Last week, the way we remove chemical contamination from victims of a terror attack or chemical accident has changed… well, not quite yet, but it should soon. A partnership between the US Department of Health and Human Services’ (HHS) Office of the Assistant Secretary for Preparedness and Response (ASPR) and the University of Hertfordshire in England and Public Health England found that “…removing clothes removes up to 90 percent of chemical contamination and wiping exposed skin with a paper towel or wipe removes another nine percent of chemical contamination. After disrobing and wiping with a dry cloth, showering and drying off with a towel or cloth provides additional decontamination, bringing contamination levels down 99.9 percent.”
Essentially, what they discovered was that despite recommendations for doing so, victims have often not been required to disrobe for decontamination. When victims would progress through a decontamination (water spray down), much of the chemical they have been exposed to remains in the clothing and trapped against the skin. Clearly this is not effective.
I see this new methodology being a significant change to how we decontaminate victims. As the study hypothesizes, decontamination is much more effective when the chemical is wiped from the body after the victim disrobes. Following this, they may progress then through a water spray. This, essentially, adds a step to the typical protocols used in North America, Europe, and other locations. I’m told the wipe methodology has been used in Japan for some time now. I also believe that wipes have been in use by the US (and other) military forces for units in the field.
Links of interest:
HHS Press Release on the study.
Implementation of new protocols in the UK and other European nations
Many thanks to my colleague Matt for passing this information on to me.
As with any new procedure, the devil is in the details. Standards must be established and adopted, supplies and equipment must be identified and obtained, personnel must be trained, and exercises must be conducted to validate.
I’m interested to hear opinions on these findings and recommendations, as well as thoughts on implementation in the US and abroad.
© 2016 – Timothy Riecker, CEDP
Emergency Preparedness Solutions, LLC – Your Partner in Preparedness
The Contrarian Emergency Manager 
Numbers is a funny animal. You can do all kinds of things with numbers. Are suggesting you and I are contaminated with the same agent at the same time, you have on jeans, long sleeve shirt, boots and a hat, I have on flip flops, shorts and a tank top. We both undress and we both are decontaminated 90% by disrobing? Is there a difference in the type of agent? Gas, liquid, solid? Do the garments absorb, soak, cling, transfer the chemicals?
I think a retrospective study is in order and a methodology of the assessment is in order.
Hi Chuck,
Thanks for the comment. It’s a valid question. I’m assuming the research dealt with the law of averages. Certainly different chemicals in different phases will have different qualities as they pertain to clothing and skin adherence. I’m sure their research is or will be available somewhere, as you are likely not the only one to inquire.
Tim
Tim,
As a CBRN officer in the U.S. Army I’m well-versed in decon methods at both the individual soldier level and large troop decon scenarios, and I can without a doubt say the military has never considered the use of similar mass decon techniques currently being used by local fire services. I can’t say when exactly they were fielded, but M291 personal skin decontamination kits (using XE-555 Resin) have been standard issue for all individual soldiers until recently when the DoD transitioned from this antiquated technology to RSDL (Reactive Skin Decontamination Lotion) and Fibertech wipes. The RSDL is meant to be used in combination with the Fibertech wipes to not only quickly remove the contaminants, but RSDL has actually been proven to break the material down in the process. Bottom line: the DoD prefers the wipe method and has for decades. We only use water on our vehicles and certain pieces of equipment.
I’m a firm believer in science and have the utmost confidence in the professionals and the studies carried out by HHS/ASPR. If we can’t trust their results, whose can we trust? What I think is needed if for fire services who still plan on utilizing this mass decon water method is to prove, with sound scientific methods, that their technique is actually superior to the HHS recommendations, i.e., their technique will improve patient health outcomes, because as of right now, this new data doesn’t support it. I’m not saying we need to reinvent the wheel right now, but I do believe we need to seriously consider the findings presented in this study and start a dialogue among the relevant ESF disciplines.
Matt,
Thanks for the insight – and a public thank you for making me aware of the research and findings!
It’s interesting that the DoD has historically used one methodology, while domestic public safety has used another. Further, it’s interesting that CERF-P National Guard units adopted a decon approach more similar to that of public safety, with a focus on water-based decon. With this research and these recommendations, I’m hopeful the techniques will come closer together.
Overall, I think the big push will now be up to standards organizations (i.e. NFPA) and the larger lobby/membership organizations (i.e. IAFC). I’m certainly interested to hear their thoughts on this, as well as those from the NFA and health-centered organizations.
Thanks again!
TR
Tim,
Disrobing prior to decontamination via a warm water shower/cleaning in a decon shelter has been standard protocol for patient decontamination operations at U.S. military medical treatment facilities (MTFs) for at least the past several years. Gross decontamination at the incident site, for those that wait for the response, is still predominantly conducted by base fire department personnel/equipment, and it doesn’t typically include disrobing. Base hospitals and clinics with a patient decontamination capability are trained to disrobe all patients prior to processing them through their decon shelter. The additional step of wiping down exposed skin prior to showering makes sense for any patients waiting to be processed through the decon shelter and many military MTFs train to use RSDL (as described in a previous comment) for just this purpose.
