EMERGENCY book CH 40.docx

14. Discuss the specific reference materials that EMTs use to recognize a hazmat incident.(pp 1510-1513) 15. Explain the role of EMTs during a hazmat incident both before and after the hazmat team arrives; include the precautions required to ensure the safety of civilians and responders.(pp 1514-1515) 16. Describe how the three control zones are established at a hazmat incident, the characteristics of each zone,and the responders who work within each one.(pp 1514-1515) 17. Describe the four levels of personal protective equipment (PPE) required at a hazmat incident to protect responders from injury by or contamination from a particular substance.(pp 1516-1517) Introduction Some of the most challenging situations you will encounter are disasters and mass-casualty inci-dents. In this text, a disaster refers to any situation that overwhelms your resources. A single incident with two critical patients can constitute a disaster if there is only one EMS unit available to respond.A mass-casualty incident (MCI) refers to any call that involves three or more patients, any situation that places such a great demand on available equipment or personnel that the system would require a mutual aid response (an agreement between neighboring EMS systems to respond when local resources are insufficient to handle the response), or any inci-dent that has the potential to create one of the pre-viously mentioned situations. Bus or train crashes and earthquakes are obvious examples of MCIs.These incidents can be overwhelming because you will encounter a large number of patients and not enough resources. When you respond to an event with a large number of patients, you must use a systematic ap-proach to manage the incident efficiently. By learn-ing to use the principles of the incident command system (ICS), you will be able to do the greatest good for the greatest number of people. As an EMT,you will typically be assigned to work within the EMS/medical branch under an ICS, but you may be asked 18. Explain patient care at a hazmat incident;include the special requirements that are necessary for those patients who require immediate treatment and transport prior to full decontamination. (pp 1517-1519) SKILLS OBJECTIVES 1. Demonstrate how to perform triage based on a fictional scenario that involves a mass-casualty incident.(pp 1497-1501) 2. Using a reference,correctly identify Department of Transportation (DOT) labels, placards, and markings that are used to designate hazardous materials.(pp 1508-1509) 3. Demonstrate the ability to use a variety of reference materials to identify a hazardous material.(pp 1510-1514) to function in other areas, which will be discussed later in this chapter. The National Incident Man-agement System (NIMS) was developed to promote more efficient coordination between emergency re-sponders at the regional, state, and national levels.To reduce on-scene problems and to increase your efficiency, you need a solid understanding of the basics of the NIMS. Training courses may also be accessed through the Federal Emergency Manage-ment System (FEMA) website. National Incident Management System The Department of Homeland Security imple-mented the National Incident Management System (NIMS) in 2004. Most incidents are handled at the local level, but major incidents require the involve-ment of multiple jurisdictions, agencies, and emer-gency response disciplines. The NIMS provides a comprehensive framework to enable federal,state,and local governments, as well as private-sector and nongovernmental organizations, to work to-gether effectively. The NIMS is used to prepare for,prevent, respond to, mitigate, and recover from do-mestic incidents, regardless of cause, size, or com-plexity, including acts of catastrophic terrorism and hazardous materials (hazmat) incidents. Two important underlying principles of the NIMS are flexibility and standardization. The orga-nizational structure must be flexible enough to be rapidly adapted for use in any situation. The NIMS provides standardization in terminology, resource classification, personnel training, certification, and more.This standardization allows for unity of effort,which is a third guiding principle of NIMS. Unity of effort allows various agencies to achieve common objectives by supporting each other while main-taining individual authorities. In other words, mul-tiple agencies can work together toward the same goal,while maintaining their autonomy. The unity of effort is possible due, in part, to the NIMS con-cept of interoperability, which refers to the ability of agencies of different types or from different ju-risdictions to communicate with each other. In-teroperability can be accomplished by maintaining a shared frequency or by having radio systems pro-grammed to other agencies' frequencies. The ICS is one component of the NIMS.The three major NIMS components are as follows: 1. Communications and information manage-ment. Effective communications, information management, and information sharing are critical aspects of domestic incident man-agement.The NIMS communications and in-formation management systems enable the essential functions needed to assess available information, provide interoperability, and en-sure appropriate communication of decisions. 2. Resource management. The NIMS sets up mechanisms to describe, inventory, track, and dispatch resources before, during, and after an incident.The NIMS also defines standard pro-cedures to recover equipment used during the incident. 3. Command and coordination. The NIMS stan-dardizes incident management for all hazards and across all evels of government. It pro-vides comprehensive frameworks and recom-mended organizational structures. The NIMS standard incident command structures are based on three key constructs: ICS, multia-gency coordination systems, and public infor-mation systems. Incident Command System It is important for you to be familiar with the ter-minology and concepts of the incident command system (ICS). (Some agencies refer to the incident command system as the incident management sys-tem.)The purpose of the ICS is to ensure responder and public safety, achieve incident management goals, and ensure the efficient use of resources. As you know, communication is the building block of good patient care. Common terminology and the use of clear text communications (plain En-glish as opposed to 10-codes) help responders from multiple agencies work efficiently together. Using the ICS gives you a modular organiza-tional structure that can be applied to all hazards.The ICS can be activated for incidents ranging from a single vehicle crash with one patient to a natural gas pipeline explosion involving multiple commu-nities and numerous injuries. The goal of the ICS is to make the best use of your resources to manage the environment around the incident and to treat patients during an emergency. The ICS is designed to avoid duplication of effort and freelancing,in which individual units or different organizations make independent and often inefficient decisions about the next appropriate action. Follow your lo-cal standard operating procedures for establishing the ICS. One of the organizing principles of the ICS is to limit the span of control of any one individual. This principle refers to keeping the supervisor/worker ratio at one supervisor for five subordinates. A su-pervisor who has more than five people reporting to him or her is exceeding an effective span of control and needs to divide tasks and delegate the super-vision of some tasks to another person. The NIMS does acknowledge that this is a guideline. Incident personnel may evaluate the actual incident and use their best judgment to determine the appropriate span of control. The organizational levels may include sections,branches, divisions, and groups FIGURE 40-1: · Sections are responsible for a major functional area such as finance/administration,logistics,planning, or operations. Branches are managed by the branch direc-tor and may be functional or geographic in nature. These tend to be established when span of control is a problem-for example, at larger incidents, where more oversight may be needed. Branches are in charge of activity directly related to the section (ie,fire,law en-forcement,EMS,operations,etc.). Divisions and groups serve to align resources and/or crews under one supervisor. Divisions usually refer to crews working in the same geographic area. Groups usually refer to crews working in the same functional area, but pos-sibly in different locations. To better visuaize how divisions and groups work, think about an incident involving a mid-air collision between two commercial aircraft.With two scenes sep-arated by almost a mile, Division A, composed of a fire suppression group, a rescue group,and an EMS group, may be assigned to work the site where the first aircraft came down. Generally,the larger the incident, the more di-visions there will be. A small incident may require FIGURE 40-1 The ICS organizational structure may include sections, branches, divisions, and groups. ©Jones &Bartlett Learning. only an incident commander and support from fire,EMS, and law enforcement. An incident on a much larger scale, such as the Boston Marathon bombing in 2013, will require massive efforts and many agen-cies working together. In some regions, emergency operations centers may exist. The centers are usually operated by the city, state, or federal government. These centers will usually be activated only in a catastrophic event that may go on for days, or a pandemic that may be problematic for weeks or months. Such events can involve hundreds of patients and tax the entire sys-tem.Most emergency operating centers were acti-vated during the COVID-19 pandemic to coordinate resources between government resources and pre-hospital care, healthcare, and public health. The responders who will participate in an MCI or a disaster should use the ICS. When an incident oc-curs,find out from your service who is in charge,how it is activated, and what your expected role will be. ICS Roles and Responsibilities There are many roles defined in the ICS. The general staff includes command, finance/administration,logistics, operations, and planning. It is important for you to understand the specific duties of each and how they work to coordinate the response.Command staff include the public information offi-cer (PIO), safety officer, and liaison officer. Command The incident commander (IC) is the person in charge of the overall incident.The IC will assess the incident, establish the strategic objectives and pri-orities, and develop a plan to manage the incident (FIGURE 40-2). The number of command duties the IC takes on often varies by the size of the incident.Small incidents often mean the IC will assume re-sponsibility for all command duties. In an incident of medium size or complexity, the IC may delegate some functions but retain others. For example,at a motor vehicle crash site with multiple patients,the IC may designate a safety officer or assign a PIO but maintain responsibility for the other command functions. In a complex situation, the IC may ap-point team members to all command roles. Large MCIs, such as a hazmat incident,require a multiagency or multijurisdictional response and need to use a unified command system.In this case,plans are drawn up in advance by all agencies that FIGURE 40-2 The person in command at a mass-casualty incident oversees the incident and develops a plan for the response. ©David Crigger/Bristol Herald Courier/AP Images. assume a shared responsibility for decision making.The response plan should designate the lead and support agencies in several types of MCIs.