Schools fail at biologic events

U.S. Schools receive a failing grade in pandemics

If a biological agent targeted schools and children would try to prevent it?

Despite the global awareness of biological terrorism, emerging infectious diseases and the impact of diseases such as influenza, a majority of schools in the United States remain unprepared for a biological event. Only 40 percent of schools have updated their infection control/pandemic preparedness according to a study published in the American Journal of Infection Control. The study, conducted by Saint Louis University suggests that many schools in the United States are not prepared for a biological event despite experiences from the 2009 H1N1 pandemic event. As the threat from naturally occurring infectious disease and intentional acts of bioterrorism grow, the importance of community preparedness will increased. We know that one of the keys to a successful outcome in disaster situations is the preparation of local response agencies. Traditional responders and non-traditional responders (public health, hospitals) are the primary responders in any community during times of crisis. Unfortunately, hospital and public health preparedness may still be lacking. Schools should be included in the non-traditional responder group, considered part of critical infrastructure and as such, should be given direction for biologic preparedness according to their role in a biologic event. Best media coverage from Science Daily (http://www.sciencedaily.com/releases/2012/08/120830105323.htm)

• For biologic agent details, see Understanding Flu and Biologic events
• Need help writing your biologic response plan?
• Planning tips: What good plans have that bad ones don't
• Avoid these four pitfalls in biologic planning

Could school preparedness be any worse? Yes.
These findings question the general preparedness of critical infrastructure. The Saint Louis study looked at responses from about 2000 school nurses encompassing only in 26 states. If the results truly represent the biological preparedness efforts (or lack thereof) the school preparedness situation could be much, much worse and equate to greater risks. Closing schools during a biologic or pandemic event will not replace preparedness as studies have shown that kids don't often stay home.

Traditional elementary and high schools draw students together from a variety of social, economic, and cultural background. Bringing a student population together to share ventilation systems, food, water and sanitation, in close quarters, provides opportunity for disease spread. With this in mind, school systems must be a leader in educating students on proper hygiene and infection control measures. Non-pharmacological  interventions are vital to prevent the spread of disease and include hand hygiene, respiratory etiquette and appropriate social distancing. These simple measures are important for everyday health promotion but could be even more important in preventing or limiting the spread of influenza.

• Three things everyone should be doing to get bio-event ready

By the numbers, per the Saint Louis study.
According to the Saint Louis study, less than one-third of the sample schools maintained a supply of personal protective equipment (PPE). Even more concerning is the over 20% of the staff in these schools have no members trained in the schools disaster plan. Infection control training for students was reported by only one third of schools and conducted usually once a year or less.

The study also asserts a positive note, finding that nearly 75% of school nurses have recieved seasonal flu vaccination.While this is good news, its only a drop in the bucket. One person (school nurse) vaccinated for seasonal influenza will do little to stop the spread of the disease. When it comes to emerging diseases and intentional biologic releases there may be no vaccine and we'll need to rely on those non-pharmacological interventions.

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. 

Chemcials in Suicide

Chemical Assisted Suicide: Agent Review

Chemical assisted suicides continue to change and challenge emergency responders. Recent cases have demonstrated the ability to utilize various products and expand that challenge to health care facilities and providers. While we've focused much of our attention on Hydrogen Sulfide, cyanide and numerous other chemicals with high hazard potential have been used. For more, follow this link for background information on Chemical Assisted Suicide. In this series Mitigation Journal continues coverage of chemical suicide/blood agent suicide that began in 2008.

Recent Cases:

New York City - a man was found in a running car with an open bucket containing about 10 gallons of unknown chemicals. The car was parked near a "big box" home improvement store. We can only speculate based on media reports, that the open container of chemicals played a role in the death. This situation may have been one of many that mix various chemicals to form Hydrogen Sulfide.  

Boston - a woman ingested sodium azide and subsequently metabolized a form of Cyanide resulting in her death, causing the evacuation of the building and the quarantine of several responders.

Florida  - a man ingests a pesticide, malathion, and was transported to the hospital by EMS. The man vomits, exposing the ambulance crew and hospital providers to the effects of this organophosphate/cholinesterase inhibitor material. (see Are you ready for nerve agent exposure? Mitigation Journal)

The locations are different as are the chemicals used but, they're all part of a growing trend that poses extreme risks to civilians, responders and healthcare facilities.

