Col Ram Athavale reviews hospital preparedness for CBRN incidents

An incident involving the accidental or intentional release of CBR material and other high-consequence biological events can lead to many deaths or serious illnesses and injuries. Hospitals would have to respond rapidly to such high-impact CBRN incidents

Large speciality hospitals and laboratories have radioactive scanning machines and medicines wherein radioactive isotopes are used for medical treatment and diagnosis. Similarly, a hospital uses many toxic chemical agents. Toxic fumes from fires and accidental releases and spills would also cause casualties of a CBRN nature.
In effect, hospitals and healthcare need to prepare for two distinct possibilities, which at times may even overlap:

  • The hospital receives or responds to a major CBRN incident (accident or terrorist attack). Scores of casualties and victims are likely to overwhelm the capabilities and capacities: CBRN-trained medics (if they exist) and paramedics, ambulances, field medical facilities, adequacy of beds, casualty decontamination, intensive care facilities, acute treatment and isolation wards.
  • The hospital is faced with a CBRN incident on its premises. It could be release of or exposure to radioactivity, exposure or ingestion of toxic chemicals, or cross- or secondary biocontamination from other patients/bio waste. This calls for training of all staff, early detection, immediate response mechanisms, decontamination measures and hospital evacuation procedures.

All hospitals and healthcare facilities face biothreats on a daily basis – and radiation and chemical threats also lurk in these facilities.

Radioactive material in hospitals
Among the many uses of radiation in medicine are X-rays in radiology, along with more specialised areas of mammography, computerised tomography (CT) and nuclear medicine.

Radiation or radioactive material for treatment of cancer include radioisotopes used in hospitals: technetium-99m (Tc-99m), iodine-131, 125, and 123 (I-131, I-125, and I-123), fluorine-18 (F-18), and carbon-14 (C-14). Sodium iodide (Na 131-I) is used in thyroid scans. Radioactive materials are used to kill cancerous tissue, shrink a tumour or reduce pain in three main types of radiotherapy:

  • Teletherapy – targets cancerous tissue with an intense beam focusing radiation from cobalt-60 sources onto a spot deep within tissue.
  • Brachytherapy – lower-activity sources sealed in ‘seeds’ are surgically placed close to or within cancerous tissue such as in the breast, prostate or cervix, and are removed after the patient receives the prescribed dose.
  • Therapeutic nuclear medicine – high doses of radiation from materials are injected into or ingested by the patient.

Uncontrolled exposures to radiation, residual radiation from medicines, and accidental release of radiation from medical machines can cause grave radiation illness.

Chemical hazards
Hazardous chemicals in hospitals and healthcare settings may pose an exposure risk for healthcare workers, patients, and others when used to:

  • Treat patients (antineoplastic drugs, aerosolised medications, anaesthetic gases)
  • Clean, disinfect and sterilise work surfaces (phenolics, quaternary ammonium compounds, bleach) and medical supplies and instruments (ethylene oxide, glutaraldehyde)
  • Fixatives for tissue specimens (xylene, toluene, formaldehyde). Formaldehyde is also used to preserve training carcasses and biosamples for further study
  • Asbestos, urea-formaldehyde and other unhealthy building materials. Asbestos and urea-formaldehyde are carcinogens. Formaldehyde is found in plasterboard, carpeting products and glues.Asbestos is used for roofing. Such materials are low-cost substitutes for their flame retardant and insulation properties
  • Surgical smoke generated by lasers and electrosurgical devices during surgical procedures contains many chemical substances, in addition to viruses and bacteria
  • Mercury, a potent human neurotoxin, has traditionally been used in thermometers and sphygmomanometers (blood pressure measurement devices). Exposures can occur when devices are broken or disposed.
  • Phthalates are additives in PVC commonly used in components of intravenous (IV) bags and IV tubing. Patients may be exposed to phthalates leaching from PVC plastics during IV-infusions.

A structured system is needed to empower hospitals to meet the advanced surge capacities and infrastructural requirements of CBRN incidents. All hospitals also need to institute measures to prevent and respond to a CBRN incident on-site.

CBRN preparedness and training
To prepare a hospital to be proactively secure against CBRN threats, basic steps are:

  • Awareness Generation and Enhancement to educate staff, technicians and hospital workers on CBRN threats, effects, symptoms and basic mitigation and response measures. A standard awareness module is needed for all hospitals.
  • Conduct of site survey, mapping, gap analysis and plan development by a team of CBRN experts and specialist technicians in liaison with the hospital staff to understand and assess the existing state of CBRN preparedness, or lack of it, followed by a mapping exercise to compile available resource (equipment and human) for CBRN incident prevention and response. A gap analysis to identify areas that need addressing and a plan developed to meet the gaps and optimally secure the hospital against CBRN threats.
  • Training of on-site response teams once the staff and personnel are fully aware of the CBRN threats and mitigation process – drawn from existing hospital security personnel along with some trained technicians. The response team trained to use CBRN equipment and carry out CBRN detection, site isolation, immediate prophylaxis, triage, first aid and decontamination.

Medical capacity enhancement
To enhance the infrastructural capacity of the hospitals and clinics to prevent and survive a CBRN strike or incident entails the same measures as for any critical infrastructure CBRN protection, with these additional elements:

  • Planning for the hospital to be a contamination-free zone
  • Protect paramedics and staff in Accident & Emergency departments
  • Casualty evacuation calls for clean air isolation bags and suitably kitted ambulances for their transportation to designated hospitals
  • Adequate and appropriate placement of CBRN sensors, early warning devices, immediate response kits, personal protective equipment and trauma kits
  • Regular exercising and acclimatisation to PPE by the response personnel
  • Plan and institute effective casualty decontamination prior to a contaminated casualty entering clean areas of the hospital or clinic
  • HAZMAT/CBRN treatment is mostly empirical and requires extra study and field improvisation
  • Plan and provision of field medical posts with antidotes, resuscitators and other special drugs for treating CBRN casualties
  • All medical specialties will be involved – multidisciplinary preparation and response
  • Speciality hospitals using many radiotherapy machines and toxic chemicals should incorporate integrated CBRN control and situational awareness systems
  • Introduce ‘HAZMAT/CBRN Medicine’ and ‘Medical management of CBRN casualties’ to medical schools’ curricula – invest in the future

Hospital preparedness and capacity and capability enhancement to address effectively any CBRN threat is imperative for any CBRN risk mitigation programme. Even in these highly demanding times of a protracted pandemic and shortage of funding, hospitals need to adopt and embrace these best practices and be empowered to deal with CBRN situations as rare as they are – both for their own security and safety and to cope with an incoming surge of casualties and patients.

Col Ram Athavale is a Veteran Indian Army Officer with extensive experience in Command and General Staff assignments. He has been a Key Adviser to the Government of India (MoD and MHA) on CBRN Security and a Key CBRN Expert for the EU CBRN Risk Mitigation Centres of Excellence Initiative in Eastern and Central Africa. He holds a PhD in CBRN Security and Incident Management and is currently a freelance CBRN Security and Risk Mitigation Consultant based at Pune, India.

NHS doctors and nurses practise their medical skills at the British Army’s Ebola training facility, near York.
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