(For ex-ample,the hazmat team will take the lead in a chem-ical leak, whereas the medical team will take the lead in a multivehicle crash.) Agencies that share a border should train often with each other to ensure that a unified command system will function well and that communication among the responders is well established before a real incident occurs. A single command system is one in which one person is in charge, even if mltiple agencies re-spond. It is generally used with incidents in which one agency has the most responsibility for incident management. Ideally, it is used for short-duration,limited incidents that require the services of a single agency. Your IC should be on or near the scene,where he or she can easily communicate with all emergency responders. It is important that you know who the IC is, how to communicate with the IC,and where the command post is located. If the incident is very large,you will report to a supervisor working under the IC.This will help to maintain a manageable span of control. To make the IC easily identifiable,some type of garment is worn, such as a brightly colored vest labeled with the word COMMAND. The com-mand post may be set up at a vehicle, and it may be identified by a placard or unique color strobe (green is commonly used to identify a command post).Make sure your supervisor or the IC knows of any plans or operations before they are initiated. Communication is particularly important if a transfer of command takes place. Because an incident can rapidly change in size and complex-ity, an IC may turn over command to someone with more experience in a critical area. This change,or transfer of command, must take place in an orderly manner and, if possible, face-to-face.In extreme sit-uations, it could be done by phone, radio, or email,although these methods are not recommended. It is imperative that the transfer of command be com-municated to those involved in the incident, es-pecially the command staff and general staff.Your agency should have standard operating procedures that govern the transfer of command. Make cer-tain to follow the standard operating procedures.When an incident draws to a close, there should be a termination of command. Your agency should im-plement demobilization procedures as the situation deescalates or comes to an end. Finance/Administration The finance/administration section chief is respon-sible for documenting all expenditures at an inci-dent for reimbursement. Finance personnel are not usually needed at smaller incidents, but at larger incidents it is necessary to keep track of personnel hours and expenditures for materials and supplies.Ultimately, that information is reported at meetings of the general staff. Responding agencies and organ-izations may be eligible for reimbursement after the incident, and an efficient finance/administration section chief will help your agency to succeed in the reimbursement process. Finance personnel should be trained in the process of assessing expenditures long before an actual incident. The various functions within the finance/administration section include (1) the time unit,(2) the procurement unit,(3) the compensation and claims unit, and (4) the cost unit. The time unit is responsible for ensuring the daily recording of per-sonnel time and equipment use. The procurement unit deals with all matters concerning vendor con-tracts. The compensation and claims unit has two major purposes: dealing with claims as a result of the incident, and injury compensation. Finally, the cost unit is responsible for collecting, analyzing,and reporting the costs related to an incident. Logistics The logistics section is responsible for communi-cations equipment,facilities,food and water, fuel,lighting, and medical equipment and supplies for patients and emergency responders.Local standard operating procedures will list the medical equip-ment needed for the incident, depending on the type of incident. Logistics personnel are trained to find food, shelter, fuel, and health care for you and the other responders at the scene of an MCI. In a large incident, it is often necessary for many people to handle logistics, but only the section chief will re-port to the IC. Operations At a large or complexincident, the IC should appoint an operations section chief,who is responsible for managing the tactical operations usually handled by the IC on routine EMS calls. This frees the IC to coordinate with other agencies and the media, en-gage in strategic planning, and ensure that logistics are functioning effectively.The operations section chief will supervise the people working at the scene of the incident, who will be assigned to branches,divisions, and groups. Operations personnel often have experience in management within EMS. Planning The planning section solves problems as they arise during the incident. Planners obtain data about the problem, analyze the previous incident plan, and predict what or who is needed to make the new plan work.They need to work closely with the oper-ations, finance/administration, and, especially,logistics sections. Planners can and should call on technical experts to help with the planning process.They should document their decisions and what they learned from the incident and set out a course for demobilizing the response when necessary. Another function of the planning section is the development of an incident action plan, which is the central tool for planning during a response to a disaster emergency. The incident action plan is pre-pared by the planning section chief with input from the appropriate sections and units of the incident command team. The purpose of an incident action plan is to provide clear, concise information about incident activities, including objectives, tactics, and assignments. It should be written at the outset of the response and revised continually throughout the response. In an initial response for an incident that is readily controlled, a written plan may not be necessary. Larger, more complex incidents will require an incident action plan to coordinate ac-tivities. The level of detail required in an incident action plan will vary according to the size and com-plexity of the response. Command Staff Three important positions that help the general staff (described previously) and the IC are the safety officer, the PIO, and the liaison officer.The safety officer monitors the scene for conditions or oper-ations that may present a hazard to responders and patients. The safety officer may need to work with environmental health and hazmat specialists. The importance of the safety officer cannot be under-estimated-he or she has the authority to stop an emergency operation whenever a rescuer is in dan-ger. A safety officer should remove hazards to EMS personnel and patients before the hazards cause injury. The public information officer (PIO) provides the public and media with clear and understand-able information. A wise PIO positions his or her headquarters well away from the incident com-mand post and, most important, away from the incident, to minimize distractions. Also, the PIO must keep the media safe and from becoming part of the incident. The designated PIO may cooperate with PIOs from other agencies in a joint information center (JIC). In some circumstances,the PIO/JIC may be responsible for distributing a message de-signed to help a situation, prevent panic, and pro-vide evacuation directions. The liaison officer relays information and con-cerns among command, the general staff, and other agencies. If an agency is not represented in the command structure, questions and input should be given through the liaison officer. Communications and Information Management Communications has historically been the weak point at most major incidents. To minimize the effects of communications problems, it is recom-mended that communications be integrated. This means that all agencies involved should be able to communicate quickly and effortlessly via radios.Communications allow for accountability through-out the incident, as well as instant communication between recipients. As always, and more so during a large incident, you must maintain professional-ism on all radio communications, and remember to communicate clearly and concisely using plain language (not 10-codes or language specific to just your system). Mobilization and Deployment When an incident has been declared and the need for additional resources has been identified, a re-quest is made for additional resources. Once a re-quest is made, these resources are mobilized and deployed to the scene. It is important to wait until the request is made before you depart for the scene,to