Rethinking the solution to mass casualty decon

Published:  01 July, 2008

Dr. Howard Levitin, MD, FACEP is the president and founder of US company DQE, a hazmat decon supplier that began eighteen years ago as a research project into emergency preparedness. Levitin became interested in the role of hospitals in a hazardous materials incident after being confronted with two contaminated patients while working the night shift in the emergency department. While researching the methodology for handling contaminated patients in the ED he met a firefighter who was working to improve the design, quality, and dependability of portable decontamination equipment. They joined forces and the result is DQE.

Levitin points out that 9/11 played an important part in the shift from using portable decon systems to buying and training, with large shelters alongside massive decon systems. However, the tide is now turning back. “In the last two years people have realised that the equipment is too large for the typical decon, and too small for a large scale incident. The thinking on the way those big units are used has changed significantly because the concept that all victims have to be showered has been found to be unrealistic.”
In the paper Decontamination of Mass Casualties – Re-evaluating Existing Dogma (Prehospital and Disaster Medicine, Vol 18, No. 3), it is outlined how first-responders must rapidly implement effective triage, provide appropriate decontamination, and effect rapid scene evacuation to maximise victim survival and responder safety. However, determining how these processes are best conducted during a chemical, mass-casualty incident is described as “controversial”.
“There only is cursory consensus in this regard,” says the report. “The procedures have been utilised only infrequently, and thus, are not well understood, well-studied, or standardised. Current plans may reflect the inclinations of individuals or groups (dogma) rather than scientifically supported doctrines.”
The report then sets out an example of how it is commonly believed that all victims of a hazmat release require soap and water showering – hence explaining why communities have purchased multi-casualty decon tents and trailers etc. But their usefulness as an effective means of providing mass-casualty decon “has not been demonstrated”.
A study by the US Agency for Toxic Substances Disease Registry over seven years and 13 US states, found that in 90 per cent of cases only six or fewer human casualties required care after chemical exposures. In 70 per cent of the cases only two or fewer human casualties needed care.
The Re-evaluating Existing Dogma report – which Levitin co-authored – advocates a more focussed approach to water decon, whereby only the symptomatic victims with obvious exposure to the hazard are treated. Such treatment, says the report, “will be very difficult if water decontamination, which is heavily reliant upon large manpower and equipment resources, is directed towards the ambulatory survivors with minimal or no symptoms.”
Unfortunately, this type of scenario is not replicated in “live” training exercises, as Levitin explains. “The people doing the exercises are volunteers, usually young men wearing bathing suits underneath, and they stand in an orderly line waiting to be showered. That is not realistic. In a real incident it is not young males who don’t mind taking off their clothes because they have bathing suits underneath. In a real situation people may not be co-operative especially if there is no evidence that the decon is necessary.”
Test case
Just how far reality can differ from prescribed measures was demonstrated seven years ago in Michigan State University (MSU), in an incident widely reported in the student press.
In October 12, 2001, a police dispatcher mix-up resulted in 15 women – employees of MSU’s Graduate School’s Linton Hall – being forced to take their clothes off before an all-male crew of firefighters and police officers, who thought there was a risk of chemical/biological contamination.
An employee had opened a letter and subsequently felt a burning sensation down her throat. She called the MSU police but unfortunately the call handler got confused with an earlier call that had reported a suspicious letter containing white powder – an incident that had actually occurred a month earlier.
Within minutes firefighters arrived and told eight employees that they would have to be decontaminated – even though employees repeated that no powder was present or indeed had been reported.
One employee working across the hall who initially refused to go through the procedure was told that if she did not cooperate, she would be dragged down the hall, and have her clothes forcibly ripped off.
The decon experience involved being hosed down in one pool while fully clothed, and then in another being washed with bleach and water with brushes, then rinsed with water and soap. The experience was described as dehumanising and humiliating, and the women felt threatened by the forcefulness of the all-male officers standing around them.
More complaints followed because additional personnel not in uniform or protective equipment were reported to be watching from only a few feet away. Also, windows and doors had been inadequately covered and fellow co-workers could see what was happening.
Levitin believes that with the focus on decon moving to clothing removal, there are serious legal/human rights implications. “We have seen how in real incidents you can have people who simply won’t take their clothes off, whether for modesty or for religious reasons. Unless processes are in place to provide privacy and a sense of personal space, victims will not cooperate with the vital first step of decon. In a similar light, several years ago I took part in a talk in Japan on the topic of mass casualty decon. One of the fire chiefs from the UK showed a way of building multiple, interconnecting decon systems designed to quickly wash injured victims on rollers. It was an impressive set up, and the feeling was that everyone required decontamination and needed to be prepared for multiple injured patients on backboards. I asked him how long they had been using it. He said over 20 years. When I asked him how many contaminated patients confined to a backboard had they cared for, he said zero.”
Levitin’s company has come up with a solution to the question of decency during decon and patient care – the Doff-it and the Don-it over-garments. The Doff-it provides privacy before decontamination while the Don-it ensures the same privacy and protection from cold exposure after showering.

  • Operation Florian

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