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Thu, 7 Feb 2002 17:24:18 -0500

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Greg,

 " You are absolutely incorrect.  St. Lukes Hospital in Toyko was
contaminated because they were not prepared.  In Tokyo, 688 people were
transported via EMS, however over 4,000 sought emergency care.  Their first
error was in failing to recognize contaminated patients.  Unless your plan
involves having HazMat teams screen patients 24/7, this responsibility falls
upon the ED staff, and requires training.   Massive self triage is a common
characteristic of these types of incidents and must be planned for.    

Answer me objectively: what constitutes adequate preparation for large-scale
toxic exposure?  Are you comfortable blaming Japanese nurses for not being
day-to-day experts in chemical weaponry?  

Consider that in America, adequate preparation by your standards involves
something in excess of five thousand hospitals, employing (on average)
probably 50 or more ED staff who'll require thorough training and regular
review.  Then add equipment, plus expansion or new construction to allow for
a safe decontamination area (pretty dangerous to shower victims in our ED
parking lot this time of year).  How much do you want to spend?  I'd
estimating a domestic expenditure of something between fifty and a hundred
million dollars annually.  Considering the actual impact of large-scale
hazmat incidents in this country each year, I have to suggest that the
cost-benefit analysis ain't flattering.  The terrorists have already bruised
up our economy enough for my liking.  Fifty million dollars would buy a hell
of a lot of free bike helmets and car seats.

All this assumes that there's any predictable "benefit" to hazmat training
for clinical personnel who, like as not, will NEVER see practical experience
in the course of their careers.  Can we realistically expect all those
nurses and techs to retain training to sufficient to perfectly protect
themselves--much less the hospital--next week?  Next month?  Next September?
Recall that a single business-sized, tightly-sealed envelope carrying a few
grams of anthrax shut down a rather beefy federal office building for four
months...

I think of "massive self triage" as less a clinical conundrum, more a threat
to my colleagues and my community.  I think of the hospital as a collateral
target, not a clinical objective.  My response--especially in the case of
WMD--would be to lock down the facility until appropriate decontamination
can be assured.  If regional or community disaster resources were more
methodically assigned, under the more realistic assumption that hospitals
are thoroughly incapable of defending themselves, then the first National
Guard hazmat team would be headed for the Eastern Maine Medical Center.

" Based upon several exercises and critiques of actual incidents, we have
come to the conclusion that we can not depend on the local hazmat team to
perform at-hospital decon in every situation.  This is not a reflection on
their quality, but rather a realistic assessment of what our resources are.
Since we cannot be assured of outside decon resources, we are training our
own personnel.  Pret, your hospital emergency planners may have discovered
the same thing.  Are they idiots as Dr. Frykberg suggest, or have they
thought things through better? " 

I'm less inclined than some to assert that anybody's an idiot, besides me:
I prefer to work with established truths.  But let's not waste time chasing
down points of etiquette.  So far, each response has given me more insight,
and I'm grateful.

The whole point of this thread is that I think your exercises and incidents
have suffered from a flawed response paradigm.  Hazmat cannot be depended
on, because it has not been properly tasked.  Reconsider your scenarios, but
imagine that a solid portion of the hazmat response is assigned downstream,
to the bottom of the funnel: to the hospital.  Any of your exercises
structured that way?

 " Those of you that live in areas with multiple HazMat teams, do you also
have multiple hospitals in the same jurisdiction?    If so, who gets the
HazMat team(s)?  When do you call them?  Your staff still must be trained in
awareness and recognition.  How long of a response time does the HazMat team
have?  Add this to the briefing and set-up time.  How long will contaminated
patients be waiting?  Where will they wait?  How much more product will be
inhaled/absorbed in that time?  Will they wait that long? "

Most of these questions are quite reasonable, and directly dependent on the
rational construction of a disaster management plan which acknowledges both
a) how little can be clinically accomplished at the scene, and b) how
vulnerable the hospital is to secondary catastrophe.