minimize the potential for freelancing. Check-in at the Incident On arrival at an incident, first check in with the IC at the base, staging area, or other location designated by the IC. If the incident is large in size or complex-ity, you will be assigned to a supervisor working under the IC. Check-in also allows for personnel tracking throughout the incident, and ensures that costs, wages, and reimbursement can be calculated accurately. Should a building collapse or secondary incident occur, it is vita for the IC to have an ac-curate report of what resources and personnel were on scene prior to that secondary event. Initial Incident Briefing After the check-in process is complete, report to your supervisor for an initial briefing that will al-low you to obtain information regarding the in-cident, as well as your specific job functions and responsibilities. Incident Record Keeping Record keeping is important for financial reasons and for documentation purposes. If a large piece of equipment becomes inoperable, it may be pos-sible for the agency to be reimbursed for replace-ment costs. Record keeping also allows for tracking of time spent on the incident for reimbursement purposes. Accountability Because of the large number of responders at a large incident, accountability is important. Accountability means keeping your supervisor advised of your location, actions, and completed tasks. It also in-cludes advising your supervisor of the tasks that you have been unable to complete and what tools you need to complete them. Incident Demobilization Once the incident has been stabilized and all of the hazards mitigated, the IC will determine which resources are needed or not needed and when to begin demobilization. This process allows for a prompt return of resources to their parent organi-zations to be placed back in service. EMS Response Within the ICS Preparedness Preparedness involves the decisions made and basic planning done before an incident occurs.Every state is at risk for natural disasters, such as hurricanes,tornadoes,earthquakes,and wildfires.Therefore,preparedness in a given area involves an-ticipating the most likely natural disasters for that specific area, among other disasters. Your EMS agency should have written disaster plans that you are regularly trained to carry out. A copy of the disaster plan should be kept in each EMS vehicle. EMS facilities should have disaster supplies for at least a 72-hour period of self-sufficiency. Your EMS service should have mutual aid agreements with surrounding organizations; these will facilitate requests for help in an emergency. All groups with mutual aid agreements should practice using the plans frequently. Organizationsshould share a list of resources with each other so they will know early on what they can access. Also, your local EMS orga-nizations should develop an assistance program for the families of EMS responders. If EMS responders have concerns about their families during a disaster,their effectiveness on the job could be diminished. Scene Size-up Remember that scene size-up starts with dispatch.If dispatch information indicates a possible unsafe scene, stay away from the scene or get only close enough to make an assessment without putting your-self in harm's way. When you arrive first on the scene ofan incident, you will make an initial assessment and some preliminary decisions. The size-up will be driven by three basic questions that you must ask yourself: ·What do I have? ·What resources do I need? ·What do I need to do? These questions have a symbiotic relationship.The answer from one helps to answer the others,and each answer represents a piece to the puzzle.Work as a team when you answer these questions because overlooking just one safety issue early on can start a chain reaction of problems. What Do I Have? Start with scene safety. First, assess the scene for hazards.Warn all other responders about hazard-ous materials, fuel spills, electrical hazards, or other safety concerns as soon as possible. Confirm the in-cident location. Establish whether the incident is open or closed.An open incident is one that is not yet contained; there may be patients who are yet to be located and the situation may be ongoing, producing even more pa-tients. A closed incident is one that is contained and in which all casualties are accounted for. However,as with any situation, a closed incident may quickly be-come an open incident as situations change. FIGURE 40-3 This mobile emergency room is staffed by EMTs, paramedics, and physicians who are able to provide advanced life support to multiple patients simultaneously on the scene of a mass-casualty incident. ©Jones & Bartlett earning.Courtesy of MIEMSS. Estimate the number of casualties. Immedi-ately provide a brief incident report to dispatch.An example of such a report would be: “EMT unit number one arriving on scene, multiple vehicles involved, full road blockage, no apparent hazards at this time, EMT unit number one is assuming command.” What Do I Need? Decide what resources are needed. You may need more EMS responders, ambulances, or other forms of transportation. If extrication is required, a rescue unit and fire department response may be needed.If there are hazardous materials, request a hazmat team immediately (discussed later in the chapter).Many large EMS systems deploy specialized MCI units or mobile emergency room vehicles that have the capacity to treat dozens of patients at the scene (FIGURE 40-3). What Do I Need to Do? Keep the following priorities in mind: ·Safety · Incident stabilization · Preservation of property and the environment You need to consider these priorities in the order they are given. Safety is paramount. Safety includes your life, your partner's life, and other re-sponders' lives. Then, consider the safety ofthe pa-tients and any bystanders. Thi will be difficult for anyone dedicated to saving lives, but it is important to put yourself and your partner first-you have the skills, and bystanders usually do not; the situation can worsen if you become a victim yourself. Often,if a responder is injured, other responders will focus on “their own,” removing critical resources from the incident. Initially, you may have to work to isolate or stabilize the incident before providing care to in-jured people-this is another difficult concept for all emergency workers. Remember, you cannot help the injured if the scene is unstable. An unsta-ble scene can lead to an injured EMT or additional bystanders becoming injured, thereby making your job much more difficult. Establishing Command Once you have performed a good scene size-up and answered the three basic questions, command should be established by the most senior official,notification to other responders should go out, and necessary resources should be requested. Recall that a command system ensures that resources are effectively and efficiently coordinated.Command must be established early, preferably by the first-ar-riving, most experienced public safety official from the most relevant service. These officials may in-clude police, fire, or EMS personnel. Communications As discussed earlier, communication is often the key problem at an MCI or a disaster. The infrastructure may be damaged, or communications capabilities may be overwhelmed. If possible, use face-to-face communications to limit radio traffic, Some organ-izations responding to a disaster might not know how to use a radio. As mentioned previously, if you communicate via radio, do not use 10-codes or language specific to your EMS system. Doing so could be confusing for ancillary services and other personnel who are responding. Most communica-tions problems should be worked out before a di-saster happens by designating channels strictly for command during a disaster.Whatever form of com-munications equipment is used, it must be reliable,durable, and field-tested. Be sure there are backups in place if the primary communications system does not work. Some regions have mobile self-con-tained communications centers,whereas others use local radio groups such as ham radio operators to assist with communications. Most important,your plan should include a “plan B” in case of com-munications failure. The Medical Branch of Incident Command What has traditionally been referred to as medical incident command is more commonly known as the medical (or EMS) branch of the ICS (FIGURE 40-4).At incidents that have a significant medical factor,the IC will designate someone as the chief of the medical branch under the operations section.This person will supervise the primary roles of the med-ical branch-triage, treatment, and transport of in-jured people. The medical branch director helps to ensure that EMS units responding to the scene are working within the ICS, each medical division or group receives a clear assignment before beginning work at the scene, and personnel remain with their vehicle in the staging area until they are assigned their duties. Triage Supervisor The triage supervisor is ultimately in charge of counting and prioritizing patients. During large incidents, a number of triage personnel may be needed.The primary duty of the triage division or group is to ensure that every patient receives initial assessment of his or her condition. One of the most difficult parts of working as triage personnel is that you must not begin treatment until all patients are triaged, or you will compromise your triage efforts. Treatment Supervisor The treatment supervisor will locate and set up the treatment area with a tier for each priority of patient. FIGURE 40-4 Components of the medical branch within the incident command system. Jones& Bartlett Leaming. The treatment supervisor ensures that secondary triage of patients is completed and that adequate patient care is provided as resources allow.The treat-ment supervisor also assists with moving patients to the transportation area. As the treatment super-visor supervises the responders, he or she must communicate with the medical branch director to request sufficient quantities of supplies, including bandages, burn supplies, airway and respiratory supplies, and patient packaging equipment. Transportation