Dry Decontamination

James Augustine is a featured speaker at EMS World Expo, Sept. 15–19, in Las Vegas. Visit EMSWorldExpo.com.

The Attack One crew is preparing for lunch on a beautiful summer day. The tones drop, and the dispatcher delivers a message in a relatively higher tone of voice than usual: “Report of multiple people ill due to a chemical exposure."

The address is a high-security industrial site known to the department. There have been prior hazardous-material responses to this location, some of which required activation of the regional hazmat team. As the Attack One crew responds, the battalion chief places that team on standby.

On arrival the Attack One crew is assigned to perform triage. They report to the front of the building and find a single woman being attended to by others, an oxygen mask in place. A bystander who’s an EMT gives a report to the crew.

“This lady opened an envelope, and white powder sprayed out of an enclosed plastic pack. There was a threatening note inside. She attempted to clean it up, but more people walked through the area of her desk and were also exposed to the powder. Everyone has been asked to leave that area of the building, and we will collect them here in front as they arrive. I’ve performed vital signs, and all appear relatively normal.”

“How many people do you think are in that group?” asks the paramedic.

“Probably 20 or so.”

The paramedic reports this exchange to Incident Command, who has arrived on scene and is organizing the response.

The Attack One crew begins to assess the initial patient and pulls out an MCI bag in preparation for those remaining.

The first patient, the letter opener, is a middle-age lady not in any significant distress. She can speak in full sentences and is concerned mostly because she violated work rules. She is not supposed to open envelopes in the area where she was working. This company performs high-level security functions and receives threatening messages regularly. The mail system is typically well organized, but today the lady decided to open the day’s mail on her desk, rather than in a designated security area.

The lady wants to give more detail, so the EMT takes careful notes to deliver to the hazardous-materials officer. The envelope was a hand-addressed yellow envelope, which she said contained a sealed plastic bag. As she opened the seal on the envelope, the bag open and sprayed white powder. It immediately made her cough. Fellow workers noted her in distress and moved to assist her. She’d asked them to move away, but more kept coming closer. She finally stuck the envelope in a trash can and carried it to the designated safe area, where she left it. A supervisor was aware of the location of the envelope but did not have any further information on its contents.

The EMT gives this report to both the Attack One paramedic and the hazardous-materials officer. An entry crew is preparing to enter the building, and the information is vital to achieving their mission. Each of the entry team members receives a pre-suit evaluation by the Attack One crew.

At the same time, a number of other company employees are arriving from inside and being directed to a safe triage location away from the building. Several ambulance crews are assigned to assist in triage; they begin evaluating the arriving employees. None appear to be in significant distress. Most complain only of sore throats.

Of great concern to the arriving employees is that they will be asked to strip and be hosed down with firehoses. According to several employees, that is what occurred the last time the company experienced an event like this. That incident resulted in no significant medical outcomes and was found to be a hoax, but the workers reported that the experience was so humiliating that many employees left the company. It resulted in a new work protocol that requires individuals to open mail in a safe location, a negative-pressure room. The employees are quite angry at the individual who opened the envelope today, resulting in their exposure. All are concerned that it may result in them having to disrobe in front of their fellow employees again.

The paramedic is in a position to alleviate their concerns. “There will be no public disrobing today,” he announces. “We have a process called dry decontamination, and for those of you exposed, we will ask you to move to a closed area and disrobe in private. We will place all of your exposed clothing in a safe location, then do a medical evaluation and wait for news from our hazardous-materials team. It is likely all of you will be going home in your own clothing.” This gets a welcome round of applause from the 25 or so employees who have arrived.

It is fortunate that the initial patient is being kept away from the others. She has developed no further symptoms and at this point will not be removed from the scene. This lady will be the first to go into a changing area and receive her ongoing evaluation in an area separate from the other employees.

The hazmat resource truck has about 100 cinch bags that contain all the elements necessary for dry decontamination. On those bags are instructions for victims that describe how to don a pair of gloves, remove their clothing, place it into the bag and then dress in a safe set of clothes for appropriate treatment.