Review of Chemicals

Various chemicals are used in suicide attempts and can include:

• Simple Asphyxiants - carbon dioxide, methane, and propane - displace oxygen in an enclosed space, promoting asphyxiation and suffocation by causing an oxygen deficient atmosphere.
• Systemic Asphxiants - carbon monoxide - exclude oxygen from the red blood cell by altering hemoglobin, decreasing the oxygen carrying capacity of the blood and resulting in hypoxia/hypoxemia .
• Blood Agents - Cyanide/Cyanide forming compounds, Nitrates, and Sulphides. Hydrogen sulphide, hydrogen cyanide, cyanogen chloride are major concerns. These materials interfere with cellular respiration and result in cellular hypoxia. Each of these products are toxic and can lead to rapid death. 
• Choking Agents - Chlorine and Phosgene - stress the respiratory system and the respiratory tissues. Exposure to choking agents results in mechanical compromise as well the potential for chemical damage that may result in pulmonary edema. 
• Consumer Level Hazardous Materials -  hydrogen peroxide, acetone, drain cleaners, and bleaches - can be combined to create toxic environments. Commercial pesticides may become contain hazards similar to chemical never agents.

Many drain cleaners contain sodium hypochlorite (bleach) and lye, an oxydizer/caustic. Chlorine (bleach) mixed with an acid creates chlorine gas and chlorine gas combined with ammonia results in chloramine gas. All of these materials are severe inhalation and contact hazard.

Many cases of chemical assisted suicide, sometimes described as detergent suicide, involve some form of bathroom cleaner (acid), pesticides (sulfur) , laundry detergent (chlorine), and in some cases bath salts (not the synthetic drug type). Hydrogen sulfide is created by combining acids and sulfides with other materials. There is usually some type of mixing container and empty chemical containers nearby.

In some instances, chemicals have been combined and created other materials that have resulted in differing signs and symptoms including those similar to nerve agent exposure with a similar toxidrome.

The details of the chemicals presented in this post are presented solely for the benefit of responders and health care providers. The intent is to increase the awareness to the growing threat of chemical suicide and Consumer Level Hazmat situations.

Consumer Level Hazardous Materials Events

Consumer Level Hazardous Materials Events...A New Way of Thinking.

When you hear "hazardous materials" what comes to mind? Toxic materials housed in some giant factory? A tanker truck overturned on a busy highway? Level 'A' protection and special response teams? If so, you're not alone. The scenes mentioned are what most people think of in terms of hazmat or toxic chemicals.

Its time to change the way we think.

I'd like to introduce you to the concept of Consumer Level Hazardous Materials (CLHM )situations. These are situations where there is a creative use or misuse of chemicals that can be found in any grocery store, do-it-yourself center, or your local drug store. CLHM's can be accidental or intentional. Accidental events, as the title implies, is the unintentional use or misuse of chemical products. Examples of unintentional CLHM events can range from simply mixing two different cleaning products; bleach and an acid of some type, to produce chlorine gas. CLHM's can also be used to carry out an intentional act such as Homemade Chemical Bombs or Chemical Assisted Suicide.

To illustrate the CLHM situations, lets look at this case study -

A homeowner is attempting to clear a clogged drain in his kitchen sink. Over the course of three days, he uses several consumer level products from his local grocery store. None of the products work. Indesparation the homeowner now visits the local builders labyrinth (big box do-it-yourself store) for something stronger...still, no results.

Finally, he pours the remainder of all the drain cleaning products into the drain at the same time. In this case, he used Liquid Plumr, Rooto Professional Drain Opener, Comet, liquid bleach, and some sulphuric acid for good measure.  The mixture reacts resulting in a severe inhalation hazard and the homeowner dies. His wife and son are overcome. Responder were called for trouble breathing and entered the structure as anyone might. They are also exposed to the fumes.

This situation actually took place.

Lets take a look at the CLHM involved and get a picture of how bad this is:

• Liquid Plumr = Sodium Hypoclorite and Lye
• Bleach and Acid (from comet) = chlorine gas
• Bleach and Ammonia = Chloramines
• Lye, an oxydizer = caustic burns, defatting/soapification injury
• Take a deep breath
  

All this from products bought in any grocery or department store.  Until next week, just imagine what we could do if we wanted to really hurt somebody...

