Medical responders

Although these agents do not produce any significant vapor, aerosolization of residual dusts on casualties could cause impacts to medical responders. Once the casualty has been... 

In the Expert Consensus survey (Rush and Frances, 2000) the expert clinicians rated newer atypical antipsychotics highest for treatment of schizophrenic patients who are compliant with medication. Risperidone was rated highest of the atypicals, followed by olanzapine. In the case of patients with numerous failed trials with other antipsychotics, the experts voted for clozapine. For patients noncompliant with oral medication, respondents endorsed long-acting depot antipsychotics. Once again, these were impressions based on personal clinical experiences rather than hard empirical data. 

An emergency response incident that involves the release of any chemicals or toxic materials will typically be referred to as a HAZMAT incident. The response to a HAZMAT incident is somewhat standardized across the country, and specialized HAZMAT teams are called in to address these situations. HAZMAT teams are typically affiliated with the fire services and will possess a majority of the locality s chemical detection equipment. Emergency medical responders arriving on the scene must first be capable of determining that a HAZMAT incident has occurred. These first responders are the individuals responsible for determining whether the HAZMAT team should be called for assistance. Responders may have different levels of training and preparedness for HAZMAT response (see Table 25.2). 

Emergency Medical Technicians (EMTs) and Paramedics (EMT-Ps) - Trained emergency medical respondents (both paramedics and EMTs are trained to diagnose and treat most common medical emergencies in the field and to provide medical treatment while en route to the hospital paramedics are more highly trained than EMTs). 

Tissue sample collection is obviously the most invasive and usually limited to a deceased casualty. Consequently, tissue collection is not normally used for diagnosis to medically respond but for forensic analysis, such as the formalin-fixed brain tissues from the Tokyo subway attack victims, to verify GB as the agent employed (Matsuda et al., 1998). 

What can we as medical responders do about a terrorist attack ... 

Security forces should maintain ongoing discussions with, and have frequent training exercises with, police, rescue organizations, emergency medical responders and healthcare providers. 

This is an example of a biological attack using botulism toxin. Because of the incubation period before the victims developed symptoms, the banquet food had already been dumped in the local landfill before an investigation could begin. The medical responders were not affected because the agent was a toxin placed in food and not a contagious agent. 

In practical terms, knowledge of whether a substance is persistent or non-persistent is essential in assessing the risks to medical responders at the scene of the toxic release and also the dangers of transmission of a toxic substance from patients who have been brought undecontaminated to the hospital. 

The use of lightweight suits allows essential life support and other medical care to be given early to victims by protected medical responders. 

It is therefore important that medical responders understand all aspects of the potential hazards of the release of toxic chemicals. The management of chemical releases is usually done by specialist arms of the fire and rescue services and the police and involves considerable detail about the properties of the agents involved. However, there is a need for medical teams to be aware of the principles of management of chemical incidents, particularly in the provision of emergency life support within a contaminated area. 

Box 5.1 Role of the emergency medical responder at each stage of the HAZMAT management chain... 

The number of emergency personnel involved in the management of contaminated casualties should be kept to the minimum in order to contain any potential risks of secondary contamination. Emergency medical responders must always be alert to the dangers of the spread of contamination throughout all stages of resuscitation and treatment of casualties. 

Basic life support for toxic trauma provided by non-medical responders who are present at or near the site of the chemical release. This is the chemical equivalent of basic life and trauma support or first aid ... 

Advanced life support for toxic trauma provided by medical responders who are trained in ALS and ATLS protocols and who are able to respond safely within a contaminated zone... 

HD is the most important of the vesicants and has been widely used in warfare in the twentieth century. Although the onset of signs and symptoms is insidious and has considerable latency, the action of the agent is rapid with skin penetration within 3 min. HD is persistent and therefore a danger to medical responders. It has a relatively low mortality but a high morbidity. 

There has been considerable research into the actions of HD. However, this has not so far produced any major advance in the management of HD exposure and no antidote exists. An overall understanding of the actions of HD is, therefore, useful for emergency medical responders but detailed knowledge of the research into the mode of action is not essential to the actions needed to manage casualties. 

The eye is the organ most vulnerable to exposure to HD and which requires the earliest possible attention. The signs and symptoms of HD exposure are related to the concentrations of exposure. These concentrations are unlikely to be known to emergency medical responders but are presented in Box 8.9 as an illustration of the dose dependency. 

The attack was revealed only after 2 h by a telephone call for emergency medical care. Eight of the medical responders including one doctor suffered anticholinergic effects as a result of cross-contamination. 

Medical responders themselves became victims of secondary contamination from the original attack. 

The examples of chemical incidents above provide important lessons for emergency medical responders who may have to deal with the management of mass casualties following the release of a toxic chemical agent. These should be integrated into a planned approach for an effective response to such an incident. 

The overall approach to management must be based on knowledge of the incident and the properties of the agents causing toxic trauma. In particular, the potential hazards to medical responders from secondary contamination must be borne in mind. 

It is important for emergency medical responders, faced with a potential BW attack to be aware of the essential features which are different from C, R and N releases. These are listed in Box 12.3. Because the effects of a BW attack are more insidious than those of C, R or N attacks and the release is less obvious, it is essential that emergency responders should maintain a high level of suspicion about possible BW agent release. 

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