Emergency Medical Services in CBRNE/HAZMAT Incidents

Aim: The purpose of the study is to work out a new emergency medical service (EMS) tactic to be employed in CBRNE/HAZMAT incidents, which would allow performing emergency medical procedures in the area so far inaccessible to the State Emergency Medical System (Polish abbreviation: PRM). Project and methods: Incidents involving new hazardous materials, especially terrorist ones, demand emergency services to be well prepared in order to respond accordingly. Latest technological advances regarding both personal protective equipment (PPE) for preventing contamination and respiratory protection equipment bring effective and safe methods of medical professionals’ protection at every stage of rescue operations being performed. The research study was conducted in 2016–2018 and its main focus was on providing medical care at all stages of rescue operations. The CBRNE/HAZMAT incident procedures of the State Emergency Medical System (PRM), the National Firefighting and Rescue System (KSRG), the Bureau of Anti-Terrorist Operations of the National Police Headquarters (BOA KGP) and the Epidemiological Response Centre of the Polish Armed Forces (CRESZ) were thoroughly analysed. An analysis of procedural shortcomings within rescue operations of all services was also conducted. In addition, the PPE for preventing contamination and the respiratory protection equipment that is used by various emergency services and may also be applied within PRM operations was thoroughly examined. Results: Based on the study, a new EMS tactic was developed using the available PPE, a management system of rescue operations and a model of organisation of any operations. The in-depth analysis of PPE for preventing contamination and respiratory protection equipment indicated new solutions and methods for protecting professionals of the State Emergency Medical System (PRM) while providing pre-hospital and hospital care (in Hospital Emergency Departments). A set of training drills employing new tactics and PPE indicated real possibilities to transfer new solutions to EMS that would compensate the shortcomings identified within the procedures of responses at the subsequent stages of CBRNE/HAZMAT incidents. Conclusions: The suggested tactic of emergency medical services shall enhance the effectiveness of the emergency rescue system in CBRNE/HAZMAT incidents as it enables emergency medical procedures (Polish abbreviation: MCR) to be more promptly performed in patients with life-threatening conditions, along with providing medical care at all stages of rescue operations.


Introduction
The National Firefighting and Rescue System, accord-

Challenge
Hazardous materials are expected to become a major threat for the population in the 21st century [3][4][5][6] as predicted by researchers whose main focus is on current and impending threats. This stems from the fact that biological, chemical, ra-