Survival Basics for Civilians and Responders

Survival basics for your car will keep you going and improve response.

Hundreds of motorists were stranded on the New York State  Thruway this week when a tractor-trailer jackknifed blocking the road during a snowstorm. The storm eventually dumped over 2 feet of snow in the region south of Buffalo, New York. Hundreds of occupants of personal vehicles and commercial vehicles were stranded without any means of escape during the storm. Many were stranded for over 24 hours. Eventually, local fire department and police crews were able to make their way down the miles long lanes of stranded motorists to deliver extra fuel, food, and to assess the situation.

Criticism of the New York State Thruway authority has been building since the event on December 1, 2010. One of the criticisms was that the authority allowed traffic to enter the block area of roadway during the storm even though they were aware of the traffic jam. Another shortcoming has been described as the lack of a plan to deal with such emergencies and allowing the area to go on monitored and not being able to remove the truck blocking the lanes of travel.

This event has important emergency management and preparedness implications for us. First, we have to remember that no response will be successful if the public involved has not done at least some preparedness. In this case, it appears that few if any of the motorists in either private or commercial vehicles had any emergency supplies. Most complained of being cold yet did not have any spare clothing with them… some did not even appear to be dressed appropriately for the environment found in western New York this time of year. Another important thing to consider is the length of time it took traditional responders (police and local fire apartment) to get to those trapped in the snow. Most accounts indicate that it was over 12 hours before rescuers were able to make their way into the traffic jam to deliver supplies and assess the situation. One source was quoted as saying the reason for this delay was because this area of roadway is not routinely monitored by any jurisdiction.

Another frustration expressed by stranded motorists was that the responders were not able to give them any information on the situation. While this may be difficult to do, we should make every attempt to craft a generic statement that will give the civilians some information. That statement could be as simple as which radio station to tune into to get information and updates. A common misconseption is that if we inform the public of the actual situation they will panic. This is clearly a false belief. Information helps keep people calm and promotes compliance with instruction. Disaster research shows that when people are poorly informed, feel trapped, and hopeless that they begin to panic and make poor decisions.

Once again we have a local example of Optimism Bias in action. That is, it won't happen to me… if it happens to me, someone will be there to rescue me. We have to take measures to protect ourselves and be able to be self-sufficient (even rudimentary effort would help) in cases where rescue or assistance may be delayed.

Here are my tips for survival when stranded:
 
First, be sure to keep your car's fuel tank greater than half-full. Keeping your vehicles fuel tank  above half full or better will help make sure you can navigate detours if you're route is blocked. Keeping that much fuel in your vehicle will also allow you to run the engine for much longer in order to stay warm. It's important to keep in mind also that you should run the vehicle's motor only intermittently when stranded… just enough to warm up the interior every 30 to 45 minutes. On this point we should also mention the need for good ventilation in your vehicle… keeping a window cracked open to allow for fresh air and periodically checking the exhaust pipe to ensure it has not become blocked with snow or debris. Failing to do either of those could result in exposure to automobile exhaust and carbon monoxide poisoning.

Second keep a survival kit in your car. It does not have to be elaborate put should contain a few simple items. A hat, gloves, extra socks, and a pair of boots would be helpful as well as a warm blanket. It's best also to have some shelf stable snacks available. Candy bars, energy bars, and those little crackers and cheese combinations will work just fine. Along with something to eat you should try to keep something to drink in your vehicle as well.

Third, communications is key. Although we all have cellular phones these days it won't do us much good if the battery runs out. Therefore, keeping your cell phone charger (the car adapter type) in the vehicle will go a long way to letting people know where you are and getting information… especially if you were stranded for a prolonged period of time. Another important part of communications is your communications plan. Although we take traveling for granted it's important to let people know when were leaving and when we plan to arrive at our next destination. This is especially helpful when traveling during inclement weather seasons or in unfamiliar areas.

And finally, don't forget the shovel and salt. Keeping a small shovel in your vehicle may mean the difference between being stranded and effecting a self rescue. Also keeping a small bag of sand, gravel, or rock salt may be able to provide the needed traction to get yourself unstuck.

