Ems operations

EMS Operations

• EMS Operations

• Knowledge of operational roles and responsibilities to ensure patient, public, and personnel safety.

Hazardous Materials Awareness

• Hazardous Materials Awareness

• Risks and responsibilities of operating in a cold zone at a hazardous material or other special incident.

Hazardous material: any substance or material capable of posing an unreasonable risk to health, safety, or the environment when transported, used incorrectly, or not properly contained or stored.

• Hazardous material: any substance or material capable of posing an unreasonable risk to health, safety, or the environment when transported, used incorrectly, or not properly contained or stored.

Regulations are created by OSHA and EPA.

• Regulations are created by OSHA and EPA.

• HAZWOPER is the OSHA document.
• Training levels are:
• Awareness
• Operations
• Technician
• Specialist
• Incident commander

Awareness level should be able to:

• Awareness level should be able to:

• Understand what hazardous substances are.
• Understand potential outcomes.
• Recognize presence of hazardous substances.
• Identify hazardous substances.
• Understand role in the response plan.
• Determine the need for additional resources.

Consensus-based standards can help guide responders.

• Consensus-based standards can help guide responders.

• All personnel should receive appropriate response training.

When on the scene of an incident you must rely on training and references sources.

• When on the scene of an incident you must rely on training and references sources.

• Know how and when to access specific toxicologic information.
• Understand how a hazardous materials scene is organized and where you fit in.

Familiarize yourself with the following:

• Familiarize yourself with the following:

• Different types of PPE
• How patients will be decontaminated
• How to assess and treat exposures

Hazardous materials incidents may include:

• Hazardous materials incidents may include:

• Highway or rail incident in which a substance is leaking from a tank or car
• Leak/rupture of underground natural gas pipe
• Buildup of methane or other by-products in sewers, sewage plants, landfills

It is critical to ensure your own safety.

• It is critical to ensure your own safety.

• It may not be possible to identify what hazards are present.

• Warning signs include:

• Signs and symptoms from patients
• Placards and labels

Always maintain a high level of suspicion during your first assessment of a scene.

• Always maintain a high level of suspicion during your first assessment of a scene.

• You may identify leaks and spills by:
• A visible cloud or strange-looking smoke
• A leak or spill
• An unusual, strong, noxious, acrid odor

You should suspect the presence of hazardous materials if you approach a scene where more than one person:

• You should suspect the presence of hazardous materials if you approach a scene where more than one person:

• Has collapsed
• Is unconscious
• Is in respiratory distress

Follow proper safety measures.

• Follow proper safety measures.

• If signs suggest a hazardous materials incident, stop at a safe distance (upwind and uphill).
• Once you rapidly size up the scene, isolate the hazardous area the best you can.
• If you do not recognize the danger until you are too close, leave the danger zone immediately.

Provide as much information as possible when calling for additional resources.

• Provide as much information as possible when calling for additional resources.

• Don’t reenter or leave the hazardous area until a hazardous materials team clears you.

Information may come in the form of:

• Information may come in the form of:

• Observations
• Reports from bystanders
• Signs and symptoms of victims
• Labels and placards
• Shipping papers
• Material safety data sheets

DOT’s Emergency Response Guidebook (ERG) should be carried on every response vehicle.

• DOT’s Emergency Response Guidebook (ERG) should be carried on every response vehicle.

ERG guidebook provides information on:

• ERG guidebook provides information on:

• Specific properties of hazards and substances
• What is shown on placards
• Recommended isolation distances

DOT chemical families:

• DOT chemical families:

• DOT Class 1: Explosives
• DOT Class 2: Gases
• DOT Class 3: Flammable combustible liquids
• DOT Class 4: Flammable solids, spontaneously combustible materials; and dangerous when wet materials/water-reactive substances

DOT chemical families (cont’d):

• DOT chemical families (cont’d):

• DOT Class 5: Oxidizing substances and organic peroxides
• DOT Class 6: Toxic and infectious substances
• DOT Class 7: Radioactive materials
• DOT Class 8: Corrosive substances
• DOT Class 9: Miscellaneous

US DOT marking system is characterized by labels, placards, and markings.

• US DOT marking system is characterized by labels, placards, and markings.

Placards

• Placards

• Placed on all four sides of vehicles
• Identify a broad hazard class

Labels

• Labels

• Placed on boxes and smaller packages

Not all chemical shipments are marked.

• Not all chemical shipments are marked.

• You may also identify hazardous materials in transport from:

• The bill of lading or freight bill
• The waybill or consist

CHEMTREC

• CHEMTREC

• Operates a 24-hour telephone line
• An extensive database of chemical information
• Must have information ready when calling

Characterized by a placard with a set of diamonds

• Characterized by a placard with a set of diamonds

• Placards are colored, indicating specific hazards.