Wyzwanie
Według przewidywań naukowców zajmujących się problematyką współczesnych i nadchodzących zagrożeń, materiały niebezpieczne stanowić będą jedno z głównych zagrożeń dla ludności w XXI wieku [3][4][5][6]. Znajdują one swoje źródło w czynnikach biologicznych, che-SFT VOL. 54 ISSUE 2, 2019, PP. 142-159 diation and nuclear agents might be used as weapons of mass destruction (WMD) or be released into the environment in the course of technical breakdowns, which is the most probable occurrence in Poland. As reported by the National Headquarters of the State Fire Service, in 2016 there were 415 plants located in Poland which were likely to experience a serious industrial failure due to hazardous materials being stored. 179 plants were qualified as high-hazard worksites, and 236 as increased-risk worksites [7].
Exposure to hazardous materials may be dangerous both to incident casualties and medical rescue workers involved in providing medical care.
Much is yet to be done when it comes to training medical staff on how to effectively respond to the above mentioned threats. Various studies have revealed a gap in medical professionals' knowledge and skills at all stages (pre-hospital, early hospital and specialised care) [8][9][10][11]. There is a clear trend to introduce some changes to solve the problem, which was rec- All the changes in environmental conditions which medical professionals need to face require an appropriate protection of rescue teams including the medical staff (depending on the type and size of the threat). They need to be provided with PPE, e.g., respiratory protection equipment and protective equipment to prevent contamination of the skin (protective suits). Accessibility to such a type of protective equipment changes the rescue responses. A conventional approach "it is dangerous so I am not in" is already gone. Nowadays, the medical rescue management related to hazardous materials incidents is no longer procedural but based on knowledge, risk analyses, and accurate management of available resources, and both the negative and potentially positive consequences are duly considered. Such a change stems from different society's expectations due to an increased awareness of existing threats and a different approach taken by medical professionals, resulting from a wider knowledge and accessibility of PPE to prevent contamination and respiratory protection equipment.
Emergency medical services define the term hazardous materials as each and every CBRN substance which is potentially life-threatening and hazardous to health, irrespective of whether a single or mass casualties may be involved, or general public health may be at stake. Thus, emergency medical services face the challenge of improving responses to the above events regardless of the type, size and number of casualties.
The medical staff may be exposed to hazardous materials in two types of events: accidental and intentional. The accidental event is caused by an accident, breakdown, fire or disaster -the so called HAZMAT (hazardous materials) [12]. The chemicals, especially toxic industrial chemicals, released to the environment are highly dangerous and lead to mass casualty incidents [3]. Another burning issue is the outbreaks of infectious diseases (epidemics) and the radiation threat. The Chernobyl nuclear power plant disaster in 1986 [13], the accident at the Three Mile Island nuclear power station in 1979 [14] or the dramatic consequences micznych, radiacyjnych i nuklearnych, które mogą być użyte jako broń masowego rażenia lub zostać uwolnione w wyniku awarii technicznych (co jest najbardziej aktualnym zagrożeniem w warunkach polskich of tsunami on the Fukushima nuclear power plant in 2011 [15] are but a few examples of such incidents. The second type of incidents involves medical staff's exposure to hazardous materials released intentionally. The release is done for military (via combat operations), criminal or terrorist purposes. The emergency medical services use the CBRN acronym (C -chemical, B -biology, R -radiological, N -Nuclear) [16] and since such incidents usually involve the use of explosives, the CBRNE acronym is used (E -explosive) [3], [17].
The division into those groups in terms of rescue tactics and operational organisation is reasonable. No natural sequence of events, intercurrent tactical threats (firearms), a control factor (an assassin), secondary risks (secondary explosives), or the extensity and often multidimensionality of events -all these require different priorities of actions. In CBRNE incidents, the delegated police units (anti-terrorism units) are in most cases the leading service responsible for the organisation and operations.
It is crucial to eliminate "the control factor" first. Once it has been eliminated and a pyrotechnic risk of the scene and participants have been assessed, the event should proceed almost naturally, becoming manageable for the emergency medical services.
From that moment, the course of rescue actions in both CBRNE and HAZMAT incidents will be similar. There is no dramatic difference between those two types of incidents from the medical perspective as the medical treatment provided in both cases is comparable. Hence, it is vital to develop medical strategies and equip the medical staff adequately to allow them to respond effectively.
The ability to operate and cooperate with other services in CBRNE/HAZMAT indents becomes a paramount skill of emergency medical services facing existing and impending threats.
The emergency medical services operating worldwide have already changed their approach towards patient care and responses to critical hazards in every zone and at every stage of rescue operations [20][21].

Research Material and Method
The possible ways to improve the effectiveness of rescue operations in CBRNE/HAZMAT incidents were investigated. The

Research Outcomes
The new tactic is a combination of theoretical and practical skills used to manage accessible resources in order to ac-  From the patient's perspective, it is crucial to eliminate exposure to the hazardous factor, to perform triage and to immediately start life-support activities if needed. In the event of HAZMAT contamination, a prompt evacuation from the danger zone, triage and early decontamination are essential.

Organisation of Rescue Operations
Three safety zones have been defined for the purposes of the In medical sciences the hot zone is defined as an area within which a casualty (or casualties) is exposed to a hazardous substance. Entering this zone requires certain safety conditions to be met, i.e., applying protection equipment to prevent contamination as well as respiratory protection equipment (see Figure 1).

