@National Level Training Programme on On-Site and Off-Site

Emergency Management Planning; Guhawati, 23rd December, 2008

Dr. RAKESH KUMAR SHARMADivision of CBRN Defence,

Institute of Nuclear Medicine and Allied Sciences, Brig SK Mazumdar Road,

Delhi 110 054 (rks@inmas.drdo.in)

Emergency Medical Preparedness and

Response to Chemical Disasters

Assessing the RiskAssessing the Risk• MIC Gas Leak in Bhopal- accounts for nearly 20000

casualties till date. 1,20,000 still suffering• Equally important are the ‘peripheral emergencies’

which results in mass casualty events resulting in 10s to 100s of casualties.

• Due to increase in growth of chemical industry , the risk of occurrence of chemical disaster associated with Hazardous Chemicals (HAZCHEM) has gone up.

• The recent incidences of chemical Attacks by extremists in Iraq has now put the importance of preparedness for chemical disasters in the forefront

Mass Casualty Incident

Any event resulting in number of victims large enough to disrupt the normal course of emergency and health care services is called as a mass casuality event (WHO)

CIDM

Management of mass casualty incidences due to incidences/man-made accidents involving them or overt/covert attacks involving chemical agents, needs overall preparedness and risk reduction at all levels, including contingency planning and capacity development for an efficient response.

National Vision for Management of Chemical Disasters

National Vision for Management of Chemical Disasters

National Vision for Management of Chemical Disasters

1. To prevent Chemical Disasters

National Vision for Management of Chemical Disasters

1. To prevent Chemical Disasters

National Vision for Management of Chemical Disasters

2. In the event of occurrence of CD, various stakeholder shall under take certain pre-planned and established Structural and Non-structural measures so as to minimize risks to health, life and environment

Something may go wrong in spite of best system.

History repeats itself as we don't learn from it.

Many big mishaps have apparently small causes behind, which are likely to be

overlooked.

Scale of Disasters: Factors affecting

• Inventory; geographic and demographic factors• Vulnerability of population• Frequency of occurrence • Public awareness• Intensity – distance relations• Energy factor(release, mode & rate)• Time factor (release rate and warning time)• Exposure factor (nature, duration & extent)• Type of response mechanisms

Scale for Grading of Chemical Disasters

Multiple life threatening injuries and / or fatality Uncontained release with potential for major environment

effects

4

Severe injuries or potential for a fatality Uncontained release with potential for moderate

environment effects

3

Injuries requiring a physician’s care Uncontained release with potential for minor environment

effects Chances of fire and explosion

2

Injuries requiring first-aid only Contained release with local environmental effect and

pollution problem

1

Qualitative Severity/ Consequence CriteriaGrades

Sequel of Major Chemical Disasters • Fire & violent Explosion• Uncontrolled Reaction• Leakage of highly toxic cloud of gaseous and

particulate material, which spreads to neighboring habitations

• Environmental (Air release, ground spill to water bodies, cultivated land, waste disposal etc.)

• Dissemination of aerosolized chemical warfare agents or liquid toxicant/poisons to contaminate the environment or food product by terrorists

• Chemical Burns (strong acids, strong bases)• Heat Burns (flammable materials)• Poisoning (many chemicals are damaging or

fatal if taken internally, whether by swallowing, injection, or leaching through skin)

• Chronic illness (long-term exposure to even low doses of certain chemical agents can lead to chronic health conditions)

• Etc.

Modes of Chemical Injury

General Signs and Symptoms

Cough

Chest pain

Lacrimation

Eyelid oedema and

Unconsciousness

Leads toAcute lung injury

Cardiac arrest

DEATH

CorrosivenessErythemasIrritations

Corneal OpacityRetinal Damage

SensitizationPneumoconiosisFibrosisAdenomasAsphyxiation

MiscarriageNeonatal deathFetal abnormalities

Behavior ChangesPeripheral neuro degenerationLocomotion rigidityNarcosis or DepressionRespiratory Paralysis

MFO inductionCholeostasisCarcinogenesisNecrotic/Cirrhotic liverDefense system loss

Aminoacid ureaUremiaRenal failure

Bone marrow depressionAnaemiaCancerMet hemoglobinemia

OsteoporosisArthritisImmuno

Suppression

TARGET ORGANS AND EFFECTS INDUCED BY CHEMICALS

Gather information regarding: place, time and type of emergency also type of chemical,

chemical toxicity, route of exposure

Mobilization of Resources

o Manpower: Disaster Management Team medical , nursing and other Personnel

o Material and supply eg: antidotes o Transportation means

Transport to the critical patients for medical care / hospitals

Decontamination done at decontamination area in the hospital

Triage

Documentation done at reception

Treatment to the patient (Emergency Dept.)