Supervisor The transportation supervisor coordinates the trans-portation and distribution of patients to appropriate receiving hospitals and helps to ensure that hospi-tals do not become overwhelmed by a patient surge.The transportation supervisor coordinates with the IC to ensure that enough personnel and ambulances are in the staging area or have been requested. Some regions may plan for a designated hospital to coor-dinate with area hospitals on destination decisions.An MCI typically disrupts the everyday functioning of the region's trauma system, so good coordination is needed. The transportation supervisor documents and tracks the number of transport vehicles,pa-tients transported, and the facility destination of each vehicle and patient. Staging Supervisor A staging supervisor is assigned when an MCI or disaster requires a multivehicle or multiagency re-sponse. Emergency vehicles receive direction from the staging supervisor to enter an MCI scene and should drive only in the directed area. The staging area should be established away from the scene so that the parked vehicles are not in the way.If a staging area is located too close to a chaotic scene,patients or fellow responders may see the number of ambulances waiting and bring patients directly to the staging area as opposed to the triage area.The staging supervisor locates an area to stage equipment and responders, tracks unit arrivals,and releases vehicles and supplies when ordered by command. This position plans for efficient access to and exit from the scene and prevents traffic con-gestion among responding vehicles. Physicians on Scene In an MCI or disaster, some areas have plans in place for physicians to respond to the scene.Sometimes this includes the EMS medical director or another physician who regularly works, trains, and interacts with your agency. Sometimes, even without a plan,the enormity of the situation may require physi-cians on scene. EMS physicians, especially,will have the training to make difficult triage decisions.They also provide secondary triage decisions in the treatment area, deciding which priority patients are to be transported first. Physicians can provide on-scene medical direction for EMTs, and they can provide care as appropriate. Like other fire and EMS providers, there is the possibility that physi-cians who are nearby may self-dispatch to respond to the scene to help. If you encounter a physician,you should ensure that he or she is assigned to the incident. This precaution will verify the physician's credentials and will ensure this new resource is fac-tored into the ICS. As mentioned previously, the IC must be able to account for all people on scene should a secondary event occur. Rehabilitation Supervisor In disasters or MCIs that will last for extended periods,a rehabilitation section for the responders should be established. The rehabilitation supervisor establishes an area that provides protection for responders from the elements and the situation. The rehabilitation area should be located away from exhaust fumes and crowds (especially members of the media) and out of view of the scene itself. Rehabilitation is where a responder's needs for rest, fluids, food, and protec-tion from the elements are met. The rehabilitation supervisor must also monitor responders for signs of stress.These signs may include fatigue, altered think-ing patterns, and complete collapse.Remember that all EMS personnel must be aware of signs of stress.Your service might consider having a defusing or debriefing team in this area. Responders should be encouraged to take advantage of these services but should never be forced to participate. Extrication and Special Rescue Some MCIs or disasters require search and rescue or extrication of patients (FIGURE 40-5), A unit leader may need to be appointed, such as an extrication FIGURE 40-5 Some disasters will involve search and rescue or extrication. New York City firemen,police,and rescue crews work to clear rubble and extract workers trapped after the brick facade of a 20-story building collapsed on Wednesday, October 24, 2001.Four were killed and six more were missing. ©Edward Keating/POOL/AP Photos. supervisor or rescue supervisor. These officers determine the type of equipment and resources needed for the situation. In some incidents, victims may need to be extricated or rescued by specifically trained personnel before they can be triaged and treated. Extrication and rescue can be dangerous,so team member safety is of utmost importance. Morgue Supervisor In some MCIs or disasters, there will be many dead patients. The morgue supervisor will work with area medical examiners, coroners, disaster mortuary as-sistance teams, and law enforcement agencies to coordinate removal of the bodies and even, possibly,body parts.The morgue supervisor should attempt to leave the dead victims in the location found, if possible, until a removal and storage plan can be determined. The location of victims may help in the identification of the dead victims in mass-fa-tality situations, or there may be crime scene con-siderations. If it is determined that a morgue area is needed, the morgue supervisor should ensure that the morgue is out of view of the living patients and other responders because te psychological impact could worsen the situation. In addition, the morgue should be secured from the public to prevent theft of any personal effects of the dead victims. Mass-Casualty Incidents As discussed earlier, an MCI is an emergency situa-tion that involves three or more patients, places great demand on the EMS system, and/or has the poten-tial to produce multiple casualties (FIGURE 40-6).However, other causes of MCIs are far more com-mon than disasters and are usually much smaller in scope.FIGURE 40-7 is a diagrammed example of a residential building fire confined to one apartment that may only produce one patient but that has the potential to generate dozens of patients from among the responders and residents. Loss of power FIGURE 40-6 Mass-casualty incidents can be large,such as the attack on September 11,2001, or they can be much smaller in scope. Courtesy of Michael Rieger/FEMA. to a hospital or nursing home with ventilator-de-pendent and nonambulatory victims is considered an MCI, although no one is injured. By using the ICS and the NIMS and understanding the various roles and responsibilities of each position, the respond-ers and/or IC can manage the incident in a smooth,organized manner. All systems have different protocols for when to declare an MCI and initiate the ICS; however,as an EMT, ask yourself the following questions when considering whether the call is an MCI: How many seriously injured or ill patients can I care for effectively and transport in the ambu-lance?One?Two? What happens when I have three patients to manage? How long will it take for additional help to arrive? What happens if the number of patients ex-ceeds the number of available ambulances? FIGURE 40-7 Diagram of a mass-casualty incident.The incident command system established at the scene of a building fire may look similar to this diagram. ©Jones & Bartlett Learning. FIGURE 40-8 Mass-casualty incidents require additional ambulances and EMS providers from the immediate region. ©NurPhoto/Getty Images. Obviously, you and your team cannot treat and transport all injured patients at the same time. At an MCI, you will often experience an increased de-mand for equipment and personnel.For example,you may realize that you are the only ambulance crew currently at the scene and there is a wait of 15or more minutes before the next ambulance arrives.Never leave the scene with patients if there are still other patients present who are sick or wounded.This would leave patients at the scene without medical care and can be considered abandonment.If there are multiple patients and not enough re-sources to handle them without abandoning vic-tims, you should declare an MCI (at least for the present time), request additional resources, and initiate the ICS and triage procedures (discussed next) (FIGURE 40-8).Although this may cause some delay in initiating treatment to all patients, it will not adversely affect the patient care. Always follow your local protocol. Many large EMS systems de-ploy specialized MCI units or mobile emergency room vehicles that have the capacity to treat dozens of patients on the scene. Triage Triage simply means to sort your patients based on the severity of their injuries (FICURE 40-9).The goal of doing the greatest good for the greatest number means the triage assessment is brief, and you will group the patients into basic categories based on their acuity. Primary triage is the initial triage done in the field, allowing you to quickly and accurately FIGURE 40-9 Triage is the process of sorting and prioritizing patients based on severity of conditions.Medical personnel and volunteers work the first medical triage area set up outside the Pentagon after a hijacked commercial airliner crashed into the southwest corner of the building on September 11, 2001. Courtesy of Journalist 1st Class Mark D. Faram/US Navy. categorize the patient's condition and transport needs, whereas secondary triage is done as patients are brought to the treatment area. During primary triage, patients are briefly assessed and then identi-fied in some way, such as by attaching a triage tag or colored triage tape. The main information needed on the tag is a unique number and a triage cate-gory.Rapid and accurate triage will help bring order to the chaos of the MCI scene and allow the most critical patients to be transported first. After the primary triage, the triage supervisor should com-municate the following information to the medical branch director: ·Total number of patients Number of patients in each of the triage categories Recommendations for extrication and move-ment of patients to the treatment area Resources needed to complete triageand be-gin movement of patients When the initial triage has been completed, sec-ondary triage, or retriage, can occur, allowing you to reassess all remaining patients and, if necessary,to upgrade their triage category. In smaller MCI events, this step may not be necessary