CBRNeWORLD Dr Alzamani Mohammad Idrose, emergency physician and disaster medicine specialist, and Dr Shah Jahan Mohd Yusof, emergency physician, Kuala Lumpur General Hospital, Malaysia, on the time an exercise went live Fronting up to malathion Introduction Tabun, soman, sarin and VX are potent nerve agents, all with the basic chemical properties of organophosphates. They were produced for use in war and such usage has been reported. In the context of terrorism, the agents have been used in a variety of attacks, most notable was the use of sarin gas on civilians by a Japanese cult in 1995, resulting in 12 deaths and a morbidity of about 6,000 people. Malaysia has never experienced a mass casualty incident involving nerve agents. This case describes a major incident drill whereby 55 volunteers were exposed to malathion, an organophosphate insecticide. CBRN preparedness in Malaysia Malaysia has some experience in dealing with chemical, biological, radiological and explosion incidents. Some of the more notable occasions relate to industrial ammonium gas exposures, pandemic flu and minor bomb scare and explosion events. Under the Malaysian response system, lead agencies for any mass casualty incidents are the police, fire and rescue, and hospital emergency services. This list of lead agencies may be expanded subject to the nature of the incident. For CBRN incidents, the specialised hazardous material (HAZMAT) team,which is under the purview of the fire and rescue department joins the responding teams. For radiological or nuclear incidents the atomic energy licensing board is also included. All these lead agencies work within Malaysia s incident command system guided by the prime minister s Directive 20 under the national security council. For incidents involving terrorism, Directive 18 is used as the standard operating procedure. As a measure of preparedness, a series of drills are conducted throughout the year. The drill scenarios are varied and some include terrorism as well as CBRN features. Examples of past drills involving CBRN situations have included nerve gas, chlorine gas, pandemic flu, explosions, air crashes, radioactive situations and terrorism. In conducting these drills, we have benefitted from good support by private sector entities like the airports, monorails and high rise buildings. These exercises have been carried out with good interagency cooperation over the years. A valuable learning experience Of the many exercises we have held, one which took place in 2010 provided a significant learning opportunity as it progressed to become a real incident within the drill. The drill was organised by one of Malaysia s rescue agencies and multiple responding agencies took part. To avoid any untoward problems, we are not providing the name of the organiser while attempting to share this case purely for its learning values. The exercise scenario Multiple incident scenarios were created at a building on an abandoned construction site near a beach. One scenario involved an explosion of a makeshift lab operated by a group of terrorists in the building. Following the explosion a major fire spread through the building. The fire and rescue agency was alerted and fire engines from a nearby station arrived within five minutes and started to douse the flames, following their standard operating procedures. The police and a nearby hospital were also alerted. The police came and provided security around the incident site. The emergency medical team from the responding hospital sent an ambulance team to the site. The initial medical response The first ambulance arrived at the site within 10 minutes. The five-strong medical comprised a medical officer, an assistant medical officer, a staff nurse, a health attendant and a driver. The medical officer assumed the role of medical commander and on arrival reported to the forward field commander, who was the chief of fire and rescue response. He quickly assigned tasks to all team members and two of them started triaging at the casualty collecting area (CCA). He performed the scene size-up, and based on information from the forward field commander he reported the status back to the hospital s call centre. More assistance was requested. An adjacent site was chosen for setting up an advanced medical base station, and by this time 20 simulated patients had been evacuated. The fire and rescue agency doused the fire effectively. Triaging victims At the CCA victims were triaged according to the simple triage and rapid treatment (START) system. Critical patients were tagged red, semi-critical as yellow and non-critical as green. The medical commander initially called out to those who could walk to follow the triageur to the base station and these were tagged green. Those who could not walk were then tagged as red, yellow or if dead as white, since white is the colour associated with mourning in Malaysia. Patients brought to the advanced medical base station were retriaged according to Malaysian triage system. The patients personal information was collected and basic first aid was provided before transportation to medical facilities. Those with green tags were taken to the nearby health clinic for outpatient treatment. Those who were either on red or yellow were transported to the nearest hospital according to priority, with the red-tagged patients going first, followed by the yellow tags. The process went smoothly. Setting up the medical base station Assistant medical officers and health attendants erected a tent as a medical base station. Areas for red, yellow and green tagged patients were created for CBRNe Convergence Asia, Shinagawa Marriott Hotel, Tokyo, 1-2 June 2016 www.cbrneworld.com/cbrneconvergenceasia 14 CBRNe WORLD February 2016 www.cbrneworld.com