OT

IPD / ICU

OPD

Discharge

Getting initial alert from:

Police, casualty and telephone

On site treatment / operations

o Mass decontaminationo Transported in a safe placeo Provide necessary treatment , first aid and antidote administration to chemical contaminated patients

Notify to Key Personnel

Initiate preparationo All the dept & designated staff get into

readiness to attend casualtieso Crisis expansion of hospital beds.o Preparation for decontamination area

o Diagnostic Services o Other support services

Chemical Disaster Action Plan

Five steps to Emergency Response

Secure the Area – To keep Non-Emergency Response Personnel out of danger.

Approach with Care – No Blind Rushing, Approach upwind.

Identify Products – Placards / Labeling for the hazard.

Assess the Situation – Fire / Spill / Leak / Weather conditions / Terrain like / At risk, people, property, environment / evacuation necessary / what to be done right away.

Respond – In an appropriate manner. Establish Command Post / Lines of Communication / Control of the site / Safety of the People in the Area / Own Safety.

Management of Chemical accident

• Pre-hospital

• Hospital

• Post-hospital

• Preventive

PREHOSPITAL RESPONSEServices Involved

POLICE

FIRE

MEDICAL

VOLUNTARY

Primary Health CentreCommunity Health CentreFirst Referral UnitCivil HospitalMedical Colleges

Rapid Response Team

• After the initial management of the victims Triage Red will get the first priority.

• All events must be coordinated with the doctors of the receiving hospital.

• While shifting patients back, neck and airway need to be protected.

• Keep the facilities till the last victim is transported.

Medical Preparedness

1. Medical Preparedness will be based on regular practice of medicine and should include recognition of the impact of chemical disaster

2. It should focus on injuries, illness and public health problems including psychosocial trauma and should address integration of medicine and public health

3. It must also focus on Disaster management onsite plan, offsite plan and crisis management at the hospital

Medical Preparedness (Contd./..)

4.Medical preparedness should also address necessity of planning and practice, exercises involving local, district, state, central government and voluntary agencies

5. It must include problem solving, based on the past experience of disasters

6. Specialized first responder and specialized medical first responder of NDRF need to be prepared to handle chemical disaster

• Doctor • Chemist• Nursing Asst. • Mobile Van • Resuscitative Equipment • Protective Clothing• Detection Equipment & Decontamination Material • Regular Rehearsal/ Exercises • Ready to move at very short notice  

QUICK REACTION MEDICAL TEAM (QRMT)

A separate team of chemists is needed to analyze the exact type of chemical (mobile lab fitted with chemical analyzer).

Knowledge of exact nature of chemical will facilitate proper antidote administration & effective treatment for early recovery

• O2 Cylinder • O2 Concentrator• Suction Apparatus• Laryngoscope • Endotracheal Tube

• Ventilator • Airway

• Pulse Oxymeter• Defibrillator • IV fluid

• Emergency Drugs• Dressing material

Resuscitation Equipment & Drugs

Chemical Casualty Treatment Kit

• Autoinjectors (Obidoxime x3)• Obidoxime, bottles , x3• Atropine sulphate injection, bottles, x10, ampoules, x20• Pyridostigmine bromide tablets, packs, x10• Dimercaprol injection, ampoules, x10• Sodium thiosulphate, bottles, x4• Syringes, hypodermic disposable, 5 ml , x5• Guedel airways, 2 sizes• General surgical scissors• Bandage, gauze, 5 cm , x5 • Bandage , gauze, 7.5 cm, x5

Capacity Building (Manpower)

• The selection of dedicated team is the first step in capacity building. Manpower from Govt., NGOs, specialized response team, etc.

• Formulation of QRMT consisting of Doctor, Nursing Asst. & Chemist

• Chemical trained team of medics and paramedics at the hospitals as part of integrated Disaster Management Plan.