if enough re-sources have arrived on the scene. Triage Categories There are four common triage categories. You can remember them using the mnemonic IDME,which stands for Immediate (red), Delayed (yellow), Mi-nor or Minimal (green; hold), and Expectant (black;likely to die or dead) (TABLE 40-1). This is the order of priority for treatment and transport of the pa-tients at an MCI. Immediate (red-tag) patients are your first pri-ority. They need immediate care and transport.They usually have problems with the ABCs,head trauma, or signs and symptoms of shock. Delayed (yellow-tag) patients are the second priority and need treatment and transport, but it can be delayed. Patients usually have multiple inju-ries to bones or joints, including back injuries with or without spinal cord injury. Minimal (green-tag) patients are the third prior-ity. Patients may require no field treatment or only minimal treatment. In some parts of the world, this is the hold category. These patients are the “walking wounded" at the scene. If they have any apparent injuries, they are usually soft-tissue injuries such as contusions, abrasions, and lacerations. The last priority is the expectant (black tag) pa-tients who are dead or whose injuries are so severe that they have, at best, a minimal chance of sur-vival. This category may include patients who are in cardiac arrest or who have an open head injury,for example. If you have limited resources, this cat-egory may also include patients in respiratory ar-rest. Patients in this category receive treatment and transport only after patients in the other three cat-egories have received care. An interesting development is the possible ad-dition of a new, fifth triage category-the orange-tag category. This category represents an intermediate category between the critcal (red tag) and non-critical, nonambulatory (yellow tag) categories of patients. During a true MCI,there may be am-bulatory patients who require prompt evaluation and treatment for symptoms that are the result of medical comorbidities and not the acute traumatic injuries associated with the initial event. Consider patients who are having nontraumatic chest pain or shortness of breath following the event.In the Triage Category Typical Injuries Red tag: first priority (immediate)Patients who need immediate care and transport Treat these patients first,and transport as soon as possible ·Airway and breathing compromise ·Uncontrolled or severe bleeding ·Severe medical problems · Signs of shock (hypoperfusion) ·Severe burns ·Open chest or abdominal injuries Yellow tag: second priority (delayed)Patients whose treatment and transport can be temporarily delayed ·Burns without airway compromise ·Major or multiple bone or joint injuries ·Back injuries with or without spinal cord damage Green tag: third priority, minimal (walking wounded)Patients who require minimal or no treatment and transport can be delayed until last ·Minor fractures ·Minor soft-tissue injuries Black tag: fourth priority (expectant)Patients who are already dead or have little chance for survival Treat salvageable patients before treating these patients Obvious death Obviously nonsurvivable injury, such as major open brain trauma Respiratory arrest (if limited resources) Cardiac arrest past, these patients may have been undertriaged as stable, requiring little or no treatment, simply because they were ambulatory. A patient placed in this intermediate category could be more appropri-ately prioritized for treatment and transport if his or her condition required a specific destination that was not a trauma center (ie, cardiac catheterization center or hyperbaric chamber). The New York City Simple Triage and Rapid Treatment (FDNY-START)system now incorporates the orange tag category,and there may be ongoing developments as other systems adopt similar classifications. Triage Tags Whatever triagesystem is used, it is vital that a pa-tient has a tag or some type oflabel.Tagging patients early assists in tracking them and keeping an accu-rate record of their condition. Triage tags should be waterproof and easily read (FIGURE 40-10).The pa-tient tags or tape should be color-coded and should clearly show the category of the patients. The use of symbols and colors to indicate the triage cate-gories is important in case some responders are color-blind. The tags will become part of the patient's medical record. Most have a tear-off receipt with a number correlating with the number on the tag.When torn off by the transportation officer, it will assist him or her in tracking the patient. If the pa-tient is unconscious and cannot be identified at the scene, the tag will be an identifier for tracking purposes. Some areas use digital photography to assist in identifying patients later. The photograph FIGURE 40-10 Triage tags (from left to right). A. Waterproof triage tape. B. Triage tag: back. C. Triage tag:front. ©Jones & Bartlett Learning. is catalogued with the patient's tag number, and the patient's location is tracked with this information.When family members are brought to crisis centers to help locate loved ones, the pictures may be of as-sistance. This technique has been used effectively in Europe and Israel with Polaroid or digital photos.Another way of tracking and accounting for patients is to issue only 20 to 25 cards or tags at a time with a scorecard to mark how patients are triaged and their priority. When the responder returns for more tags, the scorecard will provide a patient count to help command and the staff to develop a plan to respond and ensure that appropriate resources are either available or summoned. Whatever labeling system is used, it is imperative for the transporta-tion officer to be able to identify which patient was transported by which unit and to which destina-tion, and the priority of the patient's condition. START Triage START triage is one of the easiest methods of triage.START stands for Simple Triage And Rapid Treat-ment. The staff members at Hoag Memorial Hos-pital, Newport Beach, CA, developed his method of triage. It is easily mastered with practice and will give you the ability to rapidly categorize patients at an MCI. START triage uses a limited assessment of the patient's ability to walk, respiratory status, he-modynamic status (pulse), and neurologic status. The first step of the START triage system is per-formed on arrival at the scene by calling out to pa-tients at the disaster site, “If you can hear my voice and are able to walk...” and then directing patients to an easily identifiable landmark. You should pick a landmark that is away from your ambulance.Bringing a large number of patients toward you and your ambulance will hinder your ability to properly triage all of the patients. You can send the ambulatory patients toward a landmark, such as a lamp pole or the corner of a street. This will help to manage the chaos of an MCI. The injured people in this group are the walking wounded and are con-sidered minimal (green) priority, or third-priority,patients. The second step in the START process is dir-ected toward nonwalking patients. Move to the first nonambulatory patient and assess the respiratory status. If the patient is not breathing, open the air-way by using a simple manual maneuver. A patient who still does not begin to breathe is triaged as expectant (black). If the patient begins to breathe,tag him or her as immediate (red), place in the re-covery position, and move on to the next patient (FIGURE 40-11). If the patient is breathing, make a quick es-timation of the respiratory rate. A patient who is breathing faster than 30 breaths/min or slower than 10 breaths/min is triaged as an immediate priority (red). If the patient is breathing from 10to 29 breaths/min, move to the next step of the assessment. The next step is to assess the hemodynamic status of the patient by checking for bilateral radial pulses. An absent radial pulse implies the patient is likely hypotensive; tag him or her as an immediate priority.If the radial pulse is present, go to the next assessment. B FIGURE 40-11 A. A START triage tag is ripped to the level of severity. B.A SMART triage tag folds to the level of severity. A:Nancy G Fire Photography, Nancy Greifenhagen/Alamy Stock Photo;B;Courtesy of Richard Pibery. The final assessment in START triage is to as-sess the patient's neurologic status, which simply means to assess the patient's ability to follow simple commands, such as “Show me three fingers."This assessment establishes that the patient can under-stand and follow commands. A patient who is un-conscious or cannot follow simple commands is an immediate priority patient. A patient who complies with a simple command should be triaged in the delayed category (yellow). Another triage method is the Sort,Assess, Lifesaving interventions, and Treatment and/or Transport (SALT) triage system. This triage system begins with a global sorting of patients. This step identifies the patients who are able to understand verbal instructions and are therefore likely to have good systemic perfusion. Patients who can walk are asked to move to a designated area and are assigned last priority. This is an attempt to decrease the number of patients leaving the scene and overwhelming local hospital resources before EMS can begin to move highest priority patients. Once those patients have been identified and moved,each remaining patient is assessed individually. The SALT method differs from others in its lifesaving intervention steps,which include bleeding control, opening the airway,and two rescue breaths for children. It also includes needle decompression for tension pneumothorax and auto-injector antidotes for ALS providers. These interventions may be all that is needed to upgrade the patient's condition on the SALT triage scale. The final step is treatment and/or transport. JumpSTART Triage for Pediatric Patients Lou Romig, MD, recognized that the START triage system does not take into account the physiologic and developmental differences of pediatric pa-tients. She developed the JumpSTART triage sys-tem for pediatric patients. JumpSTART is intended for use in children younger than 8 years or who appear to weigh less than 100 pounds (45 kg).As in START, the JumpSTART system begins by identi-fying the walking wounded. Infants or children not developed enough to walk or follow commands (including children with special needs) should be taken as soon as possible to the treatment area for immediate secondary triage. This action assists in getting children who cannot take care of their own basic needs to a health care provider. There are several differences within the respiratory status assessment compared with that in START. First, if you find that a pediatric patient is not breathing,immediately check the pulse. If there is no pulse,label the patient as expectant (black). If the pa-tient is not breathing but has a pulse, open the air-way with a manual maneuver. If the patient does not begin to breathe, give five rescue breaths and check respirations again. A child who does not begin to breathe should be labeled expectant. The primary reason for this difference is that the most common cause of cardiac arrest in children is res-piratory arrest. The next step of the JumpSTART process is to assess the approximate rate of respirations. A child who is breathing fewer than 15 breaths/min or more than 45 breaths/min is tagged as an immedi-ate priority (red), and you move on to the next pa-tient.If the respirations are within the range of 15 to 45 breaths/min, the patient is assessed further. The next assessment in JumpSTART triage is also the hemodynamic status of the patient. Just like in START, you are simply checking for a distal pulse. This does not need to be the brachial pulse;assess the pulse that you feel the most competent and comfortable checking. If there is an absence of a distal pulse, label the child as an immediate pri-ority and move to the next patient. If the child has a distal pulse, move on to the next assessment. The final assessment is for neurologic status.Because of the developmental differences in chil-dren,their responses will vary. For JumpSTART, a modified AVPU score is used. A child who is unre-sponsive or responds to pain by posturing or with incomprehensible sounds or is unable to localize pain is tagged as an immediate priority. A child who responds to pain by localizing it or withdrawing from it or is alert is considered a delayed-priority patient(yellow). Triage Special Considerations There are a few special situations in triage. Patients who are hysterical and disruptive to rescue efforts may need to be handled as an immediate priority and transported off the site, even if they are not ser-iously injured. Panic breeds panic, and this type of behavior could have a negative effect on other pa-tients and on the responders. A responder who becomes sick or injured during the rescue effort should be handled as an immediate priority and be transported off the site as soon as possible to avoid negative effect on the morale of remaining responders. Hazmat and weapons of mass destruction inci-dents force the hazmat team to identify patients as contaminated or decontaminated before the regu-lar triage process. Contamination by chemicals or biologic weapons in a treatment area,hospital,or trauma center could obstruct all systems and orga-nizations coping with the MCI or disaster. Bear in mind that some incidents may require multiple tri-age areas or teams because the victims are located far apart. Destination Decisions All patients triaged as immediate (red) or de-layed (yellow) should preferably be transported by ground ambulance or air ambulance, if available,to the most appropriate facility (trauma, burn,or pediatric center). In extremely large situations, a bus may transport the walking wounded. If a bus is used for minimal-priority patients, it is strongly suggested that they be transported to a hospital or clinic distant from the MCI or disaster site to avoid overwhelming the local area hospital resources.Re-fer to the Centers for Disease Control and Preven-tion 2011 decision scheme for field triage of injured patients. This scheme is presented in Chapter 25,Trauma Overview. If a bus is used, plan for at least one EMT or paramedic to ride on board and to have an ambulance follow the bus. If a minimal-prior-ity patient's condition worsens, the patient could be moved to the ambulance and transported to a closer facility.The EMT or paramedic can stay with the minimal-priority patients until their arrival at the designated hospital. Any worsening of a pa-tient's condition must be relayed to the receiving hospital as soon as possible in whatever manner the incident dictates. Immediate-priority patients should be trans-ported two at a time until all are transported from the site. Then patients in the delayed category can be transported two or three at a time until all are at a hospital. Finally, the walking wounded are trans-ported. Expectant patients who are still alive would receive treatment and transport at this time. Dead victims are handled or transported according to the standing operating procedure for the area. It is important to remember that during an MCI, local hospitals may have their resources over-whelmed. Early notification to receiving facilities will allow for hospitals to increase staffing and move pa-tients within their facility as required. Typically, EMS agencies will know a hospital's surge capacity, which will tell the agency how many patients of each cat-egory the hospital is able to safely handle and care for. Disaster Management A disaster is a widespread event that disrupts func-tions and resources of a community and threatens lives and property. Many disasters do not necessar-ily result in personal injuries-for example, droughts causing widespread crop damage. However, many disasters such as floods, fires, and hurricanes will result in widespread injuries. Unlike an MCI, which generally lasts no longer than a few hours, emer-gency responders will generally be on the scene of a disaster for days to weeks and sometimes months(as in the events following Hurricane Katrina in 2005).Although you can declare an MCI as an EMT,only an elected official can declare a disaster. Your role in a disaster is to respond when re-quested and to report to the IC for assigned tasks.In a disaster with an overwhelming number of cas-ualties, area hospitals may decide that they cannot treat all patients at their facility. In this case, they may mobilize medical and nursing teams with equipment and set up a casualty collection area at a facility near the disaster scene, such as a warehouse.Once at the casualty collection area, the teams can perform triage, provide medical care, and transport patients to the hospital on a priority basis. If a casualty collection area is established, it will be coordinated through the ICS in the same way as all other branches and areas of the operation. This is usually done only in a major disaster such as an earth-quake when transportation to a hospital facility is impossible or involves prolonged delays. It may take several hours to establish a casualty collection area. MCls and disasters take a physical and emotional toll on emergency responders. Make certain that you are medically evaluated if you have been injured, come in contact with any hazardous substance, or inhale any dust, fumes, or smoke. Often the health effects of such exposures do not manifest for years and are difficult to link back to a specific event. In addition,you should be aware of the signs of stress inyourself and in your coworkers. Consider taking advantage of critical incident stress debriefing (CISD)/critical incident stress management (CISM) opportunities after an incident if you feel they may be valuable.Chapter 2, Workforce Safety and Wellness, covers stress and CISD/CISM in detail. Urban Search and Rescue teams (USARs) and Disaster Medical Assistance Teams (DMATs) may be mobilized in the event of a natural disaster or MCI. USARs typically provide rescue and initial medical stabilization to patients entrapped in confined spaces, such as from a structural collapse. DMATs provide medical care during an incident; they include providers such as physicians,paramedics, nurses, and EMTs who work at the federal level. DMATs are typically activated for periods of 2 weeks, and they arrive with sufficient supplies and equipment to provide care for 3 days. Using the ambulance's public address system, you ask for anyone who can walk to come to the front gate, where a bus will be positioned to transport them. Next, you approach a supine middle-aged woman who is unresponsive with slow respirations. She has weak radial pulses. The next patient you encounter is a teenage boy who is apneic with a weak carotid pulse and no radial pulses. You note exposed brain matter. The third patient is an older woman with a severe laceration through the neck and chest; the neck injury has caused near-decapitation. She is apneic and pulseless. 5. What are your considerations in determining whether you should stop and provide treatment for the first patient? 