Dr. RAKESH KUMAR SHARMA Division of CBRN Defence,

1. Emergency Medical Preparedness and Response to Chemical Disasters Dr. RAKESH KUMAR SHARMA Division of CBRN Defence, Institute of Nuclear Medicine and Allied Sciences, Brig SK Mazumdar Road, Delhi 110 054 (rks@inmas.drdo.in) @National Level Training Programme on On-Site and Off-Site Emergency Management Planning; Guhawati, 23rd December, 2008

2. Assessing the Risk • MIC Gas Leak in Bhopal- accounts for nearly 20000 casualties till date. 1,20,000 still suffering • Equally important are the ‘peripheral emergencies’ which results in mass casualty events resulting in 10s to 100s of casualties. • Due to increase in growth of chemical industry , the risk of occurrence of chemical disaster associated with Hazardous Chemicals (HAZCHEM) has gone up. • The recent incidences of chemical Attacks by extremists in Iraq has now put the importance of preparedness for chemical disasters in the forefront

5. Mass Casualty Incident Any event resulting in number of victims large enough to disrupt the normal course of emergency and health care services is called as a mass casuality event (WHO)

6. CIDM Management of mass casualty incidences due to incidences/man-made accidents involving them or overt/covert attacks involving chemical agents, needs overall preparedness and risk reduction at all levels, including contingency planning and capacity development for an efficient response.

7. National Vision for Management of Chemical Disasters CD

8. National Vision for Management of Chemical Disasters CD

9. National Vision for Management of Chemical Disasters • To prevent Chemical Disasters CD

10. National Vision for Management of Chemical Disasters • To prevent Chemical Disasters CD

11. National Vision for Management of Chemical Disasters • In the event of occurrence of CD, various stakeholder shall under take certain pre-planned and established Structural and Non-structural measures so as to minimize risks to health, life and environment Something may go wrong in spite of best system. History repeats itself as we don't learn from it. Many big mishaps have apparently small causes behind, which are likely to be overlooked.

12. Scale of Disasters: Factors affecting • Inventory; geographic and demographic factors • Vulnerability of population • Frequency of occurrence • Public awareness • Intensity – distance relations • Energy factor(release, mode & rate) • Time factor (release rate and warning time) • Exposure factor (nature, duration & extent) • Type of response mechanisms

13. Scale for Grading of Chemical Disasters Grades Qualitative Severity/ Consequence Criteria 1 • Injuries requiring first-aid only • Contained release with local environmental effect and pollution problem 2 • Injuries requiring a physician’s care • Uncontained release with potential for minor environment effects • Chances of fire and explosion 3 • Severe injuries or potential for a fatality • Uncontained release with potential for moderate environment effects 4 • Multiple life threatening injuries and / or fatality • Uncontained release with potential for major environment effects

14. Sequel of Major Chemical Disasters • Fire & violent Explosion • Uncontrolled Reaction • Leakage of highly toxic cloud of gaseous and particulate material, which spreads to neighboring habitations • Environmental (Air release, ground spill to water bodies, cultivated land, waste disposal etc.) • Dissemination of aerosolized chemical warfare agents or liquid toxicant/poisons to contaminate the environment or food product by terrorists

15. Modes of Chemical Injury • Chemical Burns (strong acids, strong bases) • Heat Burns (flammable materials) • Poisoning (many chemicals are damaging or fatal if taken internally, whether by swallowing, injection, or leaching through skin) • Chronic illness (long-term exposure to even low doses of certain chemical agents can lead to chronic health conditions) • Etc.

16. General Signs and Symptoms Cough Chest pain Lacrimation Eyelid oedema and Unconsciousness Acute lung injury Leads to Cardiac arrest DEATH

17. TARGET ORGANS AND EFFECTS INDUCED BY CHEMICALS Corneal Opacity Retinal Damage Behavior Changes Peripheral neuro degeneration Locomotion rigidity Narcosis or Depression Respiratory Paralysis Osteoporosis Arthritis Immuno Suppression Corrosiveness Erythemas Irritations Sensitization Pneumoconiosis Fibrosis Adenomas Asphyxiation MFO induction Choleostasis Carcinogenesis Necrotic/Cirrhotic liver Defense system loss Aminoacid urea Uremia Renal failure Bone marrow depression Anaemia Cancer Met hemoglobinemia Miscarriage Neonatal death Fetal abnormalities

18. Chemical Disaster Action Plan Gather information regarding: place, time and type of emergency also type of chemical, chemical toxicity, route of exposure OT Treatment to the patient (Emergency Dept.) Decontamination done at decontamination area in the hospital Triage IPD / ICU Documentation done at reception OPD • Mobilization of Resources • Manpower: Disaster Management Team medical , nursing and other Personnel • Material and supply eg: antidotes • Transportation means Transport to the critical patients for medical care / hospitals Discharge Getting initial alert from: Police, casualty and telephone • Initiate preparation • All the dept & designated staff get into readiness to attend casualties • Crisis expansion of hospital beds. • Preparation for decontamination area Notify to Key Personnel • Diagnostic Services • Other support services • On site treatment / operations • Mass decontamination • Transported in a safe place • Provide necessary treatment , first aid and antidote administration to chemical contaminated patients