As for the wait times for initial victims, call me a hard-hearted bastard,
but I think the first priority is to shut off the chain of exposure.  We're
not accomplishing much if, while rushing one victim to treatment, we expose
a doctor and three nurses and contaminate the trauma bay and the entrance to
the ED.

 " Bottom line, just like trauma, there is not one right way to plan for a
WMD incident.  It depends on your resources.  If an outside team is
available, will be there when you need them, and the logistics are
satisfactory, great.  If not, you better have another plan."

No argument, except to assert that only the methodology must be flexible.
The objectives must remain fixed: ensure the safety of the rescuers, THEN
rescue the victims.

 " Greg  "

Pret 

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<DIV><FONT color=#800000 face=Arial size=2><SPAN 
class=950295811-07022002>Greg,</SPAN></FONT></DIV>
<BLOCKQUOTE>
  <DIV><FONT size=2><FONT face=Arial><FONT color=#800000><SPAN 
  class=950295811-07022002>&nbsp;<FONT 
  color=#000000>"&nbsp;</FONT></SPAN></FONT></FONT><FONT face=Arial></FONT><FONT 
  size=2><EM>You are absolutely incorrect. &nbsp;St. Lukes Hospital in Toyko was 
  contaminated because they were not prepared. &nbsp;In Tokyo, 688 people were 
  transported via EMS, however over 4,000 sought emergency care. &nbsp;Their 
  first error was in failing to recognize contaminated patients. &nbsp;Unless 
  your plan involves having HazMat teams screen patients 24/7, this 
  responsibility falls upon the ED staff, and requires training. 
  &nbsp;&nbsp;Massive self triage is a common characteristic of these types of 
  incidents and must be planned for.&nbsp;&nbsp;&nbsp;</EM><FONT 
  color=#800000></FONT><FONT size=2><SPAN 
  class=950295811-07022002>&nbsp;</SPAN></FONT></FONT></FONT></DIV>
  <DIV><FONT face=Arial><FONT color=#800000><FONT size=2><SPAN 
  class=950295811-07022002>&nbsp;</SPAN><BR><SPAN 
  class=950295811-07022002>Answer me objectively: what constitutes adequate 
  preparation for large-scale toxic exposure?&nbsp; Are you comfortable blaming 
  Japanese nurses for not being day-to-day experts in chemical weaponry?&nbsp; 
  </SPAN></FONT></FONT></FONT></DIV>
  <DIV><FONT face=Arial><FONT color=#800000><FONT size=2><SPAN 
  class=950295811-07022002></SPAN></FONT></FONT></FONT>&nbsp;</DIV>
  <DIV><FONT face=Arial><FONT color=#800000><FONT size=2><SPAN 
  class=950295811-07022002>Consider that in America, adequate preparation by 
  your standards involves something in excess of five thousand hospitals, 
  employing (on average) probably 50 or more ED staff who'll require thorough 
  training and regular review.&nbsp; Then add equipment, plus expansion or new 
  construction to allow for a safe decontamination area (pretty dangerous to 
  shower victims in our ED parking lot this time of year).&nbsp; How much do you 
  want to spend?&nbsp; I'd estimating a domestic&nbsp;expenditure of something 
  between fifty and a hundred million dollars annually.&nbsp; Considering the 
  actual impact of large-scale hazmat incidents in this country each year, I 
  have to suggest that the cost-benefit analysis ain't flattering.&nbsp; The 
  terrorists have already bruised up our economy enough for my liking.&nbsp; 
  Fifty million dollars would buy a hell of a lot of free bike helmets and car 
  seats.</SPAN></FONT></FONT></FONT></DIV>
  <DIV><FONT face=Arial><FONT color=#800000><FONT size=2><SPAN 
  class=950295811-07022002></SPAN></FONT></FONT></FONT>&nbsp;</DIV>
  <DIV><FONT face=Arial><FONT size=2><FONT color=#800000><SPAN 