When the dry decon bags are brought into the triage zone, the paramedic makes one announcement to the exposed employees. In a direct but calming voice, he says, “Each of you are to take one of these bags and go into the safe building behind me. There you will follow the instructions on the bag, which tell you to empty the bag, take out the pair of gloves inside and use them to remove your clothing. You will write your name on the outside of the big cinch bag and on the small sealed bag inside. Then place your valuables into that sealable bag. You will use the wet cloths inside to wipe off your glasses, hands and face. You will then dress in the hospital scrubs that have been taken out of the bag. There is also a mask for you to put in place and some booties for your feet. When all of your clothes have been placed inside the big cinch bag, walk back to meet me. We will place all of your clothing bags in a room with one of your company security officers. Your valuables bag, which contains your wallet, jewelry, cell phone and other personal items, will remain sealed and with you. Our team will then do a full medical evaluation, and when decisions are made about the material you were exposed to, we will either reunite you with your clothes to redress or take you to the hospital for further evaluation.”

There are 26 bags given to employees, beginning with the index employee who opened and handled the envelope.

Now the Attack One paramedic makes several phone calls. He notifies the local poison control center of the incident, as well as the hospital that will serve as medical control. Neither is aware of victims arriving on their own at any hospital, and both advise they will stand by for further information from the scene.

Within several minutes the entire group has completed the task, and 26 bags of clothing are placed in an area under control of the company security officer. The patients each receive a complete evaluation, then are asked to seat themselves comfortably until the hazmat team reports on the material.

The media trucks, which arrived on the scene almost as quickly as the hazardous-materials team, are preparing for live broadcasts on the midday news. Several of the exposed individuals are allowed to leave the area to be interviewed.

About 30 minutes later the paramedic is requested to attend a face-to-face meeting at the Incident Command site. The initial analysis of the envelope by the hazmat team has not indicated any significant hazard. Although the envelope contains a threatening note, chemical analysis indicates the material is white pepper. The team will do several confirmatory analyses before their final report, but this initial information is enough for the paramedic to begin to relieve the fears of those exposed. With the new information, he reports to Command that no patient transports are likely to be necessary from the scene.

The initial information is relayed by the paramedic to the company employees. At this point they are all resting in a separate building, and the company has brought them some food and nonalcoholic drinks. No patients are suffering any symptoms except for the initial employee, who remains separate from the rest of the group and anxious about the status of her job.

Incident Resolution

Within an hour, the hazardous-materials team confirms the substance as white pepper, an irritant material. The initial team cleans up all debris and hands over the envelope to law enforcement and Homeland Security personnel. The paramedic joins the Incident Command staff, entry team officer and company officials on a walkthrough of the building to make sure there are no remaining dangers, powder or other concerns. None are found.

The paramedic joins the triage staff to announce to the employees that no medical hazards were found, the substance was pepper, and they can redress and return to work. Each cinch bag is returned to its proper employee, and then the used scrub suits are returned to the bags. The department process then calls for the used bags to be disposed of.

After dressing, the initial employee involved in this incident becomes more distressed. She complains of being short of breath, although her pulse oximetry readings remain normal. The paramedic decides that appropriate care for this patient would be transport to the hospital for complete medical evaluation. This is arranged, and the hospital is briefed on issues related to the incident and her exposure.

A media briefing is also conducted. The medical control hospital is notified, and the poison control center briefed.

Case Discussion

This case involved a criminal act that resulted in a number of patients requiring evaluation. This is a frequent occurrence in modern EMS. In the past, patients like these might have been stripped and subjected to water decontamination. There are now processes and equipment that allow dry decontamination to take place safely and effectively. The kits required for this can either be assembled locally or purchased from a variety of vendors.