6. What triage categories should you assign to the second and third patients? Introduction to Hazardous Materials Your training has taught you that rapid response to the scene of a crash can save lives. However, when you arrive at the scene of a possible hazmat inci-dent, you must first step back and assess the situ-ation. It can be very difficult to stop yourself from immediately engaging in patient care, particularly if you can see a patient. However, rushing into an un-safe scene can have catastrophic results. If you are overcome by a hazardous substance, not only will patients suffer because you will be unable to assist them, but you will also place a strain on the system because you will require emergency care. Methamphetamine (meth) is an illegal substance that has gained in popularity due to its increased accessibility, highly addictive properties,and relatively low cost. Meth is manufactured in llegal labs with highly volatile chemicals in a process known as cooking. The toxic fumes from meth labs not only create respiratory hazards, but may also ignite, causing fires or explosions.Exposure to the toxic fumes may cause irritation to the nose and throat,headaches, confusion, altered mental status,dizziness, nausea and/or vomiting, and respiratory problems. You may find meth labs anywhere in the country,including homes, garages, abandoned trailers, or the trunk of a vehicle. People who cook meth are often exposed to the toxins or have burn injuries because the risk of explosion is high. Therefore, your potential for contact with a meth lab is high. When responding to a general medical call,you may not realize that you are responding to a hazardous area.A house with all windows covered,glass cookware with a powdery residue, or a strong smell of an unusual odor such as ammonia, cat urine, or nail polish remover is a sign of a potential meth lab.If you have any suspicions that you may be in the presence of a meth lab, leave the area immediately and notify law enforcement to secure the scene and arrange for decontamination and cleanup. Because of the unique aspects of responding to and working at a hazardous materials (hazmat)incident, the Occupational Safety and Health Administration (OSHA) has published a set of guidelines known as the Hazardous Waste Oper-ations and Emergency Response (HAZWOPER).All providers, including EMTs, must meet specific additional training requirements before becoming involved in hazmat incidents. As an EMT, you need training at the First Responder Awareness Level.This text does not include the skills and information necessary to meet those requirements. You need to check with your agency for information about spe-cific awareness-level training. On the basis of the HAZWOPER regulation,first responders at the awareness level should have suf-ficient training or experience to demonstrate com-petency in the following areas: An understanding of what hazardous sub-stances are and the risks associated with them An understanding of the potential outcomes of an incident The ability to recognize the presence of haz-ardous substances The ability to identify the hazardous sub-stances,if possible An understanding of the role of the first re-sponder awareness individual in the emer-gency response plan The ability to determine the need for addi-tional resources and to notify the communica-tion center Recognizing a Hazardous Material A hazardous material is any material that poses an unreasonable risk of damage or injury to people,property, or the environment if it is not properly controlled during handling, storage, manufac-ture,processing, packaging, use and disposal, and transportation. Recognizing a hazmat incident,determining the identity of the material or ma-terials, and understanding the hazards involved often require some detective work. You must train yourself to take the time to look at the whole scene so that you can identify the critical visual indica-tors and fit them into what you know about the problem. Hazardous materials may be involved in any of the following situations (FIGURE 40-12): ·A truck or train crash in which a substance is leaking from a tank truck or railroad tank car Aleak,fire,or other emergency at an industrial plant, refinery, or other complex where chemi-cals or explosives are produced, used, or stored A leak or rupture of an underground natural gas pipe Deterioration of underground fuel tanks and seepage of oil or gasoline into the surrounding ground B FIGURE 40-12 Two examples of hazardous materials incidents. A. Burning container of flammable liquid. B.Crashed tanker truck. A:Courtesy of Rob L. Jackson/US Marines; B:Courtesy of Geore Roarty/Virginla Department of Emergency Management. · Buildup of methane or other by-products of waste decomposition in sewers or sew-age-processing plants A motor vehicle crash in which a gas tank has ruptured Initially, it is important to approach the scene from a safe location and direction. The traditional rules of staying uphill and upwind are a good place to start. In addition, it may be wise to use binoc-ulars and view the scene from a safedistance. Be sure to question anyone involved in the incident-a wealth of information may be available to you if you simply ask the right person. Take enough time to assess the scene and interpret other clues such as dead animals near the point of release, discolored pavement, dead gass, visible vapors or puddles, or labels that may help identify the presence of a haz-ardous material. Once you have a basic idea of what happened or determine that danger may be pres-ent,you can begin to formulate a plan for address-ing the incident. Occupancy and Location A wide variety of chemicals are stored in ware-houses, hospitals, laboratories, industrial com-plexes, residential garages, bowling alleys, home improvement centers, garden supply stores,restau-rants,and scores of other facilities or businesses in your response area. So many different chemi-cals exist in so many different locations that you could encounter almost anything during any type of emergency situation. The location and type of building are two good indicators of the possible presence of a hazardous material.For example,a biomedical laboratory is more likely than a pre-school to have chemicals that could be hazardous on site. However, it is important to remember that many common buildings may have materials, like large amounts of cleaning supplies, that could be hazardous in the right scenario. Senses Another way to detect the presence of hazardous materials is to use your senses, although this tech-nique must be used carefully to avoid exposure.The senses you can safely use are sight and sound.As a general rule, the farther you are from the inci-dent, the safer you will be.When it comes to hazmat incidents, “leading with your nose” is not a good tactic-but using binoculars from a distance is. Clues that are seen or heard from a distance may enable you to take precautionary steps. Va-por clouds at the scene, for example, are a signal to move yourself and others away to a place of safety;the sound of an alarm from a toxic gas sensor in a chemical storage room or laboratory may also serve as a warning to retreat. Some highly vaporous and odorous chemicals-chlorine and ammonia, for ex-ample-may be detected by smell a long way from the actual point of release. Containers In basic terms, a container is any vessel or recepta-cle that holds a material. Often the container's type,size, and material of construction provide import-ant clues about the nature of the substance inside.Nevertheless, do not rely solely on the type of con-tainer when making a determination about hazard-ous materials. Red phosphorus from a drug laboratory, for example, might be found in an unmarked plastic container. In this case, there may not be legitim-ate markings to alert you to the possible contents.Gasoline or waste solvents may be stored in 55-gal-lon (208-L) steel drums. Sulfuric acid, at 97% con-centration, could be found in a polyethylene drum that might be colored black, red, white, or blue.In most cases, there is no correlation between the color of the drum and the possible contents. The same sulfuric acid might also be found in al-gallon (3.8-L) amber glass container. Steel or polyethylene drums, bags, high-pressure gas cylinders, railroad tank cars, plastic buckets, aboveground and under-ground storage tanks, cargo tanks, and pipelines all are examples of how hazardous materials are pack-aged,stored,and transported (FIGURE 40-13). Some recognizable chemical containers, such as 55-gallon (208-L) drums and compressed gas cylin-ders, can be found in almost every type of manufac-turing facility. Materials stored in a cardboard drum are usually in solid form. Stainless steel containers hold particularly dangerous chemicals, and cold liquids are kept in containers designed to maintain the appropriate temperature (FIGURE 40-14). One way to distinguish containers is to divide them into two categories based on their capacity;bulk and nonbulk storage containers. FIGURE 40-13 Drums may be constructed of many different types of materials, including cardboard,polyethylene, and stainless steel. The drum shown here is made of polyethylene. Courtesy of EMD Chemicals, Inc. FIGURE 40-14 A series of chemical storage containers.©Ulrich Mueller/Shutterstock. Container Volume Bulk storage containers include fixed tanks, high-way cargo tanks, rail tank cars, totes, and inter-modal tanks. In general, bulk storage containers are found in buildings that rely on and need to store large quantities of a particular chemical. Most manufacturing facilities have at least one type of bulk storage container. Often these bulk storage containers are surrounded by a secondary contain-ment system to help control an accidental release.Secondary containment is an engineered method to control spilled or released product if the main con-tainment vessel fails. A 5,000-gallon (18,927-L) ver-tical storage tank, for example, may be surrounded by a series of short walls that form a catch basin around the tank. Large-volume horizontal tanks are also com-mon. When stored above ground, these tanks are referred to as aboveground storage tanks; if they are placed underground, they are known as under-ground storage tanks. These tanks can hold a few hundred gallons to several million gallons of prod-uct and are usually made of aluminum, steel,or plastic. Another commonly encountered bulk storage vessel is the tote, also referred to as an intermedi-ate bulk container. Totes are found in a variety of shapes and sizes, with the most common sizes be-ing 275 and 330 gallons (1,041 and 1,249 L). These portable plastic tanks are surrounded by a stain-less steel web that adds both structural stability and protection to the container. They can contain any type of chemical, including flammable liq-uids, corrosives, food-grade liquids, or oxidizers (FIGURE 40-15). Shipping and storing totes can be hazardous.These containers often are stacked atop one an-other and moved with a forklift, and a mishap with the loading or moving process can damage the tote.Because totes have no secondary containment sys-tem,anyleak has the potential to create a large pud-dle. In addition, the steel webbing around the tote may make it difficult to access and patch leaks. Intermodal tanks are both shipping and storage vessels. They hold between 4,000 and 6,000 gallons (15,142 and 22,712 L) of product and can be pres-surized or