19. Five steps to Emergency Response  Secure the Area – To keep Non-Emergency Response Personnel out of danger.  Approach with Care – No Blind Rushing, Approach upwind.  Identify Products – Placards / Labeling for the hazard.  Assess the Situation – Fire / Spill / Leak / Weather conditions / Terrain like / At risk, people, property, environment / evacuation necessary / what to be done right away.  Respond – In an appropriate manner. Establish Command Post / Lines of Communication / Control of the site / Safety of the People in the Area / Own Safety.

20. Management of Chemical accident • Pre-hospital • Hospital • Post-hospital • Preventive

21. PREHOSPITAL RESPONSE Services Involved Rapid Response Team Primary Health Centre Community Health Centre First Referral Unit Civil Hospital Medical Colleges POLICE FIRE MEDICAL VOLUNTARY • After the initial management of the victims Triage Red will get the first priority. • All events must be coordinated with the doctors of the receiving hospital. • While shifting patients back, neck and airway need to be protected. • Keep the facilities till the last victim is transported.

22. Medical Preparedness • Medical Preparedness will be based on regular practice of medicine and should include recognition of the impact of chemical disaster • It should focus on injuries, illness and public health problems including psychosocial trauma and should address integration of medicine and public health • It must also focus on Disaster management onsite plan, offsite plan and crisis management at the hospital

23. Medical Preparedness (Contd./..) 4.Medical preparedness should also address necessity of planning and practice, exercises involving local, district, state, central government and voluntary agencies 5. It must include problem solving, based on the past experience of disasters 6. Specialized first responder and specialized medical first responder of NDRF need to be prepared to handle chemical disaster

24. QUICK REACTION MEDICAL TEAM (QRMT) • Doctor • Chemist • Nursing Asst. • Mobile Van • Resuscitative Equipment • Protective Clothing • Detection Equipment & Decontamination Material • Regular Rehearsal/ Exercises • Ready to move at very short notice

25. A separate team of chemists is needed to analyze the exact type of chemical (mobile lab fitted with chemical analyzer). • Knowledge of exact nature of chemical will facilitate proper antidote administration & effective treatment for early recovery

26. Resuscitation Equipment & Drugs • O2 Cylinder • O2 Concentrator • Suction Apparatus • Laryngoscope • Endotracheal Tube • Ventilator • Airway • Pulse Oxymeter • Defibrillator • IV fluid • Emergency Drugs • Dressing material

27. Chemical Casualty Treatment Kit • Autoinjectors (Obidoxime x3) • Obidoxime, bottles , x3 • Atropine sulphate injection, bottles, x10, ampoules, x20 • Pyridostigmine bromide tablets, packs, x10 • Dimercaprol injection, ampoules, x10 • Sodium thiosulphate, bottles, x4 • Syringes, hypodermic disposable, 5 ml , x5 • Guedel airways, 2 sizes • General surgical scissors • Bandage, gauze, 5 cm , x5 • Bandage , gauze, 7.5 cm, x5

28. Capacity Building (Manpower) • The selection of dedicated team is the first step in capacity building. Manpower from Govt., NGOs, specialized response team, etc. • Formulation of QRMT consisting of Doctor, Nursing Asst. & Chemist • Chemical trained team of medics and paramedics at the hospitals as part of integrated Disaster Management Plan.

29. Training of Medics & Paramedics • Basic knowledge of Chemical substances and their properties • Handling Detection and Protective Equipment • Decontamination procedure • Symptoms and treatment ofChemical casualties • Medical care at site, during evacuation and in hospital

30. Public Awareness • Put on NBC mask/wet cloth to protect nose and eyes in case of Chemical disaster • Move away from incidence site • Report incidence to nearest authorized agency under disaster management plan • Avoid contact with Chemical agents • Do not eat, drink or smoke in contaminated area • Report to nearest medical facility

31. Capacity Building (Material) • Effective communication is very important • Facilities for evacuation by Ambulance, train, helicopters and sea etc. • Medical equipment for QRMT & hospital treatment • Mobile Hospitalfor Casualties Management at Site to Decrease the load on Hospitals • Resuscitative Equipment like O2 Cylinder, Suction Apparatus, Laryngoscope, Endotracheal Tube, Ventilator, Defibrillator, Emergency Drugs • Protective Clothing • Detection Equipment & Decontamination Material

32. Protective Devices • NBC Protective suit • Charcoal underwear • Protective boots • Protective gloves • NBC Protective mask • Disposable Plastic protective suit • Decontamination equipment • Decontamination sprayer • Hot Air Decontamination system • Contamination Clearance Module