Training of Medics & Paramedics

• Basic knowledge of Chemical substances and their properties

• Handling Detection and Protective Equipment

• Decontamination procedure• Symptoms and treatment ofChemical

casualties • Medical care at site, during evacuation

and in hospital

Public Awareness

• Put on NBC mask/wet cloth to protect nose and eyes in case of Chemical disaster

• Move away from incidence site• Report incidence to nearest authorized

agency under disaster management plan• Avoid contact with Chemical agents• Do not eat, drink or smoke in

contaminated area• Report to nearest medical facility

Capacity Building (Material)• Effective communication is very important• Facilities for evacuation by Ambulance, train, helicopters

and sea etc.• Medical equipment for QRMT & hospital treatment• Mobile Hospital for Casualties Management at Site to

Decrease the load on Hospitals• Resuscitative Equipment like O2 Cylinder, Suction

Apparatus, Laryngoscope, Endotracheal Tube, Ventilator, Defibrillator, Emergency Drugs

• Protective Clothing• Detection Equipment & Decontamination Material

Protective Devices

• NBC Protective suit • Charcoal underwear• Protective boots• Protective gloves• NBC Protective mask • Disposable Plastic protective suit• Decontamination equipment • Decontamination sprayer• Hot Air Decontamination system• Contamination Clearance Module

PERSONAL PROTECTIVE SUITSPERSONAL PROTECTIVE SUITS

Charcoal – Underwear

Chemical Agents Detectors

• Chemical Agent Monitor (CAM)• Haz-chem detector Ticket.• Chemical Agent warning Instrument• Hazmat Vehicle• Ground Area Reconnaissance

Detection System

Preparedness for Evacuation

• By road in Ambulance

• By Helicopter if warranted

• Stretcher & Life support system

• Casualty evacuation bag

• SOPs for Resuscitation, Decontamination, Triage & Evacuation

Chemical Casualties Evacuation Bags

GUIDELINES –Medical Preparedness & Response..

• Medical Preparedness shall stress upon :– Creating awareness– Creation of trained specialized medical first responders– Creation of Decontamination facilities– Uniform casualty profile and classification of causalities and illness– Risk Inventory and resources inventory– Plans for Evacuation– Proper chemical casualty treatment kits– Crisis Management Plan at the Hospitals – Mobile hospital/medical team– Preparedness for public health and environmental effect response

• Emergency Medical Response & Post Disaster Phase– Chemical related issue during , Rescue, Relief and Remedial measures– Quick Response Medical Team– Materials and Logistics requirement– Post-disaster Public Health Response – Post disaster documentation and Research– Medical response to long term effects

• Medical Rehabilitation– Psychosocial trauma – PTSD Care

Salient featuresSalient features

GUIDELINES –Medical Preparedness & Response

Section-4 of this document lays down the Guidelines for medical preparedness and response

GUIDELINES –Medical Preparedness & Response

Section-6 of this document lays down the Guidelines for Medical Preparedness for CBRN Management

Management of Medical Emergencies

The management of medical emergencies during On-Site and Off-Site emergencies is a priority area. Medical Preparedness is the weakest link in the emergency response system and at hospitals.

There is a need to address & update medical preparedness comprehensively at all levels.

Keeping in view specific preparedness and response requirements of chemical disasters gaps in the existing Medical Emergency Management have been identified

Management of Medical Emergencies

It is essential to address mechanisms for creating awareness, creation of trained medical first responders, decontamination facilities, risk and resource inventory, trauma care, plans for evacuation, mechanism to maintain uniform causality profile, availability of proper chemical casualty treatment kits, mobile teams/ hospitals, hospital disaster management plan and preparedness for public health and environmental effect response.

Non-availability of specific antidotes for chemicalsInadequacy of infrastructure for trained medical and

paramedical staff.The standard operating procedures for Emergency

Medical Response at incident site are not laid down. Absence of separate Medical Emergency Plan in the District Off-Site Plan Lack of documentation of uniform procedures to be followed during chemical emergencies

Management of Medical EmergenciesImportant GapsImportant Gaps

Gross inadequacies in terms of trained manpower and capacity in Poison Information Center and regional laboratories lying in proximity with disaster prone areas with detection facilities for hazchem

Absence of mechanism for medical surveillance Medical Response to long term effects and at

present, there are inadequacies in terms of studies on long-term effects and research

