The purpose of this small-scale research was to collect information and feed into a much larger project intended to build a new triage algorithm specifically for triaging victims within a hospital emergency department (ED) following a mass casualty incident (MCI) involving IGSAs. This research is being conducted by the Mass Casualty Triage Research Team led by Dr. Joan Culley (funding supported by the National Library of Medicines: 1R01LM011648-01A1) in response to a railroad accident that occurred in Graniteville, South Carolina in January 2005, which involved the release of chlorine gas.
Historical Perspective on IGSAs
According to the NTSB report of the Graniteville incident1, a freight train traveling approximately 47 mph was diverted onto a siding because of an improperly aligned switch. This diversion led to the collision of the freight train that was parked on the siding. The incident led to a derailment of both trains, rupturing a tank car and releasing 100,000 pounds of chlorine. After the incident occurred, victims began arriving at the nearest emergency department, traveling by their own means, before the hospital could be notified of the incident.
Chlorine, crude oil, and anhydrous ammonia are the most common IGSA chemicals. IGSA MCIs pose a significant threat to life and require rapid medical assessment by first responders and/or hospital personnel to reduce death and disability.2-8 Approximately 32 billion pounds of chlorine and five billion pounds of anhydrous ammonia are produced annually in the U.S.9 Railroads move 23 percent of these chemicals — about 35,000 carloads; trucks move approximately 53 percent, and boats move 20 percent.10 Railroads annually transport approximately 238 billion pounds of chemicals that can pose hazards of explosion, toxic release and fire. Between 1980 and 2000 the volume of hazardous materials moving by rail more than doubled; rail is now an essential means to transport hazardous materials. These chemicals are transported through small rural areas as well as urban centers. Exposure to IGSAs can happen in a variety of settings, including situations which involve deliberate release of these agents. The early identification of MCIs involving IGSA hazards is essential to an appropriate and rapid response for decontamination, triage, and treatment that could save thousands of lives. Many small communities do not have sophisticated hazardous material response teams or hospitals prepared to handle the surge from chemical incidents.
A previous study of the Graniteville chlorine disaster found that the surge of victims to a local ED from the large chlorine release resulted in:
- Difficulty identifying the type of incident and chemical involved
- Confusion regarding the best triage methods
- Difficulty with the efficient processing of patients.11, 12
In response to these concerns, the Mass Casualty Triage Research Team is developing a mobile application that will streamline triage within an emergency department, detect surges of patients, and improve communication between first responders and hospital personnel. When a surge is detected, this application will begin using triage algorithms that are evidence based to properly triage patients from the specific type of incident. As an example, research previously conducted by the Mass Casualty Triage Research Team proves that oxygen saturation — as measured by pulse oximetry — is a major determinant for the condition of a patient who has been exposed to an IGSA.11, 12 If an incident involving an IGSA is detected, patients will be triaged using an algorithm which focuses largely on oxygen saturation. Information gathered from this survey will assist Dr. Culley’s research team to develop tools to improve the response to IGSA incidents.
Wireless Information System for Emergency Responders (WISER) and Pulse Oximetry (SpO2)
WISER13 is a free mobile application developed by the National Library of Medicine (NLM) to assist first responders during hazardous material incidents. With this application, first responders determine the identity of a released chemical, collect information on the chemical, and receive information on important signs and symptoms to look for in a person that has been exposed to the chemical. WISER could be particularly helpful to responders in rural areas where specialized hazmat detection equipment or teams are not as readily available to responders in urban settings. The purpose of this survey was to learn more about the knowledge and application of such tools as WISER and SpO2 by rural and urban first responders during IGSA incidents.
Pulse Oximetry uses a small sensor that is placed on a fingertip or earlobe for measuring a person’s oxygen saturation. SpO2 is used by some first responders and during triage in EDs as a measure of respiratory function. It has the potential to provide an early indication of respiratory injury severity after a chlorine exposure. In developing a triage algorithm for IGSA disasters that rely on oxygen saturation data, it is important that we understand the availability of SpO2 equipment to first responders.
The survey included 39 questions to gather information regarding demographics, use of various tools onsite (e.g. WISER), communication protocols, triage methods and assessment tools (e.g. SpO2) used by first responders to a potential chemical incident. Scenarios where also included which required participants to determine the order in which they would complete a set of tasks based on priority. Paper and pencil surveys were used to collect information. Participants self-identified as working in either an urban or rural setting. Results were collected from 47 participants. Responses were then compared from first responders who work in rural versus in urban settings.
Participants indicated that 57 percent work in rural settings and 42 percent in urban settings. The majority of participants from both settings — 52 percent of rural, and 59 percent of urban — had more than 21 years of experience. Forty-three percent of both groups were between the ages of 18 and 44, and 56 percent were 45 years or older. Of those from rural settings, 73 percent indicated that they work as volunteer first responders, while 82 percent from urban areas indicate that they hold paid positions as first responders. We then compared the use of various tools by urban versus rural settings. Across all backgrounds, regardless of experience level and urban versus rural settings, participants consistently cited the Emergency Response Guidebook (ERG) as their main source of information when responding to a chemical incident. Most participants indicated that they also use smartphones on scene as part of their response to emergencies. Of the participants who provided information on the availability of SpO2 equipment, 92 percent of first responders from urban settings, and 72 percent from rural settings indicated that SpO2 equipment is usually/always available to them.