33. PERSONAL PROTECTIVE SUITS

34. Charcoal – Underwear

37. Chemical Agents Detectors • Chemical Agent Monitor (CAM) • Haz-chem detector Ticket. • Chemical Agent warning Instrument • Hazmat Vehicle • Ground Area Reconnaissance Detection System

38. Preparedness for Evacuation • By road in Ambulance • By Helicopter if warranted • Stretcher & Life support system • Casualty evacuation bag • SOPs for Resuscitation, Decontamination, Triage • & Evacuation

39. Chemical Casualties Evacuation Bags

40. GUIDELINES –Medical Preparedness & Response. Salient features • Medical Preparedness shall stress upon : • Creating awareness • Creation of trained specialized medical first responders • Creation of Decontamination facilities • Uniform casualty profile and classification of causalities and illness • Risk Inventory and resources inventory • Plans for Evacuation • Proper chemical casualty treatment kits • Crisis Management Plan at the Hospitals • Mobile hospital/medical team • Preparedness for public health and environmental effect response • Emergency Medical Response & Post Disaster Phase • Chemical related issue during , Rescue, Relief and Remedial measures • Quick Response Medical Team • Materials and Logistics requirement • Post-disaster Public Health Response • Post disaster documentation and Research • Medical response to long term effects • Medical Rehabilitation • Psychosocial trauma • PTSD Care

41. GUIDELINES –Medical Preparedness & Response Section-4 of this document lays down the Guidelines for medical preparedness and response

42. GUIDELINES –Medical Preparedness & Response Section-6 of this document lays down the Guidelines for Medical Preparedness for CBRN Management

43. Management of Medical Emergencies The management of medical emergencies during On-Site and Off-Site emergencies is a priority area. Medical Preparedness is the weakest link in the emergency response system and at hospitals. There is a need to address & update medical preparedness comprehensively at all levels. Keeping in view specific preparedness and response requirements of chemical disasters gaps in the existing Medical Emergency Management have been identified

44. Management of Medical Emergencies It is essential to address mechanisms for creating awareness, creation of trained medical first responders, decontamination facilities, risk and resource inventory, trauma care, plans for evacuation, mechanism to maintain uniform causality profile, availability of proper chemical casualty treatment kits, mobile teams/ hospitals, hospital disaster management plan and preparedness for public health and environmental effect response.

45. Management of Medical Emergencies Important Gaps Non-availability of specific antidotes for chemicals Inadequacy of infrastructure for trained medical and paramedical staff. The standard operating procedures for Emergency Medical Response at incident site are not laid down. Absence of separate Medical Emergency Plan in the District Off-Site Plan Lack of documentation of uniform procedures to be followed during chemical emergencies

46. Management of Medical Emergencies Important Gaps Gross inadequacies in terms of trained manpower and capacity in Poison Information Center and regional laboratories lying in proximity with disaster prone areas with detection facilities for hazchem Absence of mechanism for medical surveillance Medical Response to long term effects and at present, there are inadequacies in terms of studies on long-term effects and research Mechanisms for Medical Rehabilitation need addressals

47. Evacuation Plan • Patient Evacuation Plan with flow chart must be made, keeping the meteorological conditions in view • Resources for special ambulance helicopters, ambulance trains, etc, will be strengthened at all levels and proper resources inventory will be prepared for the purpose • The ambulance should have SOPs for treatment procedures and list of specific antidotes • Acute health risks must be defined and known to para-medical staffs, who are accompanying the patients in ambulance • Ambulances are to be fitted with resuscitation equipment to maintain vital parameters during evacuation to hospital.

48. Hospitals Preparedness • Preparing Integrated Hospital Disaster Management plan including Chemical casualties management facilities • Creation of Decontamination Room & Facilities • Surgical & Medical Team readiness • Stocking & rotation of antidotes and essential drugs. • Plan for Beds expansion by discharging sub-acute and chronic patients and activating crisis mngt. beds. • Documentation & Research for future improvement. • Appointing a PRO to deal with patients relatives, press, media, for regular medical bulletin.

49. Preparedness by Earmarked Hospitals • Hospitals must nominate an incidence officer for coordinating management of chemical casualties • A decontamination room is to be established. All chemical casualties have to be taken first to decontamination room • Contamination, clearance module, a very effective tool for dry & prompt decontamination can be utilized for walking casualties • Surgical team is to be kept ready to handle blast and heat injuries

50. Preparedness by Earmarked Hospitals (Contd./..) 5. A group of specialists like Neurologist, Hematologist, Gastroenterologist, chest physician, ophthalmologist, burn specialist & dermatologist etc. must be available to handle immediate and long term effects of chemical disaster 6. Stocking & rotation of antidotes needs to be maintained 7. Special lab for chemical analysis is to be established 8. Contingency plan be made ready for bed expansion by discharging chronic patients 9. Availability of oxygen, continuous positive air pressure (C PAP) Ventilators, dialysis facilities, blood and IV fluid for transfusion must be stocked