  class=950295811-07022002>All this assumes that there's any predictable 
  "benefit" to hazmat training for clinical personnel who, like as not, will 
  NEVER see practical experience in the course of their careers.&nbsp; Can we 
  realistically expect all those nurses and techs to retain training to 
  sufficient to perfectly protect themselves--much less the hospital--next 
  week?&nbsp; Next month?&nbsp; Next September?&nbsp; Recall that a single 
  business-sized, tightly-sealed envelope&nbsp;carrying a few grams of anthrax 
  shut down a rather beefy federal office building for four 
  months...</SPAN></FONT></FONT></FONT></DIV>
  <DIV><FONT face=Arial><FONT size=2><FONT color=#800000><SPAN 
  class=950295811-07022002></SPAN></FONT></FONT></FONT>&nbsp;</DIV>
  <DIV><FONT size=2><FONT face=Arial><FONT face=Arial><FONT color=#800000 
  size=2><SPAN class=950295811-07022002>I&nbsp;think of "massive self 
  triage"&nbsp;as less a clinical conundrum, more a threat to my colleagues and 
  my community.&nbsp; I think of the hospital as a collateral target, not a 
  clinical objective.&nbsp; My response--especially in the case of WMD--would be 
  to lock down the facility until appropriate decontamination can be 
  assured.&nbsp; If regional or community disaster resources were more 
  methodically assigned, under the more realistic assumption that hospitals are 
  thoroughly incapable of defending themselves, then the first National Guard 
  hazmat team would be headed for the Eastern Maine Medical 
  Center.</SPAN></FONT></FONT></FONT></FONT></DIV>
  <DIV><FONT size=2><FONT face=Arial><FONT face=Arial><FONT color=#800000 
  size=2><SPAN class=950295811-07022002></SPAN></FONT></FONT><BR><FONT 
  color=#800000><SPAN class=950295811-07022002><FONT 
  color=#000000><EM>"</EM></FONT>&nbsp;</SPAN></FONT></FONT><FONT 
  face=Arial></FONT><FONT size=2><EM>Based upon several exercises and critiques 
  of actual incidents, we have come to the conclusion that we can not depend on 
  the local hazmat team to perform at-hospital decon in every situation. 
  &nbsp;This is not a reflection on their quality, but rather a realistic 
  assessment of what our resources are. &nbsp;Since we cannot be assured of 
  outside decon resources, we are training our own personnel. &nbsp;Pret, your 
  hospital emergency planners may have discovered the same thing. &nbsp;Are they 
  idiots as Dr. Frykberg suggest, or have they thought things through 
  better?</EM><FONT color=#800000></FONT><FONT size=2><SPAN 
  class=950295811-07022002>&nbsp;<EM><FONT 
  color=#000000>"</FONT></EM>&nbsp;</SPAN><BR></FONT></FONT></FONT><SPAN 
  class=950295811-07022002><FONT color=#800000 face=Arial 
  size=2>&nbsp;</FONT></SPAN></DIV>
  <DIV><FONT face=Arial><FONT size=2><SPAN class=950295811-07022002><FONT 
  color=#800000>I'm less inclined than some to assert that anybody's an idiot, 
  besides me:&nbsp; I prefer to work with established truths.&nbsp; But let's 
  not waste time chasing down points of etiquette.&nbsp; So far, each response 
  has given me more insight, and I'm grateful.</FONT></SPAN></FONT></FONT></DIV>
  <DIV><FONT face=Arial><FONT size=2><SPAN 
  class=950295811-07022002></SPAN></FONT></FONT>&nbsp;</DIV>
  <DIV><FONT color=#800000 face=Arial size=2><SPAN class=950295811-07022002>The 
  whole point of this thread is that I think your exercises and incidents have 
  suffered from a flawed response paradigm.&nbsp; Hazmat cannot be depended on, 
  because it has not been properly tasked.&nbsp; Reconsider your scenarios, but 
  imagine that a solid portion of the hazmat response is assigned downstream, to 