The critical element for EMS agencies is a process that allows a large number of patients to receive timely and efficient care. With the reliable availability of kits, a single provider can instruct a large number of individuals to self-disrobe and don safe alternative clothing. The exposed individuals can he assembled into a single line, the bags with their clothing collected in one safe area, valuables kept in safe possession of the persons involved, and medical triage can occur using normal EMS tools.

This incident resulted in no hazardous material being found. When incidents occur where the material is hazardous, exposed clothing becomes legal evidence. It is processed by the appropriate law enforcement agency. A separate decision can be made about the valuables kept with each individual who undergoes dry decontamination.

The Attack Crew oversaw the patient triage operation and gathered information that was needed to process the incident. The crew was quickly able to reduce employee concerns about public disrobing. Such incidents can cause much displeasure among involved workforces.                                                                                                                 

Modern analysis equipment allows hazardous-materials teams to provide rapid scene evaluation and chemical identification. This detective work facilitates rapid decision-making for the exposed individuals. In some cases the most symptomatic victims can be transported to hospitals, and those with minor or no symptoms can be evaluated and managed at the scene. The cost and inconvenience can be minimized for all.

The Attack One crew chose to notify the regional poison control center for coordination of the toxicology information. The regional poison control center can coordinate information exchange among the broader healthcare community and is particularly helpful in incidents where there is a large chemical release.

Dry Decontamination

Dry decontamination is the process of making a patient as clean as possible through a self-implemented process of rapidly removing clothing and containing personal belongings, then cleaning the face and hands and applying a simple mask. It is utilized in the event of a biological contamination and certain chemical and radiological contamination events.

While exposure to chemical agents often requires “wet” decontamination, many incidents may be safely managed using the “dry” technique. This includes exposures to most infectious agents. The key process for decontaminating these patients is removal of clothing, cleaning the hands and placing a mask on the patient’s nose and mouth to limit the droplet spread of infectious or dangerous agents. This should be accomplished before victims are brought into a building. 

Potential victims of an exposure incident or highly infectious disease should be greeted and handed a decontamination pack. Manage these patients in an open-air environment until it is safe to bring them inside.

If the number of victims is not too great to preclude privacy, provide each patient a private area and ask them to disrobe. Provide trash containers for dirty items, including gloves, clothing that people can’t or don’t want to keep and items used for cleaning. Once they’ve disrobed, patients should put on the temporary clothing in the bag and place their old, contaminated clothing and personal effects in the bag. Make sure patients write their names on clothing and valuables bags. 

Have victims follow the instructions printed on the dry decon bag. A place should be identified for them to place their clothing bags, and a triage line area communicated to the persons involved.

A decontamination pack should include the following: 

• A printed plastic bag with a cinch tie at the top. On one side should be printed instructions for use of the decontamination pack. The other side should contain a blank space with a surface that can be written on;
• A large pair of nonsterile hospital gloves should be attached to the outside of the bag.

The bag should contain the following contents:

• An instruction sheet on how to properly dispose of belongings;
• A small clear plastic bag marked valuables, with a writing surface for the victim’s name. This bag should be able to be sealed, so a 10-inch Ziploc-type bag is ideal;
• A marking pen for writing the victim’s name on their bags;
• Post-decontamination clothing—inexpensive, lightweight cloth coveralls of a standard color would be ideal (like old hospital scrubs). Ideally the colors of these clothes will be distinct so victims will not be mistaken for emergency workers (you can bleach or dye old hospital scrubs);
• Foot coverings (booties);
• A personal mask to cover the victim’s nose and mouth;
• Two wet-wipe napkins;
• Another dry soft wipe to clean glasses or hearing aids;
• An identification bracelet;
• Instructions for proper disposal of clothing;
• A second pair of nonsterile gloves (placed inside the bag).

Learning Point

Dry decontamination is a process of managing patients potentially exposed to hazardous substances. It allows effective scene management of involved persons when wet decontamination is not immediately necessary. The process is easy to implement and the needed equipment relatively inexpensive.

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. Contact him at jaugustine@emp.com.