Although I recommend a shelter in place approach to surviving these situations, there may come a time where you have to decide to attempt self evacuation. The decision to leave safe shelter and walk out into a storm is not one to make lightly. You must consider your level of fitness, your clothing, your hydration and nutrition status, and the environment before attempting self rescue.



Planning and preparedness.
For those of us responsible for responding to such events there are several keys to successful operations. The first, of course, is pre-incident planning. If you have stretches of highway in your area you can find yourself dealing with hundreds, perhaps thousands, of stranded motorists in any season… from any cause. There is no excuse for not pre-planning your response with various size highway incidents involving multiple patients. Your threat assessment is a major part of the pre-planning process and should include natural as well as man-made events.

As a traditional responder you'll need to consider additional points:
First, what personnel and resources will I be able to bring to this situation and how long  will deployment take. In these large-scale events deployment of resources is often best done only after sufficient personnel, supplies, and equipment have been staged to support the effort. Although rapid triage crews may be effective, the main thrust of the response should only take place when all the pieces are together.

Secondly, you must make provisions early on for emergency incident rehabilitation. Your responders will be providing assessment and care in very difficult environmental conditions. Appropriate rehab and rotation of responders will go a long way to maximizing efficiency and extending crew viability.

Third, you'll have to make some difficult decisions as to shelter in place versus attempt evacuation. As noted above there are several conditions that have to be taken into account before people are moved from an area of relative safety into a hazard area.


This post will also appear in Mitigation Journal at www.mitigationjournal.org

Carbon Monoxide Background

Carbon monoxide exposure is one of the most common poisonings in the United States.  Although we often think of CO is a “winter time” problem, carbon monoxide exposure and poisonings can take place at any time of the year. Carbon monoxide exposure incidents tend to increase during the winter months we can also see an increase in these events at any time when a population uses auxiliary heating or power generating equipment; such as seen during major power failures or other natural events.

Carbon monoxide is known as the “Great Imitator” and can mimic a variety of other medical problems such as cold and flu. In fact a study done in 2006 indicated that one in four patients presenting to a hospital with cold and flu symptoms actually had carbon monoxide exposure. Carbon monoxide has also been linked to cardiac events after chronic exposure. Failure to recognize the potential of carbon monoxide exposure can lead to a deadly missed diagnosis. In some cases, carbon monoxide exposure and poisoning has been mistaken for substance abuse.

Common signs and symptoms of carbon monoxide exposure include headache, drowsiness, confusion, tachycardia. Continued exposure to carbon monoxide also lead to impaired thinking and sensory perception.  These effects of carbon monoxide reduce the ability of a person to recognize a hazard or self rescue from an environment.

Symptoms of carbon monoxide differ from person to person and level of exposure. Mild exposures (15 to 20% COHb) symptoms may include headache, nausea, vomiting, dizziness, and blurred vision. Moderate exposure is defined as 21 to 40% COHb and may present as confusion, syncope, chest pain, dyspnea, and general weakness. The severe exposure (41 to 59% COHb) may result in myocardial ischemia, rhythm disturbances seizures, and respiratory as well as cardiac arrest. Exposures to levels of carbon monoxide greater than 60% are usually considered fatal. It's important to note that CO exposure and COHb  levels do not have the same symptoms with all patients.

 Carbon monoxide alarm technology is reliable and found in many residential and commercial structures. In general, there are two types of carbon monoxide detection equipment. The first type is known is a biomimetic style detector. This type of detector uses a synthetic hemoglobin that reacts to acute and chronic carbon monoxide. Biomimetic style detectors are very common and usually resemble smoke alarms or are manufactured in combination with a smoke alarm.  These units typically have a module sensor built-in the battery compartment. Some of the most common manufacturers estimate a module life of two years and a total unit life of 10 years. This type of carbon monoxide detector can be influenced greatly by exposure to cooking products.
Another style of carbon monoxide alarm is the semiconductor style. this style of alarm uses an electronic sensor to measure carbon monoxide  and is typically plugged into a power outlet or other power supply. The general recommendation is that the unit be replaced every 5 to 10 years. Most carbon monoxide alarms activate at an estimated 10% of carboxylhemoglobin or 100 ppm of carbon monoxide.