MAJOR EVENTS SUMMIT 13 & 14 October 2016 LONDON #MEISummit event, excellent contacts made - Actavo INTERACT NETWORK LEARN RESERVE YOUR PLACE TODAY! 180 + 32 T: +44 (0)207 073 2661 E: summit@majoreventsint.com
CBRNeWORLD Fronting up to malathion critical, semi-critical and non-critical patients respectively. A mobile logistics team provided water and food around the clock while the health personnel were stationed there. Functioning under Directive 20 The multiple agencies responding at the site were coordinated under the prime minister s Directive 20. This document from the national security council makes it mandatory for the police, fire and rescue and medical departments to work together under the command of the police who provide the on-scene commander (OSC). According to this directive, the police set up a command post and liaison officers from all agencies assemble there. In the absence of the police, the top officer from the fire and rescue department is the commander. During this drill, the commander was from the fire and rescue department as the police did not participate in the command of the exercise. The drill ran smoothly and the station could be utilised well to treat simulated patients. Next phase: the chemical element On completion of the multiagency response for the fire victims from the lab explosion, the exercise controllers initiated the next phase of drill which involved a chemical element. Nonetheless, the exercise judges were not informed of the type of agent used. This was a deliberate decision as the controllers wanted to avoid bias in team response and judgment. In fact the progression of the scenario was kept a secret in order to keep the exercise real. At this stage, the medical team completed the set up of the medical base station and it was fully functional. The station had areas for triage, a patient information board and treatment areas for red, yellow and green category patients. Subsequently, the fire and rescue responder summoned the HAZMAT team since nerve gas was detected on their equipment. While waiting for the HAZMAT team to arrive, they performed decontamination using the water hose. At this time, patients were extracted one by one. The HAZMAT team then arrived, set up field-decontamination facilities and started to decontaminate nonwalking victims. Didn't think we'd be needing you today! Alzamani Drill goes wrong - the real incident After decontaminating five simulated patients, it was suddenly noted that a group of 55 people ran out of the building towards the beach. They looked sickly some were in a state of dizziness, nauseous and walking in a rather unsteady manner. Someone was heard shouting: Real incident! Real incident! Exercise abort! Exercise abort! Patients to go to medical base station! In a panicky situation with the drill turning into a real incident and patients manifesting real symptoms, the exercise controller immediately directed all patients to the medical base station. Everyone bypassed the HAZMAT decontamination station and headed to the medical base station. All 55 patients suddenly appeared at the advanced medical base station. The medical judge who was an emergency physician changed roles and joined the team as the medical commander to handle the situation. Only then did one CBRNe Convergence Asia, Shinagawa Marriott Hotel, Tokyo, 1-2 June 2016 www.cbrneworld.com/cbrneconvergenceasia 16 CBRNe WORLD February 2016 www.cbrneworld.com
To the 9th Annual 16 CBRNe CONVERGENCE 31 Oct to 2 Nov 2016 Town & Country Hotel, San Diego Platinum Sponsor www.cbrneworld.com/convergence2016
CBRNeWORLD Fronting up to malathion Got to love it when patients are rushed past decon because it is an 'emergency.' Alzamani of the controllers inform the medical commander that malathion had been used to mimic nerve gas. Malathion is an organophosphate and was detectable with a device used by the HAZMAT team. A change of wind direction and misinformation as to the amount of the malathion used in the exercise were blamed for the spread of more than the expected level of malathion gas. The organiser did not reveal the exact amount used. Actions taken The medical commander directed the medical team to perform triage, collect patient information, provide initial medical treatment and coordinate transport to the hospital based on priority. A quick visual assessment was done on all patients swarming in front of the medical base station. Those who seemed alright and could walk steadily were directed to the green zone and those who could not walk were distributed between the red and yellow zones with the more severe cases in the red zone. Triaging was largely done by visual observation as all 55 patients appeared at the medical base station at once. As soon as they were all in their respective zones, they were asked to remove their clothes. Medical personnel were instructed to wear masks and available personal protective equipment (PPE). They did not have perfect PPE, however, as no goggles were available. They used surgical masks, plastic aprons and surgical gloves. Nonetheless, they proceeded to help undress those who were weak and could not walk. Everyone undressed down to their underwear. They were not stripped off totally naked in respect of local culture. Moreover, from the incident history provided by the exercise controllers, no splashing was involved. Therefore, it was thought