Permanent manufacturing or storage facilities have material safety data sheets.

• Permanent manufacturing or storage facilities have material safety data sheets.

• Chemical makeup of a substance
• Potential hazards it presents
• Appropriate first aid in the event of exposure.
• Other data for safe handling of the material

Vessel or receptacle that holds a material

• Vessel or receptacle that holds a material

• Type, size, and material can provide clues about the nature of the substance inside.
• Often there is no correlation between the color of the drum and the possible contents.

Found in buildings that rely on and need to store a large amount of a particular chemical

• Found in buildings that rely on and need to store a large amount of a particular chemical

• Secondary containment is a method to control spills.

Large volume horizontal tanks

• Large volume horizontal tanks

• Above-ground storage tanks
• Underground storage tanks
• Can hold a few hundred gallons to several million gallons of product

Totes

• Totes

• Hold 119 to 703 gallons
• Portable plastic tanks surrounded by stainless steel
• Can contain any type of chemical

Intermodal tanks

• Intermodal tanks

• Hold 5,000 to 6,000 gallons
• Pressurized or nonpressurized
• Usually shipped, stored, and returned to the shipper

Drums

• Drums

• Barrel-like containers
• Store a variety of substances
• The nature of the chemical dictates the construction of the drum.

Bags

• Bags

• Used to store solids and powders
• Constructed out of plastic, paper, or plastic lined paper.
• Pesticide bags must be labeled with specific information.

Carboys

• Carboys

• Transports and stores corrosives and other chemicals
• Holds 5–15 gallons

Cylinders

• Cylinders

• Hold liquids and gases
• Uninsulated compressed gas cylinders store various substances.
• Sizes vary.

Cargo tank: Bulk package that may or may not be permanently attached to a vehicle

• Cargo tank: Bulk package that may or may not be permanently attached to a vehicle

• May be loaded or unloaded without being removed from the vehicle

MC-306/DOT 406 flammable liquid tanker

• MC-306/DOT 406 flammable liquid tanker

• Most common and reliable vessel
• Carries 6,000 and 10,000 gallons of product
• Nonpressurized

MC-307/DOT 407 chemical hauler

• MC-307/DOT 407 chemical hauler

• Holds 6,000 to 7,000 gallons
• May be insulated or uninsulated
• May have higher internal working pressure

MC-312/DOT 4012 corrosive tanker

• MC-312/DOT 4012 corrosive tanker

• Transports corrosives
• Reinforcing rings around the tank
• Operates at 15 to 25 psi
• Holds 6,000 gallons

MC-331 pressure cargo tanker

• MC-331 pressure cargo tanker

• Holds 1,000 to 11,000 gallons
• Constructed of steel
• Operates at 300 psi

MC-338 cryogenic tanker

• MC-338 cryogenic tanker

• Low-pressure tanker
• Relies on tank insulation to maintain low temperature

Tube trailers

• Tube trailers

• Carry compressed gasses
• Made up of individual cylinders
• Operate at 3,000 to 5,000 psi

Dry bulk cargo tanks

• Dry bulk cargo tanks

• Carry dry bulk goods
• Not pressurized
• Usually V-shaped

If dispatched to a hazardous materials incident:

• If dispatched to a hazardous materials incident:

• Protect yourself first.
• Isolate the incident.
• Notify dispatcher and other responders.
• Inform incoming responders of observations.

Hazardous materials specialists will establish hot, warm, and cold zones.

• Hazardous materials specialists will establish hot, warm, and cold zones.

The green section of ERG provides resources on evacuation distances.

• The green section of ERG provides resources on evacuation distances.

• Hazardous materials teams use air-monitoring equipment to determine:

• Explosive limits
• Oxygen levels
• Concentration of hydrogen sulphide
• Carbon monoxide

Hazardous materials teams can determine the pH of spills.

• Hazardous materials teams can determine the pH of spills.

• CAMEO is one of many programs that help predict downwind concentrations of hazardous materials.

Usually the hazardous materials team will determine the appropriate PPE.

• Usually the hazardous materials team will determine the appropriate PPE.

• You should understand what hazards certain garments create.

Level A ensemble

• Level A ensemble

• Provides greatest respiratory and skin protection
• Covers full body and self-contained breathing apparatus

Level B ensemble

• Level B ensemble

• Used when a high level of respiratory protection is needed and there is no threat of skin absorption

Level C ensemble

• Level C ensemble

• Designed to protect against a known substance
• Worn with an air-purifying respirator (APR) or powered air-purifying respirator (PAPR)

Level D ensemble

• Level D ensemble

• Worn when there is little to no threat posed by the substance

Health hazards posed by hazardous materials depends on its ability to get into the body and interfere with the body’s processes.

• Health hazards posed by hazardous materials depends on its ability to get into the body and interfere with the body’s processes.