Thanks for the comment Chris. Hopefully protocol will change for gross decon.
TR
Unfortunately, there is nothing new here. By way of bona fides, I was on the command staff of the National Medical Response Team for WMD for 15 years and taught mass decon and medical WMD operations.
The “drench drill” (cold water decon of clothed persons) was never intended as a mass decon methodology, it was a stopgap for non-ambulatory patients until technical decon (disrobing and warm decon solution) could arrive. The concept was that non-ambulatory patients were far more likely to have a significant exposure, and cold water drenching was better than doing nothing.
The fire service latched onto the drench drill as a decon methodology they could employ with existing equipment and training, without understanding the intent and limitations of the technique.
It has long been known that removing outer garments removes around 90% of contaminants. It has also been long known that cold water rinse is ineffective at removing contaminants (rub your dirty hands under cold water, how clean do they get?)
In an exercise in California, on a beautiful summer day, we used the ‘drench drill’ methodology with simulated agent on a bunch of Marines. We found it completely ineffective at removing agent.
It was, however, highly effective at creating clinical hypothermia in young, healthy Marines.
The drench drill is a dangerous, ineffective procedure likely to transform ‘worried well’ patients with no contamination into a mass casualty event of hypothermia.
Alan,
Thanks for the comment, and for posting both here and on LinkedIn. You’ve provided some great additional background to this. Hopefully the standards organizations can use this study to leverage some change.
TR
Hi Tim. First of all I agree with Alan’s concern about creating mass hypothermia, especially in a cold-weather event, and if the weather is cold enough the splash may even affect responders in full PPE. Second and on the other hand, it’s hard to see how a paper-towel wipe would clean hair, especially on top of head (esp. if long/thick) but also facial and body.
I’d also be curious to hear more from Matt on the mechanism of the RSDL/Fibertech combination.
Lastly I’d go out on an ethical limb: taking for granted the obvious that decon is a priority, in order to save life/lives it would be ethical to electrically shave off hair if not able to be quickly and safely decon’d; all concerned would obviously have to be protected from the clippings.
Hi Dave,
Very interesting points and questions! Hypothermia has always been a concern with decon. Protecting against it requires additional set up and added procedures to safeguard victims/patients. I agree that wiping can be encumbered by hair, although the recommendations still call for using a water-based decontamination after wiping to be most effective. Procedures must also be in place to ensure that responders are wiping away from sensitive areas, such as the face. Luckily, European and military models offer a great deal to borrow and learn from.
I keep referring back to the standards organizations… I’m wondering if they are talking about this yet.
Thanks,
TR
The unmentioned elephant in the room is re-clothing after decon. In the military, we would have spare clothing and/or PPE pre-positioned. How are civil agecies handling this? A tariffed assortment of disposable coveralls?
Good question, Timothy, and an important one. At a hospital decon, I would expect a gown, although in a field situation, I would at least hope for a disposable gown, or more ideally a Tyvek-type suit. What’s important is maintaining both body warmth and modesty, while also ensuring quick access for continued medical assessment and intervention, as needed. Unfortunately, providing clothing after decon is an afterthought, not only in practice but also in most guidance published on decon.
TR
To Mr Lee’s comment: I’m not aware of any plans/protocols for pre-positioned clothing, at least not here in Boston. Hopefully other jurisdictions are addressing the issue, especially those in colder climates. The biggest challenge for this, at least for no-notice decon events would be getting this clothing cache to the scene quickly (and will it even be a first responder priority?). Hypothermia is a HUGE issue, especially for children. I’m concerned with decreasing budgets and a normal habit to not want to change, our fire service colleagues will be slow to implement some much-needed updates to mass decon protocols. Sadly, patient outcomes will likely suffer.
I would disagree that there’s nothing new here. Although we suspected a significant amount of contamination would be removed by simply removing the clothing, this study confirms it’s exactly 90%. Prior to real science getting involved, anything else was just an educated guess. Also, this study clearly says unless the contaminant is a caustic substance, mass water-based decon should be delayed. Maybe a select few understood this, but I’m sure the vast majority of the decon community would not have expected this.
I agree wholeheartedly with Mr. Colon’s comments regarding the “drench method.” It’s dangerous and I’ve never seen it used for deconning a massive amount of troops in my 12 years in the DoD/Army. We use either MOPP gear exchange if contaminated while in our issued PPE (Joint Service Lightweight Integrated Suit Technology – JSLIST) or we self-deon using our issued decon kits (now RSDL & Fibertech wipes) if caught without our PPE on.
@ Mr. Sherman: Feel free to check out First Line Technology’s website. Everything you need to know about the RSDL & wipes can be found there.