring systems to detect leaks and potential exposures. Outside industrial facilities, most hazmat exposures are recognized by the chemical's effects. These effects include, but are not limited to, noxious stimuli causing coughing, eye burning, airway irritation, headaches, and, in some cases, quick asphyxiation and death. Other findings include subtle clues, such as crops, other plants, and even dead animals found in large numbers or in certain geographical patterns.

After a hazmat event is recognized, the next goal is to identify the inciting agent. Numerous resources are available for identification; however, unless the chemical is known, recognizing the expected clinical syndrome is most important. Recognition of the clinical syndrome may allow clinicians to intervene and treat appropriately. The identification should be questioned if the symptoms do not match the initially identified chemical agent.

Decontamination and Stabilization

Safety is the primary priority. First responder safety should remain at the forefront of the operation and should often guide the response plan. Once an incident is identified, the EMS response team must establish an incident command system. An incident command system is an organized approach to controlling and coordinating operations at an emergency incident. For a hazmat incident, this means designating hot, warm, and cold zones, an isolation process, and many other layers of operations, command, and communication roles.

Hot zone: The suspected hazmat agent and victims are immediately located in the hot (or exclusion) zone. The hot zone should be carefully controlled for safety and contamination purposes. Only trained personnel wearing full personal protective equipment (PPE) should be allowed to enter to remove the victims and prevent further exposure. Rescuers and bystanders within the zone have a substantial risk of contamination. Great care should be taken to control the hot zone, and the area designated hot may range from 75 to 3000 feet or more, depending on the hazmat agent involved. Notably, anything in the hot zone, including vehicles, equipment, clothing, and other items, is considered contaminated and should not be removed until it has been decontaminated.

Warm zone: A warm zone is created outside the hot zone where decontamination occurs. Each patient is taken to the warm zone, where initial medical treatment may occur simultaneously. These interventions include basic airway treatment or other lifesaving procedures. However, thorough decontamination is important. The first and most effective decontamination method is to remove the victim’s clothes, brush off solid particles, and wash and towel the face. Water is the universal decontamination agent. Most sources recommend a decontamination method in a linear or assembly-line fashion, with those involved performing each step in a line. First, affected people take off their clothes, and then warm water is used to rinse them, paying close attention to the face and areas where fluid can collect (axillae, groin, toes, and skin folds). In general, 5 minutes of thorough decontamination is adequate for patients. Next, patients are covered to protect them from the environment and moved to the cold zone. Additionally, healthcare professionals who help decontaminate patients should wear PPE and require decontamination afterward.

Cold zone: The cold zone is designated outside the warm zone, where an emergency can be directed and supported. Ideally, the cold zone should be upwind, uphill if necessary, and out of danger. Once decontaminated, patients can be taken to the cold zone for further triage and stabilization. Primary stabilization focuses on the airway and breathing. Administering oxygen and breathing treatments with bronchodilators can be done rapidly and with minimal training.

Furthermore, if appropriate personnel are available, intravenous access can be considered for fluid resuscitation and medication administration. From the cold zone, patients are triaged to the appropriate setting, including transfer to a hospital. This process underscores the importance of decontamination because patients encounter many people while navigating the incident command system.

Clinical Significance

The scale of a hazmat incident is unpredictable, and many factors affecting the scene must be considered. Factors such as wind direction, weather, and available resources, including water and electricity supplies, can make hazmat scenes difficult to control. On some occasions, decontamination inside warehouses or makeshift shelters may be considered. If decontamination occurs outdoors in a very cold climate, the incident command system must implement measures to prevent hypothermia. These factors can add many layers to hazmat incidents, increasing their already unpredictable nature.[6][7][8][9]

Further, care for hazmat survivors is often delayed. Adequately setting up an incident command system for a hazmat call takes time. Even in a well-equipped, resource-rich environment, decontamination times are often delayed. Results from one study recommended a self-decontamination protocol for large-scale hazmat exposures. This protocol would help alleviate the burden of a large patient load that overcrowds a decontamination protocol; however, it would require better community education. Despite the best-planned and rehearsed chemical response plan, most individuals self-rescue and head toward the nearest hospital or health care facility. For this reason, healthcare facilities should also have decontamination procedures in place. Audits must be conducted routinely to ensure workers comply with safety requirements.