Primary contamination

• Primary contamination

• Directly from a hazardous material

• Secondary contamination

• Hazardous material is transferred to a person from a person or contaminated object.

Four primary methods of entry:

• Four primary methods of entry:

• Ingestion
• Inhalation
• Injection
• Absorption

Local effect

• Local effect

• Reddening of skin
• Localized pain
• Blisters

Your records should include:

• Your records should include:

• Elements required by AHJ or medical director
• Description of the scene
• Anything you were told about the substance
• How your patient looked initially
• Treatment rendered
• Positive or negative changes

The dose effect principle applies no matter of the route or type of exposure.

• The dose effect principle applies no matter of the route or type of exposure.

• The greater length of time or concentration of the material, the greater the effect on the body.

Vapor pressure

• Vapor pressure

• Amount of pressure between top of liquid and container it is held inside
• Correlates to the speed at which a material will evaporate once it is released from its container

Vapor density

• Vapor density

• Comparison of hazardous material gas to air
• If the gas is heavier than air it will sink.
• If the gas is lighter than air, it rises and dissipates.

Flash point

• Flash point

• Temperature at which liquid fuel gives off sufficient vapors that will result in a flash fire
• Low flash point liquids typically have high vapor pressures.

Ignition temperature

• Ignition temperature

• Temperature at which liquid fuel will ignite without an external ignition source

• Flammable range

• Defined by upper and lower limits
• Lower flammable limit or LFL
• Upper flammable limit, or UFL

Specific gravity

• Specific gravity

• Must be determined when applying water to a chemical
• If hazardous material will sink or float in water

Threshold limit value (TLV)

• Threshold limit value (TLV)

• Concentration that a person can be exposed to for a 40-hour workweek over a typical 30-year career

Threshold limit value/ceiling (TLV-C)

• Threshold limit value/ceiling (TLV-C)

• Concentration that a person should never be exposed to

Lethal dose (LD)

• Lethal dose (LD)

• Single dose that causes the death of a specified number of test animals exposed by any route other than inhalation

Toxic

• Toxic

• A chemical that has an LD50 of more than 50 but not more than 500 milligrams per kilogram of body weight when administered orally to albino rats weighing between 200 and 300 grams

Toxic (cont’d)

• Toxic (cont’d)

• A chemical that has an LD50 of more than 200 but not more than 1,000 milligrams per kilogram of body weight when administered by contact for 24 hours to albino rabbits weighing between 2 and 3 kilograms

Toxic (cont’d)

• Toxic (cont’d)

• A chemical that has an LD50 of more than 200 but not more than 2,000 parts per million by volume, or more than 2 but not more than 20 milligrams per liter, when administered by inhalation for 1 hour to albino rats weighing between 200 and 300 grams

Highly toxic

• Highly toxic

• A chemical that has an LD50 of 50 milligrams or less per kilogram body weight when administered orally to albino rats weighing between 200 and 300 grams.

Highly toxic (cont’d)

• Highly toxic (cont’d)

• A chemical that has an LD50 of 200 milligrams or less per kilogram body weight when administered by contact for 24 hours to albino rabbits weighing between 2 and 3 kilograms

Highly toxic (cont’d)

• Highly toxic (cont’d)

• A chemical that has an LC50 in air of 200 parts per million by volume or less, or 2 milligrams per liter or less, when administered by inhalation for 1 hour to albino rats weighing between 200 and 300 grams

Immediately dangerous to life and health (IDLH)

• Immediately dangerous to life and health (IDLH)

• Atmospheric concentration of substance that will pose:
• An immediate threat to life
• Irreversible or delayed adverse effects
• Serious interference for team members

You cannot immediately begin care until you fully understand the situation.

• You cannot immediately begin care until you fully understand the situation.

• Decontamination is the highest priority when a substance provides an unacceptable risk to responders.

Method depends on:

• Method depends on:

• Type of hazardous material
• Stability of the scene
• Number, condition and location of patients

Four types of decontamination methods seen in the field:

• Four types of decontamination methods seen in the field:

• Dilution
• Absorption
• Neutralization
• Disposal

Emergency decontamination

• Emergency decontamination

• Removing the bulk of contaminants from a person as quickly and completely as possible
• Water: universal decontamination solution

Decontamination corridor

• Decontamination corridor

• Fog-stream shower set up between two fire engines
• Patients disrobe on one end and enter single file.

Thorough cleaning process used by responders to clean PPE, tools, and equipment

• Thorough cleaning process used by responders to clean PPE, tools, and equipment

• Differs from jurisdiction to jurisdiction

Invasive procedures should be minimized.

• Invasive procedures should be minimized.

• Familiarize yourself with references and how to access technical expertise.

• You are the eyes and ears of the physician.

