Hospital CBRN Defence — Threat of Chemical, Biological, Radioactive and Nuclear Weapons

Physi­cians, nurs­es and para­medics are the main com­po­nents of a hos­pi­tal CBRN response unit. Who are these peo­ple and why are they doing this? In most cas­es world­wide they belong to the EMS depart­ment of the hos­pi­tal and they know how to han­dle med­ical emer­gen­cies of any kind. The prob­lem is if they all can be involved in CBRN oper­a­tions where usage of per­son­al pro­tec­tive equip­ment is manda­to­ry. Are they all fit to oper­ate under very stress­ful con­di­tions — both phys­i­cal­ly and emo­tion­al­ly? What if those in charge but not fit hap­pen to be on duty the day of the real event?

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A ded­i­cat­ed hos­pi­tal CBRN response unit might be a good alter­na­tive. In that respect all per­son­nel involved in this unit are fit to oper­ate under extreme con­di­tions in a con­t­a­m­i­nat­ed envi­ron­ment. But they need shifts and spe­cial arrange­ments regard­ing their dai­ly duties in peace­time. Some­times this is the biggest prob­lem cre­at­ing lots of fric­tion and dis­com­fort in hospital’s admin­is­tra­tion. A best solu­tion that cov­ers all aspects does not exist. Per­haps a fixed unit with var­i­ous lev­els of mobil­i­sa­tion and deploy­ment depend­ing on the threats’ index could do the job.

I strong­ly sup­port the idea of inclu­sion of “Med­ical CBRN Defence” or “Ter­ror Med­i­cine” into the cur­ric­u­la of uni­ver­si­ties’ med­ical and nurs­ing schools. This will be an oppor­tu­ni­ty for future front-line health pro­fes­sion­als to come into con­tact with med­ical CBRN oper­a­tions and have a basic knowl­edge in the back of their heads. If some­thing real hap­pens then this basic knowl­edge might be proven ben­e­fi­cial for the over­all man­age­ment of the cit­i­zens involved

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Then it is train­ing (Fig­ure 2). Just a few the­o­ret­i­cal sem­i­nars are not enough to pre­pare some­body to be involved in med­ical CBRN oper­a­tions. Prac­ti­cal train­ing is of huge impor­tance. Accli­ma­ti­sa­tion on per­son­al pro­tec­tive equip­ment is of even big­ger impor­tance. Spend­ing 30 min­utes with a gas mask on is not enough if you do not do it again and again, day after day. Don­ning twice a year for a few hours means noth­ing. It will always be like the first time! Then there are the pro­ce­dures. It is a mis­take to believe that there is noth­ing we can do while in per­son­al pro­tec­tive equip­ment. We can do many things — all the way to intu­ba­tion (Fig­ure 3) — but we need to do them again and again in order to attain pro­fi­cien­cy and self-con­fi­dence. We can cut cloth­ing, pro­vide anti­dotes, suck secre­tions, sup­port breath­ing, clean wounds, stop /control bleed­ing (i.e. by using Quik­lot™) or con­trol seizures. These are life sav­ing inter­ven­tions that along with thor­ough decon­t­a­m­i­na­tion will save the lives of those that were unfor­tu­nate enough to be both wound­ed and con­t­a­m­i­nat­ed at the same time.

Drills and exer­cis­es (Fig­ure 4) is the next log­i­cal step. They will help per­son­nel involved to under­stand plans and prac­tice their pro­ce­dures. Night drills are of par­tic­u­lar impor­tance because then you dis­cov­er that there was no pre­dic­tion for flood lights! But even in this sce­nario, a med­ical respon­der must be able to impro­vise and oper­ate even in the dark. Intu­bate once in the dark and you will nev­er for­get it — for life!

Exer­cise (Fig­ure 4) with oth­er first respon­ders both nation­al and inter­na­tion­al. Par­tic­i­pate in inter­na­tion­al exer­cis­es and try to copy and paste things and pro­ce­dures that will help you improve your own. Cre­ate a net­work of experts that will help you solve prob­lems and exchange ideas rel­e­vant to the core CBRN med­ical oper­a­tions.

Decon­t­a­m­i­na­tion is the most impor­tant task giv­en to the hos­pi­tal CBRN response unit. Should it be fixed or deployed if need­ed? If it is fixed pre­pared­ness time is kept to min­i­mum but the over­all cost is high­er. If it is portable, the cost is low­er but pre­pared­ness time might be a prob­lem espe­cial­ly if the hos­pi­tal is close or adja­cent to the inci­dent site. My per­son­al opin­ion is that all hos­pi­tals should have fixed ded­i­cat­ed decon­t­a­m­i­na­tion sta­tions (Fig­ure 5).