Mechanisms for Medical Rehabilitation need addressals

Management of Medical EmergenciesImportant GapsImportant Gaps

Evacuation Plan1. Patient Evacuation Plan with flow chart must be

made, keeping the meteorological conditions in view

2. Resources for special ambulance helicopters, ambulance trains, etc, will be strengthened at all levels and proper resources inventory will be prepared for the purpose

3. The ambulance should have SOPs for treatment procedures and list of specific antidotes

4. Acute health risks must be defined and known to para-medical staffs, who are accompanying the patients in ambulance

5. Ambulances are to be fitted with resuscitation equipment to maintain vital parameters during evacuation to hospital.

•Preparing Integrated Hospital Disaster Preparing Integrated Hospital Disaster Management plan including Chemical Management plan including Chemical

casualties casualties management facilities management facilities •Creation of Decontamination Room & Creation of Decontamination Room &

FacilitiesFacilities•Surgical & Medical Team readinessSurgical & Medical Team readiness•Stocking & rotation of antidotes and Stocking & rotation of antidotes and

essential essential drugs. drugs. •Plan for Beds expansion by discharging Plan for Beds expansion by discharging

sub-acute and sub-acute and chronic patients and chronic patients and activating crisis mngt. beds.activating crisis mngt. beds.•Documentation & Research for future Documentation & Research for future

improvement.improvement.•Appointing a PRO to deal with patients Appointing a PRO to deal with patients

relatives, relatives, press, media, for regular press, media, for regular medical bulletin.medical bulletin.

Hospitals Preparedness

Preparedness by Earmarked Hospitals

1. Hospitals must nominate an incidence officer for coordinating management of chemical casualties

2. A decontamination room is to be established. All chemical casualties have to be taken first to decontamination room

3. Contamination, clearance module, a very effective tool for dry & prompt decontamination can be utilized for walking casualties

4. Surgical team is to be kept ready to handle blast and heat injuries

Preparedness by Earmarked Hospitals (Contd./..)

5. A group of specialists like Neurologist, Hematologist, Gastroenterologist, chest physician, ophthalmologist, burn specialist & dermatologist etc. must be available to handle immediate and long term effects of chemical disaster

6. Stocking & rotation of antidotes needs to be maintained 7. Special lab for chemical analysis is to be established 8. Contingency plan be made ready for bed expansion by

discharging chronic patients9. Availability of oxygen, continuous positive air pressure (C

PAP) Ventilators, dialysis facilities, blood and IV fluid for transfusion must be stocked

NBC Filter Fitted Ward1. Ward in isolated places may be earmarked

for NBC casualty management so that other parts of the hospital is not contaminated

2. Ideally a special ward for chemical casualties treatment is to be established in the basement of the Hospital

3. A ward shall be fitted with NBC filtration units to provide purified air with a positive pressure inside, so that NBC contaminated air will never enter from out side. Ward must have bio-waste disposal facilities also

Mobile Hospital/Medical Team

Mobile hospital/medical team should be catered in health care delivery system of DDMA so that pressure can be relieved from hospital. Capacities of mobile hospital depend on the magnitude of disaster and population to be treated.

Activation of Hospital Chemical Disaster Plan

• Declared by senior nursing staff or senior casualty officer.

• Inform the key personnel and arrange for the deployment of trained staff for the reception,triage,decontamintion and management of victims.

Preparedness of Public Health Response

1. Preparation of development of toxicology database with information on specific chemicals

2. Information on specific antidotes and other medication and where they are stockpiled must be made available

3. The public health response team must consists of physician, toxicologist, environmental specialists, public information experts, community and medical representatives

4. Creation of knowledge of safe water, standard of proper hygiene and sanitation, availability of food and nutrition

Health Care at Industrial Sites

• Factories Act, 1948~ parent Act dealing with welfare, occupational health, safety and medical emergency services ~ also in context with various hazardous processes

• Amended Factories Act, 1987 or so.. ~ specified dangerous processes !- Schedule 87

• Rules made for medical examination, once in a period of 6 months in respect of Occpational Health Services

• Essential- employ one full-time medical officers in factories with 500 workers and additionally for every 1000 workers or part there off

• Schedule also gives list of the minimal equipments to be maintained for Occupational Health Services

Legal RequirementsLegal Requirements

Action by Industry in case of Chemical Disaster

1. Onsite team First Responders must start rescue and relief work as per the laid down SOPs and drill carried out during preparedness