Chemicals that include acids and bases

• Chemicals that include acids and bases

• Can cause severe burns to the skin eyes and mucous membranes

• Once decontaminated, treatment is supportive.

May be liquids, solids, or gases

• May be liquids, solids, or gases

• Capable of dissolving other substances

• May give off potent vapors

• May require extensive decontamination

Can produce a collection of signs know by the mnemonic SLUDGEM

• Can produce a collection of signs know by the mnemonic SLUDGEM

• In addition, exposures can also produce:

• Tachycardia or bradycardia
• Twitching muscles
• Excessive pulmonary secretions

Treatment includes:

• Treatment includes:

• Aggressive decontamination
• Intubation and frequent suctioning
• High-flow oxygen
• Use of atropine
• Pralidoxime may be recommended.

Interfere with the use of oxygen at the cellular level

• Interfere with the use of oxygen at the cellular level

• Cyanide treatment (nonsmoke inhalation patients):

• Amyl nitrate ampules
• IV administration of sodium nitrate, followed with sodium thiosulfate

Cyanide treatment for smoke inhalation:

• Cyanide treatment for smoke inhalation:

• Hydroxocobalamin (Cyanokit)

• Carbon monoxide treatment:

• Removal of patient from the source
• Administration of 100% supplemental oxygen

Hazardous chemical compounds released when a material decomposes under heat

• Hazardous chemical compounds released when a material decomposes under heat

• A host of chemical by-products are created and found in the smoke.

Other toxic substances found in smoke:

• Other toxic substances found in smoke:

• Soot
• Carbon monoxide
• Carbon dioxide
• Water vapor
• Formaldehyde
• Cyanide compounds
• Many oxides of nitrogen

Paramedics should be standing by to transport patients to the ED.

• Paramedics should be standing by to transport patients to the ED.

• Do not assume that patients received are completely decontaminated.

• Never transport if there hasn’t been sufficient decontamination.

You can prepare for transportation in several ways.

• You can prepare for transportation in several ways.

• Reduce the amount of supplies and equipment that the patient will contact.
• Plan to wrap the patient in a plastic barrier.
• Give the ED plenty of notice.

You may be asked to assist with medical monitoring of the hazardous materials team.

• You may be asked to assist with medical monitoring of the hazardous materials team.

• PPE often causes heat stress.
• Toxins they are working with can cause serious health effects.

Medical monitoring includes documentation of incident factors:

• Medical monitoring includes documentation of incident factors:

• Hazardous materials involved
• Toxic effects
• PPE worn
• PPEs resistance to permeability
• Type of decontamination

Assess before they enter and after they leave the hot zone.

• Assess before they enter and after they leave the hot zone.

• Complete set of vital signs
• ECG
• Temperature
• Body weight

Before reentry, evaluate again.

• Before reentry, evaluate again.

• Hydration status
• Vital signs
• Symptoms for potential exposure

• Reassess vital signs, and perform a neurologic assessment.

Thousands of hazardous materials incidents occur each year.

• Thousands of hazardous materials incidents occur each year.

• Hazardous materials emergencies require specialized training and equipment.

• Never enter a hazardous scene without understanding the problem.

• OSHA levels of training: awareness, operations, technician, and specialist.

The roadway is where a majority of hazardous material emergencies happen.

• The roadway is where a majority of hazardous material emergencies happen.

• Signs of hazardous materials include vapor clouds, strange odors, spilled liquids, and multiple victims.

• Labels and placards, transport documents, material safety sheets, and the DOT’s ERG are resources about hazardous materials.

Hazardous materials incident management follows the principles of NIMS and ICS.

• Hazardous materials incident management follows the principles of NIMS and ICS.

• There are hot, warm, and cold zones at incidents.

• Do not enter the hot and warm zones without the correct personal protective equipment and training.

• PPE levels: level A, level B, level C, and level D

Primary contamination comes from direct contact with a toxin.

• Primary contamination comes from direct contact with a toxin.

• Secondary contamination spreads by people, clothing, or objects.

• Effects may be local or systemic.

• Inhalation, ingestion, absorption, and injection are routes of exposure.

• Rescue and decontamination of victims is second to protection of rescuers and public.

Decontamination is based on the nature of the containment.

• Decontamination is based on the nature of the containment.

• Treatment of victims is usually symptomatic and supportive of the ABCs.

• To avoid introducing contamination, invasive procedures should be avoided.

• Paramedics may be asked to provide medical monitoring to the hazardous materials team.

Chapter opener: Courtesy of London Ambulance Service

• Chapter opener: Courtesy of London Ambulance Service

• Backgrounds: Orange—© Keith Brofsky/Photodisc/Getty Images; Gold—Jones & Bartlett Learning. Courtesy of MIEMSS; Green—Jones & Bartlett Learning; Red—© Margo Harrison/ShutterStock, Inc.

• Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.