Two scenarios were presented in the survey. The first scenario described a team of first responders dispatched to the scene of a suspected chemical incident. There was no indication of the type of chemical involved. The respondents were asked to identify the first action they would take. Fifty-one percent of respondents said their first action would be to call for assistance, and 32 percent said they would try to determine the type of chemical involved before calling for assistance. A follow-up question asked participants what their second action would be in this situation; 44 percent of the respondents said that their second step would be to determine the type of chemical involved, while 35 percent indicated that they would determine the type of personal protective equipment (PPE) necessary to maintain their safety
To gain further insight into this information, a second scenario was presented. In this situation, responders know ahead of time that they are responding to an incident involving an IGSA, and that they will be the first to arrive. From a list of actions provided in randomized order, participants were asked to place these tasks in order based on priority. Table 1 shows the results of this question and sorts responses based on the settings in which first responders indicated that they work. In this table, the left column indicates the order in which the participants stated they would complete each of the listed tasks.
Analysis of the data showed several important findings. First, upon investigation of the use of WISER, 77 percent from rural settings were somewhat to very familiar with WISER, while 67 percent from urban settings indicated that they are not at all familiar with WISER. Second, there is a significant difference in how frequently information is available; 77 percent in rural settings versus 37 percent in urban settings indicated information is only sometimes available prior to arrival on scene. Third, while most participants (48 percent) indicated that they would decontaminate patients prior to treatment on scene, 30 percent indicated that they would begin treating the patient prior to decontamination. We are unable to determine if respondents who chose this option were implying that treatment would begin in the hot zone followed by decontamination, or if they would treat the patient and choose not to decontaminate altogether. Finally, 11 percent of respondents chose options involving direct patient contact prior to donning PPE or initiating patient decontamination. Table 1 sorts these responses based upon the setting in which the participants work. It is also important to note that one response from a rural setting indicated that the first action on arrival at the scene would be to transport patients directly to a treatment facility, implying that transport would occur prior to treatment or decontamination. Safety for first responders, patients, ED staff and a community depend upon the appropriate sequencing of:
- Identification of a hazardous material
- Appropriate use and selection of PPE
- Determination of the safety zones
- Evacuation from the danger zones
- Triage and treatment at the scene
- Transport to the treatment facility
Michael Pallon speaks with a first responder at the conference discussing the questionnaire and ongoing research. Thanks to the volunteer participants, we were able to collect 47 surveys in one afternoon.
While this was a small sample of first responders from South Carolina, results from this survey provide important insights into the differences in practice between first responders from urban and rural settings in situations involving IGSAs. It is essential that we understand the differences between these settings, especially the differences in the availability of tools, personnel, and the readiness of local emergency department for MCIs. MCIs, including those involving IGSAs, do not discriminate between rural and urban settings, and can happen anywhere.
The Mass Casualty Triage Research Team would like to thank all participants of the survey, and would like to especially thank the staff of the South Carolina Fire Rescue 2015 Conference for allowing us to collect survey data during this event.
- National Transportation Safety Board. (2006). Collision of Norfolk Southern Freight Train 192 with Standing Norfolk Southern Local Train P22 with Subsequent Hazardous Materials Release at Graniteville, South Carolina January 6, 2005. Railroad Accident Report NTSB/RAR-05/04 (PB2005-916304). Retrieved from http://www.ntsb.gov/investigations/AccidentReports/Reports/RAR0504.pdf
- Simon R, Teperman S. The World Trade Center attack: Lessons for disaster management. Crit. Care. 2001;5(6):318-320.
- Kirk MA, Deaton ML. Bringing order out of chaos: effective strategies for medical response to mass chemical exposure. Emerg. Med. Clin. North Am. May 2007;25(2):527-548.
- Perrow C. Disasters ever more? Reducing US vulnerabilities. Handbook of disaster research: Springer; 2006:521-533.
- Agency for Toxic Substances and Disease Registry. Medical Management Guidelines for Chlorine. http://www.atsdr.cdc.gov/mmg/mmg.asp?id=198&tid=36. Accessed October 16, 2013.
- Centers for Disease Control and Prevention. Facts about Chlorine. http://www.bt.cdc.gov/agent/chlorine/basics/facts.asp. Accessed October 16, 2013.
- News EH. Kay J. Special Report: Chlorine accidents rupture life for workers, townspeople. 2011; http://www.environmentalhealthnews.org/ehs/news/2011/chlorine-accidents. Accessed October 16, 2013.
- Agency for Toxic Substances and Disease Registry. Hazardous Substances Emergency Event Surveillance. Agency for Toxic Substances and Disease Registry
- Jones R, Wills B, Kang C. Chlorine gas: An evolving hazardous material threat and unconventional weapon. West. J. Emerg. Med. 2012;11(2):151.
- Railroads AoA. Railroads and chemicals 2012; https://www.aar.org/keyissues/Documents/Background-Papers/Railroads-and-Chemicals.pdf. Accessed August 1, 2013.
- Culley, JM, Svendsen, ER, Craig, J. & Tavakoli, A. (2014). A Validation Study of 5 Triage Systems Using Data From the 2005 Graniteville, South Carolina, Chlorine Spill. Journal of Emergency Nursing, 40(5): 453-460. DOI:10.1016/11. Culley, JM, Svendsen, ER, Craig, J. & Tavakoli, A. (2014). A Validation Study of 5 Triage Systems Using Data From the 2005 Graniteville, South Carolina, Chlorine Spill. Journal of Emergency Nursing, 40(5): 453-460. DOI:10.1016/j.jen.2014.04.020.
- Craig, J, Culley, JM, Tavakoli, A. & Svendsen, ER. (2013) Gleaning data from disaster: a hospital-based data mining method to studying all-hazard triage after a chemical disaster. American Journal of Disaster Medicine, 8(2), 97-111.
- U. S. National Library of Medicine. (2012). Wireless Information System for Emergency Responders: About WISER. Available from http://www.wiser.nlm.nih.gov