2. Onsite plan must have triggering mechanism inbuilt. Industry should earmarked the officer, who will activate the plan and will inform well established, disaster management system

3. Collector must he immediately informed about the accident. Offsite plan team must be immediately alerted to swing into action

4. Post disaster surveillance, documentation and research should form integral part of onsite plan for proper recovery and rehabilitation

Action by local Disaster Management Authority

• Ensuring proper Pre-Planning and Preparedness

• Sounding an alarm immediately on mishap

• Instantaneous instructions to various Rescue Agencies for forthwith action

• Ensuring proper rescue work

• Alerting hospitals for receiving casualties

• Mobilising resources from other places

Direction of Movement of People

CHEMICAL DISASTER

Gas leak noticed

Wind direction

Response by DDMA in a Post-Disaster Scenario

1. Instantaneous instruction for forthwith movement of rescue team with personal protective equipment (PPE)

2. Simultaneously, QRMT with PPE on will reach to Mishap site immediately along with Resuscitation, protection, detection and decontamination equipment and material. Resuscitation, triage and evacuation work must be done as per sops.

3. DDMA will immediately inform State and National Disaster Management Authorities appraising about situation and extent of damage so that SDMA & NDMA can plan to send relief teams

Response by DDMA in a Post-Disaster Scenario (contd)

4. Hospitals must be alerted to be ready to receive casualties

5. If there is a major chemical disaster and management is beyond the capacity of District resources. In that situation DC can request for help from adjacent district, state DMA and NDRF

6. Simultaneously, DDMA will instruct other agencies to plunge into action as per the responsibilities assigned to them

Standard Operating Procedures for Disaster Site

• Rescue & Quick Reaction Medical Team must put on full protective gear

• Cordon off the Disaster Site• Do not allow Entry within five kms of Disaster site• Find out the wind direction & Clear the down wind side

immediately

• Detect & Identify the Chemical Substance• Demarcate the area of Contamination• Do not crowd near the victim to avoid further contamination• Carryout Rescue, Resuscitation & Evacuation work properly

Response by Incident Commander

1. Cordon off the area and restrict entry into the cordoned area except the designated response personnel

2. Use the Detection Team to identify all hazardous substances or conditions present.

3. Designate sites for setting up decontamination centers.

4. Designate locations for triage and emergency treatment.

5. Arrange to provide directions and instructions to the population on the public address system

Cardoning off the Chemical Disaster areaWind direction

No incoming traffic except for disaster management

No incoming traffic

No incoming trafficNo incoming traffic

No incoming traffic

Site of DisasterSite of Disaster

Medical Aid PostMedical Aid Post

Control HQrsControl HQrs

POLICE POLICE CHECK POSTCHECK POST

Outer Cardon

Inner Cardon

Key issues in Managing Mass Casuality Chemical disasters

• Golden Hour/Platinum Minutes

• Triage

• Basic Life Support

• Advance Life Support

• Decontamination

• Transportation

• Training of Medical Personnel

• Education of community

• Establishment of National and Regional poison Centre

• Dissemination of Information

Casualties Management Protocol

• Resuscitation

• Protection

• Detection

• Decontamination

• Evacuation

• Hospital Rx

• Antidotes Administration

NBC CasManagement

QRM

T P

rotective Equipment

Specific Hospital Rx Facilities

•Radio-Biodosimetry •Decorporation agents •Neurologist,Chest Physician, Ophthalmologist,Dermatologist, Biowaste Disposal •Antidotes & Vaccines •Specific Training for Medical,&

para medical staff

• Protection

•Detection

•Decontam

ination

• Resu

scit

ati

on

•Tri

age

•Evacu

ati

on

Augmentation of Incident Site Management Capabilities

• Detection/Protection Equipment (conditioned to be useful in Indian climatic conditions)

• Decontamination

MANAGEMENT OF MANAGEMENT OF CONTAMINATIONCONTAMINATIONPROTECTION DETECTION

DECONTAMINATION

On-Site Emergency Medical Care • Health Care Centers ~ Two in perpendicular

directions • Inhabited with Qualified Medical Officer and

male nurses ~ 24X 7 services• Dedicated well equipped Ambulance with

driver~ safe transportation of victim• 10 bedded clinic • Equipments- Oxygen Cylinders, masks, Ambu

bags, First aid box, essential medicines, antidotes specific to particular hazard

• Minor O.T. and small laboratory to analyze routine blood samples

Legal RequirementsLegal Requirements

Off-Site Medical Preparedness

• Emergency Management at the incident Site:– Personal Protective Equipment will be made available – Temporary decontamination facility– On-Site Triage, Resuscitation and safe transportation

• Safe transportation of the chemical casualties in ambulances fitted with chemical filters

• Evacuation Plans from Plants and nearby affected communities

Off-Site Medical Preparedness

• Earmarking of health care facilities able to cater different types of chemical casualties like chemical burns, respiratory problems etc.

