Decontamination and the Chemical Suicide

How were they exposed and what was the chemical? 
Those might be the first two questions you ask when confronted with a chemical suicide or consumer level hazardous materials event. They're also the most important. Figuring out the how and the what can be difficult but is vital to a safe mitigation of the situation. Incident indicators such as product containers and patient symptoms can help with identification. (see Concerns grow as chemical suicide evolves)

Key Point:
You should not rely on your senses to identify chemical products and determine exposure.

Was it accidental or intentional? 
The answer to that question indicates intent and potential secondary hazard. Chemical assisted suicide situations are intentional events  carried out by mixing a variety of chemicals to form a lethal combination. We often think of Hydrogen Sulfide in these cases but Cyanide and other materials have been created as well. Consumer level hazardous materials situations most likely fall outside of an intentional event and may be accidental. We should also consider that chemical exposure can be the result of illicit chemical use - chemical bomb creation or drug production. Regardless of the intent, the cause or the chemical, we have to consider emergency decontamination at these event. (see Managing the Chemical Suicide)

Key Point: 
You may have to search for source of the chemical - at the event location or at prior locations the person has been at  - and send the appropriate resources.

Not all contamination is treated equally

While all contaminated persons should be considered for some level of decontamination, internal and external contamination situations require different approaches.

Example of emergency mass decon

Internal contamination is hard if not impossible to decontaminate. The product may/may not be known. Secondary exposure risk is not a "scene only" hazard. The potential threat persists into the transport and hospital phase of care. Once a person has ingested a chemical the risk of secondary exposure to that agent (exposure of other responders/hospital providers) increases substantially once the person has vomited. Vomiting can release the chemical and produce symptoms in those exposed.

Exposure may be in the form of off gassing from internal contamination or exposure to liquid from vomit. Prior to vomiting the chemical is contained within the body with the possible exception of exposure via exhaled breath.

External contamination has the potential for immediate secondary contamination and exposure to responders and health care receivers. Because of the variety of chemicals that could be used, the actual product may not be known. Atmospheric monitoring may be helpful to identify oxygen limited or other toxic environments. Treatment may be determined by the situation and hazardous conditions as access may be delayed while the patient is removed from the toxic environment and decontaminated.

Keys to Decontamination:

• Decontaminate as soon as possible
• Use properly trained and protected responders
• Removing outer clothing of victims may remove > 90% of contaminated material
• Bag contaminated clothing/items appropriate overpack drum or container - may be evidence - consider chain of custody issues. 
• Control run off whenever possible -  paramount with radiological materials
• Don't bring containers or contaminated materials (even if contained) to hospital - take a picture - or video
• High volume/low pressure water streams may be the fastest and most effective means of emergency mass decontamination
• Be prepared for outcomes resulting from:
• environmental conditions
• privacy and media issues



Sources of information

•  casualty care issues of hypothermia/re dressing/re warming

Conclusion: Decontamination Points to Remember

• Decontamination prior to treatment or transport - must be done on site
• Exposed persons will flee the scene prior arrival of rescuers - contaminated self-referrals pose a risk to hospitals and staff should be on the look out for contaminated persons arriving in the ED
• Casualties should be triaged to receiving facilities that are equipped and prepared for secondary decontamination
• The fire department should be involved in decontamination operations at scene and hospital
• Be prepared for events to take place at non-hospital health care locations - walk in/urgent care centers

Chemical Suicide: Situational Awareness

What's at stake when a person decides to carry out their chemical suicide in a public location and has desire to intentionally injure others? 

There are no rules concerning chemical suicides. Chemical agents, delivery devices, and locations are as variable as the people who attempt suicide by chemical means. A person who wants to carry out a chemical suicide is only limited by their resources and imagination. (see Concerns Grow as Chemical Suicide Evolves, MJ April, 2012)

The risks of multiple patients and potential for additional casualties dramatically increases when the desire to harm others is part of the suicide plan.

• Japan - Laundry detergent with liquid cleanser in an apartment building. Hydrogen sulfide is created and sickened 90 other people in building.
• Arizona - one individual manufactured hydrogen cyanide instead of hydrogen sulfide.
• Oregon - man mixes chlorine, bleach, ammonia and Drain-O and heats on Hibachi grill in a hotel room.
• Boston - Sodium azide is ingested and subsequently forms  Cyanide causing the evacuation of the building and the quarantine of several responders.