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The final ques­tion is “why should they do it?” A good answer could be “for their coun­try, their fam­i­lies and their soci­ety”. Although log­i­cal, log­ic is some­thing that is very rare — espe­cial­ly in West­ern soci­eties. There in order to do some­thing extra from your giv­en assign­ments you must have a very good moti­va­tion. And moti­va­tion is usu­al­ly trans­lat­ed to mon­ey. To a cer­tain point there is some right in this way of think­ing. Why? Med­ical CBRN defence is prac­ti­cal­ly a new med­ical spe­cial­ty. With a lot of study­ing, a lot of labo­ri­ous train­ing, a lot of respon­si­bil­i­ty and a very dan­ger­ous one since med­ical per­son­nel will have to save lives in a poten­tial­ly lethal envi­ron­ment. So why a sur­geon who spent many years in the med­ical school, then some addi­tion­al years in order to become a spe­cial­ist / con­sul­tant and now is work­ing in a hos­pi­tal and has his own pri­vate prac­tice to be involved in a sec­ond spe­cial­ty with no extra ben­e­fits for his future progress, no reg­u­lar patients, no extra salary and no recog­ni­tion of his role in the over­all defence of his coun­try? I expe­ri­enced all kind of atti­tudes from “what is in it for me” (Greece) all the way to “for the coun­try and the Queen” (UK) or “because they are told to” (India). Truth is always some­where in the mid­dle. I strong­ly sup­port the strat­e­gy of moti­va­tion but also the feel­ing of com­mu­ni­ty and uni­ver­sal sup­port. If there is no gain at all, then even the most pas­sion­ate respon­ders will retreat soon­er or lat­er. So why not keep­ing every­body hap­py by apply­ing a car­rot and stick pol­i­cy?

Towards the future

Igno­rance is a bad advi­sor and lack of knowl­edge regard­ing new emerg­ing threats and CBRNE in par­tic­u­lar is the main rea­son for this reluc­tant atti­tude of med­ical com­mu­ni­ty observed almost uni­ver­sal­ly. In that respect, I strong­ly sup­port the idea of inclu­sion of “Med­ical CBRN Defence” or “Ter­ror Med­i­cine” into the cur­ric­u­la of uni­ver­si­ties’ med­ical and nurs­ing schools. This will be an oppor­tu­ni­ty for future front-line health pro­fes­sion­als to come into con­tact with med­ical CBRN oper­a­tions and have a basic knowl­edge in the back of their heads. If some­thing real hap­pens then this basic knowl­edge might be proven ben­e­fi­cial for the over­all man­age­ment of the cit­i­zens involved. In oth­er words, if you have many cas­es of flu-like ill­ness­es in August and the only thing you know is flu then your dif­fer­en­tial diag­no­sis will bal­ance between “flu” and “flu” and you will miss “res­pi­ra­to­ry anthrax” because you have nev­er heard about it and how you can iden­ti­fy it and set an alarm.

“They have to be lucky all the time. We have to be lucky only once!” State­ment made by an IRA spokesper­son fol­low­ing the unsuc­cess­ful attempt to mur­der for­mer UK Prime Min­is­ter Mar­garet Thatch­er.

Many peo­ple in high places usu­al­ly mum­ble why spend all that mon­ey for some­thing that will not hap­pen. Well, if in Jan­u­ary 2011 some­one pre­sent­ed a sce­nario involv­ing a mega-earth­quake, a mega-tsuna­mi and a mega-nuke cat­a­stro­phe, then the audi­ence would sure­ly laugh and com­ment on presenter’s sci-fi capa­bil­i­ties. And then it hap­pened in Japan! So keep in mind that “the unex­pect­ed always hap­pens!” and sup­port the med­ical / hos­pi­tal CBRN pre­pared­ness by all means. It is nev­er too late to do the right thing and it has been proven that by doing the right things it costs less!

Accli­ma­ti­sa­tion on per­son­al pro­tec­tive equip­ment is of even big­ger impor­tance. Spend­ing 30 min­utes with a gas mask on is not enough if you do not do it again and again, day after day. Don­ning twice a year for a few hours means noth­ing

About the Author
Brig Gen Ioan­nis Galatas, MD, PhD, MA, MC (retd) — The writer holds a PhD degree in Med­i­cine and a Master’s Degree in “Inter­na­tion­al Ter­ror­ism, Organ­ised Crime and Glob­al Secu­ri­ty” from Coven­try Uni­ver­si­ty, UK. He is the Edi­tor of the on-line “CBRNE-Ter­ror­ism Newslet­ter”. Since August 2010 he is the CBRN Sci­en­tif­ic Coor­di­na­tor at Research Insti­tute of Euro­pean- Amer­i­can Stud­ies, holds the posi­tion of Vice Chair­man of Greek Intel­li­gence Stud­ies Asso­ci­a­tion and CEO of CBRN Hydra Con­sult­ing while being a CBRN con­sul­tant for Cristani­ni S.p.A (lead­ing Ital­ian decon­t­a­m­i­na­tion com­pa­ny). His last mil­i­tary appoint­ment before his vol­un­tary retire­ment in August 2010, was as Head of the Depart­ment of Asym­met­ric Threats at the Intel­li­gence Analy­sis Branch, of Joint Mil­i­tary Intel­li­gence Divi­sion of the Hel­lenic Nation­al Defense Gen­er­al Staff in Athens, Greece.

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