Medical operations in chemical and radiation incidents per-
formed in the hot zone are limited to life-support activities, e.g., haemorrhage control, airway management and securing the patient to allow safe transfer. Biological incidents require a different approach, and more advanced medical and rescue procedures where a specific biological (epidemic) threat has been identified.
Biological incidents require a detailed analysis and a separate research paper.
The warm zone is an area in which a hazardous substance does not occur originally. This is, therefore, where the casualties are primarily directed. In the course of an evacuation process, a hazardous substance may be transferred into the evacuation path and an area which the casualties are transferred to. Thus, this zone requires additional PPE to be used by the paramedics involved. In the warm zone, preliminary triage, cardiopulmonary  . This is how the right sequence and the scope of medical care to be provided, as well as the sequence and methods of decontamination are determined (see Figure 4).
The decontamination task force equipped with personal protection equipment supports firefighter-paramedics during the decontamination process and provides medical care. Some of the severely injured patients due to, e.g., blast injuries or poisoning require immediate medical care including life support (e.g., ventilation) during the decontamination process. At such an early stage, medical professionals (paramedics, doctors and nurses of the PRM system) may use antidotes (e.g., atropine) if a hazardous agent has been identified and the application of antidotes is medically justified.
The task force responsible for "treatment" performs triage, defines the scope of medical support which is given and prepares patients for transportation.   The task force responsible for "transportation" or a person in charge of transportation, manages ambulances at the incident scene, supervises equipment of emergency medical teams, and supervises the sequence of transportation and safe patients' transport to transportation teams. Therefore, the "clean" and "dirty" transport from the incident scene to the "safety" task force, which ensures paramedics' safety and protection, is done.
"Dirty" transport is understood as the transport of a contaminated or infectious patient. Such transport requires special precautionary measures, use of PPE protection or isolation and transport chambers.
Task force or function body called "reserve" is responsible for the smooth functioning of the tactical reserve for medical rescue.
In the place where the forces and means of rescue of the KSRG system are grouped, there is a separate sector in which emergency medical services and resources are grouped and then transferred to place of the event. A research study by Melnikova et al. has indicated that early responders, including especially firefighters and police officers, are commonly injured in chemical incidents, which proves the necessity for setting up a "safety" task force to support all participants and respondents of the incident, group constantly monitors paramedics' physical and mental condition, and analyses their capabilities to perform assigned tasks considering the impact of PPE with the use of telemetry monitoring systems and to react accordingly in the case of emergency or physical/mental exhaustion that may disturb the completion of a given task.

CBRNE/HAZMAT Rescue Task Force
The

Personal Protective Equipment (PPE)
Medical professionals must be provided with appropriate equipment to carry out the above tactics/scheme of operations.  HAZMAT incidents (see Figure 5). For better breathing comfort, suits with an integrated hood and a visor compatible with a powered air respirator have come into common use (see Figure 6 and Figure 7). Increased air supply in the hood and slightly higher pressure inside the suit give more comfort of breathing to the user and, consequently, make the user feel safer. On a daily basis, the emergency medical responders use basic protective clothing, helmets, protective gloves, gloves and half-face masks of the P3 class which do not offer enough protection against hazardous materials, mainly bio-based ones (see Figure 8). Appropriate personal protective equipment combined with new strategies, the management system and the organisational structure would facilitate meeting the objectives.

Discussion
Existing and impending challenges that the emergency medical services need to face due to the presence of a hazardous agent or its influence on the patient who has been contagious, contaminated, infected, poisoned or radiated require a different    a practical solution for CBRNEmed groups to be used in pre-hospital conditions. They provide a better head protection as ballistic helmets, along with bulletproof vests and other safety solutions, increase the overall safety of paramedics.
In HAZMAT incidents, emergency medical services should be equipped with protective clothing that display insulating capacities, unlike the filtrating protective equipment used for military or counter-terrorist purposes. Further technological developments will give rise to a new type of gas-tight suits designed for medical and medical rescue purposes that meet the specific needs of medical professionals. The United States Department of Homeland Security has released a set of predictions considering the impacts of technologies on EMS responders, to be implemented by 2030 [27]. In the future, the EMT's gear will give ballistic and puncture protection, and will be equipped with a high visible mode to be used in the dark. Sensors will monitor EMTs' health status and their location in the field. By using exosuits (powered suits), future EMTs will be able to lift and move patients easily. The above solutions will have to be applied in gas-tight suits as well.

Conclusions
Advances in personal protective equipment to prevent contamination and respiratory protective equipment adapted for medical emergencies have encouraged changes in the tactics of the State Emergency Medical System (PRM) as they let emergency teams to operate in previously inaccessible areas. Simple, safe and tested solutions allow medical professionals to cooperate safely with counter-terrorism units and the Fire Services.
Emergency teams will be able to provide care at early stages of CBRNE/HAZMAT incidents, which may save many lives.