• Hospital disaster management plans to deal with mass casualty events caused due to chemical disasters

• Creation of Trained Medical First Responders• Uniform Casualty Profile & their classification• Risk and Resource Inventories

Off-Site Emergency Medical Care

• Proper Chemical Causality Treatment Kits including essential medicines and antidotes

• Dedicated Group of Specialists to manage multi- organ dysfunctions caused by chemical exposures

• Provisions for mobile hospitals and teams, if needed• National and Regional Poison Information Centers for

information about various antidotes and treatment profiles• Preparedness for Public Health and Environmental Effect

Response • Mechanism to follow up the long term medical care to the

numerous victims

Crisis Management Plan

1. The crisis management plan will be prepared for all earmarked hospitals in the offsite plan

2. Responsibility of preparation and implementation of the plan solely lies on the medical superintendent of the Hospital

3. Establishing decontamination facilities, training of medical personnel, creating awareness of toxicants. and their antidotes and collection of biological samples like blood, urine (to be frozen) should form the part of disaster management plan

4. Emergency medical response, documents, follow up and research programme in post- disaster phase should also form the part of Disaster management plan

Hypochlorite

Large amounts of water

DECONTAMINATIONStaff allocated to the decontamination area will done protected suits.

decontamination

Casualty decontamination is a responsibility of the HEALTH SERVICES

The following procedure applies to decontamination from hazardous chemical or radiation

dirty

clean

WALKINGPATIENTS

STRETCHERPATIENTS

P1 & P2treatment

P3treatment

health worker infull protectiveequipment

health worker instandard clothing

contaminatedcasualty

cleancasualty

cut off clothes

rinse or shower+ detergent

remove ownclothes and bag

key

incident

Rinse – wipe – rinse procedure in the warm zone in the shelter.

After decontamination patient will be enter the cold zone by secondary triage team.

Secondary triage team – Triage decontaminated casualties according to the disaster management plan and hand over the victims to the clinical team for definitive treatment.

Guidelines for Preparedness

• Creating awareness to the type of illness, injuries, burns and other health problems caused by various toxicants to all the medical teams and community at large

• Creation of trained specialized medical first responders for first aid and resuscitation measures at the incident site and during transportation of casualties. All members of medical and paramedical staff team will carryout regular exercises based on the SOPs laid down by respective District Medical Management Authorities (DMMA)

Contd./..

Guidelines for Preparedness (Contd./…)

• Decontamination facilities are required to be established at accident site but outside the risk area

• Uniform casualty profile and classification of causalities and illness should he attempted for various groups so that the treatment can largely be standardized

• Risk Inventory and resources inventory must be prepared at all levels of medical management plan including both onsite plan and offsite plan

Guidelines for Preparedness

• Creating awareness to the type of illness, injuries, burns and other health problems caused by various toxicants to all the medical teams and community at large

• Creation of trained specialized medical first responders for first aid and resuscitation measures at the incident site and during transportation of casualties. All members of medical and paramedical staff team will carryout regular exercises based on the SOPs laid down by respective District Medical Management Authorities (DMMA)

Guidelines for Preparedness (contd)

• Decontamination facilities are required to be established at accident site but outside the risk area

• Uniform casualty profile and classification of causalities and illness should he attempted for various groups so that the treatment can largely be standardized

• Risk Inventory and resources inventory must be prepared at all levels of medical management plan including both onsite plan and offsite plan

Guidelines for public during chemical disaster

• Report about mishap to police or fire station• Stay upwind & uphill• Self protection by stopping breathing immediately and

closing eyes• Then put on the NBC protective mask • Avoid contact with chemical agents• Seek qualified medical advice for those persons who

have been harmed by chemicals• Do not eat, drink or smoke on contaminated terrain

