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?
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
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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