  the bottom of the funnel: to the hospital.&nbsp; Any of your exercises 
  structured that way?</SPAN></FONT></DIV>
  <DIV><FONT color=#800000 face=Arial size=2><SPAN 
  class=950295811-07022002></SPAN></FONT>&nbsp;</DIV>
  <DIV><FONT color=#800000 face=Arial size=2><SPAN 
  class=950295811-07022002>&nbsp;"&nbsp;</SPAN></FONT><FONT face=Arial><FONT 
  size=2><EM>Those of you that live in areas with multiple HazMat teams, do you 
  also have multiple hospitals in the same jurisdiction? &nbsp;&nbsp;&nbsp;If 
  so, who gets the HazMat team(s)? &nbsp;When do you call them? &nbsp;Your staff 
  still must be trained in awareness and recognition. &nbsp;How long of a 
  response time does the HazMat team have? &nbsp;Add this to the briefing and 
  set-up time. &nbsp;How long will contaminated patients be waiting? &nbsp;Where 
  will they wait? &nbsp;How much more product will be inhaled/absorbed in that 
  time? &nbsp;Will they wait that long?</EM><FONT color=#800000></FONT><FONT 
  size=2><SPAN class=950295811-07022002>&nbsp;<EM><FONT 
  color=#000000>"</FONT></EM></SPAN></FONT></FONT></FONT></DIV>
  <DIV><FONT face=Arial><FONT color=#800000><FONT size=2><SPAN 
  class=950295811-07022002></SPAN></FONT></FONT></FONT>&nbsp;</DIV>
  <DIV><FONT color=#800000 face=Arial size=2><SPAN class=950295811-07022002>Most 
  of these questions are quite reasonable, and directly dependent on the 
  rational construction of a disaster management plan which acknowledges both a) 
  how little can be clinically accomplished at the scene, and b) how vulnerable 
  the hospital is to secondary catastrophe.</SPAN></FONT></DIV>
  <DIV><FONT color=#800000 face=Arial size=2><SPAN 
  class=950295811-07022002></SPAN></FONT>&nbsp;</DIV>
  <DIV><FONT color=#800000 face=Arial size=2><SPAN class=950295811-07022002>As 
  for the wait times for initial victims, call me a hard-hearted bastard, but I 
  think the first priority is to shut off the chain of exposure.&nbsp; We're not 
  accomplishing much if, while rushing one victim to treatment, we expose a 
  doctor and three nurses and contaminate the trauma bay and the entrance to the 
  ED.</SPAN></FONT></DIV>
  <DIV><FONT face=Arial size=2><SPAN 
  class=950295811-07022002></SPAN></FONT>&nbsp;</DIV>
  <DIV><FONT face=Arial><FONT size=2><SPAN 
  class=950295811-07022002>&nbsp;<EM>"&nbsp;</EM></SPAN><EM>Bottom line, just 
  like trauma, there is not one right way to plan for a WMD incident. &nbsp;It 
  depends on your resources. &nbsp;If an outside team is available, will be 
  there when you need them, and the logistics are satisfactory, great. &nbsp;If 
  not, you better have another plan.<SPAN class=950295811-07022002><FONT 
  color=#800000>"</FONT></SPAN></EM></FONT></FONT></DIV>
  <DIV><FONT face=Arial><FONT size=2><SPAN 
  class=950295811-07022002></SPAN></FONT></FONT>&nbsp;</DIV>
  <DIV><FONT size=2><FONT face=Arial><FONT color=#800000><SPAN 
  class=950295811-07022002>No argument, except to assert that only the 
  <EM>methodology</EM> must be flexible.&nbsp; The objectives must remain fixed: 
  ensure the safety of the rescuers, THEN rescue the 
  victims.</SPAN><BR><BR><SPAN class=950295811-07022002>&nbsp;<EM><FONT 
  color=#000000>"&nbsp;</FONT></EM></SPAN></FONT><EM>Greg&nbsp;<SPAN 
  class=950295811-07022002>&nbsp;"</SPAN></EM></FONT></FONT></DIV>
  <DIV><FONT color=#800000><SPAN 
  class=950295811-07022002></SPAN></FONT>&nbsp;</DIV>
  <DIV><FONT face=Arial><FONT color=#800000 size=2><SPAN 
  class=950295811-07022002>Pret&nbsp;</SPAN></FONT></FONT></DIV></BLOCKQUOTE></BODY></HTML>

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