Direction of Movement of People

CHEMICAL DISASTER

Gas leak noticed

Wind direction

Response & Relief

Response and relief will form the part of onsite and offsite plan in post disaster scenario. All responsible parties should ensure that manpower, equipment (including communication equipment and personal protective equipment), and financial and other resources necessary to carry out emergency plans are readily available for immediate activation in the event, or imminent threat of an accident

Post-Disaster Emergency Medical Response

1. Activate resuscitation, first aid and triage system.

2. Provide immediate relief to seriously ill and injured.

3. Carry out resuscitation4. Collect biological samples of casualties and

sample from environment as well.5. Carry out proper diagnosis and proper antidote

administration.6. Carry out simultaneous documentation of the

patients.7. Provide accurate information to public health

authority and public.

Medical Response at Hospital 1. In hospital casualty will be finally

decontaminated and kept in a clean special NBC ward

2. Initially based on early symptoms, type of chemical is assumed, accordingly an antidote is given

3. Blood is to be analyzed to find out the exact chemical agents and further treatment must be modified accordingly

4. Hospital casualty room is to be equipped with resuscitation equipment like oxygen cylinder, suction apparatus, airways, laryngoscope, ventilator, pulse oxymeter, defibrillator, life saving drugs, antidotes auto injectors & dressing material

POST TRAUMATIC STRESS DISORDER & ITS MANAGEMENT

• PTSD is a psychological response to the experience of intense trauma due to Disaster.PTSD is characterized by

• Intrusive symptoms include distressing memories or

images nightmares sweating, heart racing or muscle tension

• Avoidance symptoms of PTSD trying to avoid any reminders of the trauma, such as thoughts, feelings, conversations, activities, places and people.

• Arousal symptoms of PTSD include sleep disturbances, anger and irritability, concentration problems, constantly on the lookout for signs of danger

Post-disaster Public Health Response

1. Prime responsibility of medical authorities

2. They must ensure safe water supply, clean food availability

3. Maintenance of hygiene and sanitation by proper bio- waste disposal

4. Water testing and food inspection must be carried out

Post-disaster Epidemiological Study

1. It must include accurate estimation of chemical exposure of effected population, correlation of environment and human exposure data, relationship of chemical and dose to the observed effect,

2. Sub clinical effects, morbidity and mortality must also be analyzed

3. Epidemiological studies be conducted for assessment of psychosocial effect of disaster

4. Analysis to find out the success and failure of Disaster Management Plan and failure must be addressed

5. Epidemiological studies team should have Clinician, Epidemiologist, Toxicologist, Pathologist, Environmental scientists and reps from Industry

Medical Response to Long Term Effects

1. In post-disaster scenario some of the casualties will develop sequel due to chemical injuries

2. These cases may need regular follow-up, medical care, reconstructive surgery and rehabilitation

3. Close monitoring is required to see any long term health effects like blindness, interstitial lung fibrosis and neurological deficiencies etc., and need to be treated as well

Post Disaster Documentation and Analysis

1. Information will be prepared by a medical administrator

2. During response in hospital an information centre will provide information to public, to relatives of victims and media

3. Warning guidelines, “DOs and DON’Ts” and condition of patients in the hospital

4. dissemination of information to electronics and prints media will also be carried out by medical team

5. Documentation, follow up and research programs should be used as feedback for future improvement and lessons learnt

Rehabilitation

• It involves providing temporary shelters with minimal hygiene sanitation to the affected, restoring “normalcy” through ensuring resumption of family’s daily living patterns

• Psychological impact of chemical disaster manifested as post traumatic stress disorders (PTSD) in displaced people due lo disaster, needs care by a psychologist and psychiatrist

Recovery

• Decontamination of the area, equipment, vehicles and disposal of left over contaminants, removal of dead bodies from site has to be carried out in the Post-disaster Scenario.

• It also involves restoring life of victims to normalcy.

Post-Disaster Emergency Medical Response 1. Activate resuscitation, first aid and triage system. 2. Provide immediate relief to seriously ill and

injured.3. Carry out resuscitation followed by

decontamination4. Collect biological samples of casualties and

sample from environment as well.5. Carry out proper diagnosis and proper antidote

administration.6. Carry out simultaneous documentation of the

patients.7. Provide accurate information to public health

authority and public.

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