What does a chemical suicide look like?

The first indication of a chemical suicide or consumer level hazardous materials event may come from the caller or dispatch information. The presence of strange odors or the smell of rotten eggs may be reported depending on the chemical used. While some materials give off pungent odors others may have no olfactory warning whatsoever. 

Chemical containers in or around the location may be present. Remember, these containers may be from every-day Consumer Level Hazardous Materials purchased at a local grocery store or garden center. Any unusual cluster or amount of empty cleaning product containers, even if they're same products you see on store shelves every day, should be taken as a warning. There may also be a container used to  mix various products such as large pans or buckets. Pressurized tanks, the size you'd find on a gas grill, may be present if a simple or systemic asphyxiant gas is used. The presence of commercial size containers (pressurized gas or liquid) should be a warning, too.

Chemical suicides can take place in any venue. Many cases have involved a vehicle parked in a public place while others are carried out in residential locations including apartment buildings. Selecting vehicles, residential bathrooms and other small spaces allows for a small amount of gas to quickly reach lethal concentrations. Signs indicating the intent and chemical presence may be used...or not. While confined spaces seem to be the norm, the situation can quickly become a much larger threat if a chemical suicide were to be attempted at an indoor public location as the hazardous materials will escape the immediate area, increasing the potential for unintended persons to be exposed. 

Warning signs if any, may/may not be obvious. If the warnings do exist should we trust them? The potential for additional threats should also be considered. Incomplete chemical reactions, residual products, and flammable/explosive or oxygen deficient atmospheres should be anticipated.

What to do about it

Your first decision may be the hardest...you'll have to decide if this is a rescue or recover? Once that decision has been made the remainder of decisions have to progress accordingly. The actions of the first-arriving units will dictate the progression of the event and the safety of responders and the public. (see First In? Think First, MJ July 2010)

Anyone who enters the space without proper protection may quickly become a part of the problem rather than part of the solution. (see EMS Exposed to Acid, MJ August 2010) Approach to the situation should be cautious, with a high degree of situational awareness. Be prepared for multiple exposed patients. Unintended victims (or intended victims) could be exposed to liquids or gasses depending on the materials used or created as a result of a mixture of materials. Liquid and gas exposures should be handled differently. 

Victims exposed to a gaseous product may not be efficiently decontaminated by mechanical means and initially may pose less risk of secondary (off-gassing) contamination. Those exposed to liquid chemicals may have exterior contamination and require decontamination. Removing clothing of  may remove as much as ninety percent external contamination. Secondary contamination of a rescue crew, ambulance vehicle, or hospital emergency department has to be avoided. All exposed persons and victims of chemical suicides who are receiving care or being transported must undergo the appropriate decontamination. Incidents occurring in public places may call for mass casualty decontamination.

Personal Protective Equipment...what will work, what will not

Standard body substance isolation materials used by EMS or in hospitals will provide little, if any, protection from a chemical hazard.  Air purifying masks and respirators should only be used if the they are compatible with the chemicals used in the event. Filter masks, canister masks, and air purifying respirators will be of no use in an oxygen deficient atmosphere. Self-contained breathing apparatus (SCBA) with structural firefighting clothing should be considered the minimum level of PPE for initial operations or rescue of verified, live victims.

Additional Recommendations:

• Atmospheric monitoring should take place as soon as possible. Ideally, monitors that are capable of detecting simple and systemic asphyxiants, blood agents, and choking agents should be used. 
• The most appropriate treatment facility may be one with chemical decontamination and isolation facilities. The facility should be notified well in advance of patient arrival. Fire department units capable of providing or assisting with secondary decontamination should be deployed to any hospital emergency department prior to the arrival of victims.
• Specialized treatments such as traditional cyanide antidote kits or the Cyanokit should be available as well as a variety of other "tox med" medication. (Cyanide antidote kits will be discussed in a later post). 
• Chemical suicide events may occurs with or without a hazardous materials team available. You might find yourself responding to, or receiving patients from, these events without the ideal resources...take the responsibility for situational awareness yourself.