that only exterior garments were affected by the gas. Fortunately all patients were male and there were no gender issues. All clothes were collected and sent off for disposal. We decided to only use a dry decontamination method as the contamination was more of gas than of splashes. We ask the receiving hospital personnel to wear PPE and wipe patients with wet towels if full wet decontamination in a shower was not possible. Managing the ambulances When the real incident occurred, we were fortunate in having eight ambulances from multiple governmental agencies and nongovernmental organisations at the site. One assistant medical officer became transport manager and lined up the ambulances to efficiently move patients to the hospital, taking the more severe cases first. In a matter of 15 minutes, 15 patients were sent to the hospital. The critical ones were accompanied at least by staff nurses or assistant medical officers. A few were accompanied by doctors. The non-critical patients were sent with paramedics. Communication was made with the hospital medical commander and the situation was updated. Fortunately, the hospital was prepared since red alert was declared by the hospital director earlier on for the simulated patients. Upon arrival, all patients were wiped clean with wet towels and provided with fresh hospital garments. Vital signs were checked and examinations were performed. Blood investigations comprised full blood counts, renal profiles and acetylcholinestrase level measurement. Atropine and CBRNe Convergence Asia, Shinagawa Marriott Hotel, Tokyo, 1-2 June 2016 www.cbrneworld.com/cbrneconvergenceasia 18 CBRNe WORLD February 2016 www.cbrneworld.com
CBRNeWORLD Fronting up to malathion pralidoxime were administered to 11 patients, they were admitted and urine was sent off for cholinestrase tests. Three were observed for six hours and subsequently discharged, while one patient was badly affected. Resuscitating the badly affected patient This person was stationed close to the malathion canister during the drill and had a large amount of exposure. He presented with watery eyes, nausea and muscle fasciculation, was conscious and had no seizure. At hospital he appeared anxious. Subsequently, his blood pressure dropped to 90/50 mmhg and he started to develop profound bradycardia after 30 minutes at Port Dickson hospital. A total of 12mg of atropine had to be administered and 1g of pralidoxime was infused over 30 minutes. He became much more anxious thereafter and the Glasgow coma scale score dropped from 15 to 8/15 (E2V2M4). He was subsequently intubated and was hospitalised in the intensive care unit of a tertiary centre some 30 kilometres away. The patient was in the intensive care unit for four days and then discharged to a normal ward where he stayed for another two days. He was finally discharged well. Managing the green triage patients All patients were asked to remove their clothes leaving only underwear. The clothes were collected and put into rubbish bags for disposal. A makeshift shower area was created using a water hose and all patients were asked to shower. They were given cheap new t- shirts and pants. After decontamination they were assessed by a doctor. All of them were well after decontamination, reassured and discharged. Internal hospital response The responding hospital set off a red alert, which effectively activated its major incident response plan. All hospital staff including specialists, medical officers, assistant medical officers, staff nurses, health attendants and general workers were summoned to report at the operations room. Treatment areas for critical, semicritical and non-critical patients were opened and staff were allocated according to their functions. The hospital director took the role of hospital medical commander. Discussion This incident generated a total of 50 real patients. Of these five were red cases, 10 were yellow and 35 green cases in terms of severity. Eventually all patients were discharged well without any subsequent morbidity. What we learnt This was our first experience of mass casualty organophosphate (or nerve gas) poisoning via malathion. Despite causing low human toxicity, malathion can implicate serious morbidity and mortality if not detected and treated early. Communication with medical personnel is therefore essential for the safety of all responders. Dangerous agents used must be discussed with the medical team so that preparation can be made for coping with any untoward incidents. Medical responders need to be flexible in their approach, use what they have and face each CBRN situation with scientific principles while respecting local cultural and religious values. Decontamination procedure needs to be improved so that for mass casualty situations, walking patients can decontaminate themselves. This case provided our responders with great and valuable lessons. From this experience all responding agencies re-evaluated their standard operating procedures and made improvements for CBRN response. The subsequent drills were made safer with more open discussion with multiple agencies. Responding agencies also increased their capacity to handle mass casualty CBRN incidents by acquiring more equipment such as mass decontamination tents but also via networking with other governmental bodies such as the military to enhance their response effectiveness. We'll be needing a lot of these! Alzamani CBRNe Convergence Asia, Shinagawa Marriott Hotel, Tokyo, 1-2 June 2016 www.cbrneworld.com/cbrneconvergenceasia 20 CBRNe WORLD February 2016 www.cbrneworld.com