nonpressurized. Intermodal tanks can also be used to ship and store gaseous substances that have been chilled until they liquefy, such as FIGURE 40-15 A tote is a commonly encountered bulk storage vessel. Courtesy of Tank Service, Inc. FIGURE 40-16 An intermodal tank. Courtesy of UBH International Ltd. liquid nitrogen. In most cases, an intermodal tank is shipped to a facility, where it is stored and used and then returned to the shipper for refilling. Inter-modal tanks can be shipped by all methods of trans-portation-air, sea, and land (FIGURE 40-16). Nonbulk Storage Vessels Essentially,nonbulk storage vessels are all types of containers other than bulk containers.Nonbulk storage vessels can hold a few ounces to 119 gal-lons (450 L) of product and include vessels such as drums, bags, compressed gas cylinders, cryogenic containers, and more. Nonbulk storage vessels hold commonly used commercial and industrial chemicals such as solvents, industrial cleaners, and compounds. This section describes the most commonly encountered types of nonbulk storage vessels. Drums Drums are easily recognizable, barrellike contain-ers. They are used to store a wide variety of sub-stances, including food-grade materials, corrosive substances, flammable liquids, and grease. Drums may be constructed of low-carbon steel, polyeth-ylene, cardboard, stainless steel, nickel, or other materials. Generally, the nature of the chemical de-termines the construction of the storage drum. Steel utility drums, for example, hold flammable liquids,cleaning fluids, oil, and other noncorrosive chem-icals. Polyethylene drums are used for corrosives such as acids, bases, oxidizers, and other materials that cannot be stored in steel containers. Cardboard drums hold solid materials such as soap flakes, so-dium hydroxide pellets, and food-grade materials.Stainless steel or other heavy-duty drums generally hold materials too aggressive (ie, too reactive) for either plain steel or polyethylene. Bags Bags are commonly used to store solids and pow-ders such as cement powder, sand, pesticides, soda ash, and slaked lime. Storage bags may be con-structed of plastic, paper, or plastic-lined paper.Bags come in different sizes and weights, depend-ing on their contents. Pesticide bags must be labeled with specific information (FIGURE 40-17). You can learn a great deal from the label, including the following details: Name of the product Active ingredients Hazard statement The total amount of product in the container The manufacturer's name and address The Environmental Protection Agency (EPA)registration number, which provides proof that the product was registered with the EPA The EPA establishment number, which shows where the product was manufactured Signal words to indicate the relative toxicity of the material: ·Danger-Poison:Highly toxic by all routes of entry FIGURE 40-17 A pesticide bag must be labeled with the appropriate information. Courtesy of the USDA. FIGURE 40-18 A carboy is used to transport and store corrosive chemicals. Courtesy of EMD Chemicals,Inc. ·Danger: Severe eye damage or skin irritation ·Warning:Moderately toxic · Caution: Minor toxicity and minor eye damage or skin irritation Practical first-aid treatment description Directions for use ·Agricultural use requirements · Precautionary statements such as mixing dir-ections or potential environmental hazards · Storage and disposal information · Classification statement on who may use the product In addition, every pesticide label must carry the statement, “Keep out of reach of children.” Carboys Some corrosives and other types of chemicals are transported and stored in carboys (FIGURE 40-18). A carboy is a glass, plastic, or steel container that holds 1 to 15 gallons (4 to 57 L) of product. Glass carboys are often placed in a protective wood, foam,fiberglass, or steel box to help prevent breakage. For example, nitric acid, sulfuric acid, and other strong acids are often transported and stored in thick glass carboys protected by a wooden or polystyrene (Sty-rofoam) crate to shield the glass container from damage during normal shipping. Cylinders Several types of cylinders are used to hold liquids and gases. Uninsulated compressed gas cylinders are used to store substances such as nitrogen, ar-gon, helium, and oxygen. They come in a range of sizes. As an EMT, you are already familiar with the shape of a cylinder; it holds the oxygen for your patients. Table of placards and initial response guide to use on scene.Use this table only if materials cannot be specifically identified by using the shipping document, numbered placard,or orange panel number. A The Department of Transportation Marking System The presence of labels, placards, and other mark-ings on buildings, packages, boxes, and containers can often enable you to identify a released chemi-cal.When used correctly, marking systems indicate the presence of a hazardous material from a safe distance and provide clues about the substance. The US Department of Transportation (DOT)marking system is an identification system character-ized bylabels, placards, and markings (FIGURE 40-19).This marking system is used in the United States when materials are being transported from one lo-cation to another. The same marking system is also used in Canada by Transport Canada. Placards are diamond-shaped indicators (at least 9.8 inches [250 mm] per side) that are placed on all four sides of highway transport vehicles, B FIGURE 40-19 The Department of Transportation uses labels, placards, and markings (such as these found in the Emergency Response Guidebook) to give a general idea of the hazard inside a particular container or cargo tank.Courtesy of the US Department of Transportation. railroad tank cars, and other forms of transporta-tion carrying hazardous materials (FIGURE 40-20).Labels are smaller versions (3.9 inches [100 mm]per side) of placards; they are placed on the four sides of individual boxes and smaller packages be-ing transported. Placards, labels, and markings are intended to give a general idea of the hazard inside each con-tainer or cargo tank. A placard identifies the broad hazard class (flammable, poison, corrosive) to which the material inside belongs. A label on a box inside a delivery truck, for example, relates only to the potential hazard inside that particular package (FIGURE 40-21). FIGURE 40-20 A placard is a large diamond-shaped indicator that is placed on all sides of transport vehicles that carry hazardous materials. © Mark Winfrey/Shutterstock. Hazardous Materials Warning Labels Actual label size: at least 100 mm (3.9 inches) on all sides CLASS 1 Explosives: CLASS 2 Gases: CLASS 3 Flammable Liquid CLASS 4 Flammable Solid, CLASS 5 Oxidizer, Organic Divisions 1.1, 1.2, 1.3, 1.4, 1.5.1.6 Divisions 2.1,2.2,2.3 Spontaneously Combustible, and Dangerous When Wet: 1.4 Divisions 4.1,4.2,4.3 EXPLOSIVE INHALATION HAZARD 1.5 COMBUSTIBLE EXPLOSIVE BLASTING AGENT NON-FLAMMABLEGAS FLAMMABLE GAS FLAMMABLE LIQUID ** * 1.6 EXPLOSIVE OXYGEN $172.405(b), $172.415,5172.416,§172.417 §172.419 CLASS 7 Radioactive RADIOACTIVE II CORROSIVE 8 RADIOACTIVE I RADIOACTIVE III §172.442C AGENTS FISSILE A 7 $172,436,$172.438,$172.440,$172.441HAZARDOUS MATERIALS MARKINGS OVERPACK Category B MARIN HOT DANGER Fumigant Marking (Red or Black) Biological Substances,Replaces §INNER PACKAGES UN3373 INH COMPLY WITH PRESCRIBED SPECIFICATIONS H October 1, 2007 DO NOT ENTER §173.25(a)(4) §172.325 §172.332(a) §172.302(g) and $173.9 §173.199(a)(5) §1 72.313(a)Keep a copy of the Emergency Response Guidebook handy! §172.411 Incude compatibility group letter. ·Include division number and compatibility group letter.CLASS 6 Poison (Toxic),PoisonInhalation Hazard,Infectious Substance: Divisions 6.1 and 6.2INHALATION HAZARD PG III POISON 6 NFECTIOUS SUBSTANCE BIOMEDICAL BIOHAZARD For Regulated Medical Waste (RMW), an Infectious Substance label is not required on 1910.1030(g). CDC Etiologic Agent label must be used os prescribed in 42 CFR 72.3 $172.323,§172.405(c),$172.429,$172.430,$172.432Package Orientation (Red or Black) keep away lrom heat $172.312(a) $172.317 Peroxide:Divisions 5.1 and 5.2CRGANIC PEROXIDE DANGEROUS OXIDIZER CRGANIC PEROXIDE Organic Peroxide, Transition-2011$172.420,§172.422,§172.423 §172.426,$172.427 CLASS 8 Corrosive CLASS 9 Miscellaneous Subsidiary Risk Cargo Aircraft Hazardous Material Label Only DANGER 9 §172.446 §172.411 §172.448Empty Label EMPTY §172.450 E POLLUTANT 172.322 CONSUMER COMMODITY ALATION AZARD ORM-D-AIR $172.316(a) FIGURE 40-21 A label is a smaller version of the placard and is placed on boxes or smaller packages that contain hazardous materials. Courtesy of the US Department of Transportation. Other Considerations The DOT system does not require that all chemical shipments be marked with placards or labels. In most cases, the package or cargo tank must contain a certain amount of hazardous material before a placard is required. For example, the “1,000-pound rule” applies to blasting agents (a substance that contains a fuel and oxidizer that is intended for blasting, but is not classified as an explosive),flammable and nonflammable gases, flammable/combustible liquids, flammable solids, air-reactive solids, oxidizers and organic peroxides, poison sol-ids, corrosives, and miscellaneous (class 9) materi-als. Placards are required for these materials only when the shipment weighs more than 1,000 pounds (454 kg). Commercial package delivery services often carry small amounts of hazardous materials that fall below that weight limit. The vehicle exterior will not display placards to warn you of the danger. Conversely, some chemicals are so hazardous that shipping any amount of them requires the use of labels or placards. These materials include ex-plosives, poisonous gases, water-reactive solids,and high-level radioactive substances. A four-digit United Nations number may be required on some placards.This number identifies the specific material being shipped; a list of United Nations numbers is included in the Emergency Response Guidebook. The Emergency Response Guidebook The DOT's Emergency Response Guidebook (ERG)offers a certain amount of guidance for responders operating at a hazmat incident (FIGURE 40-22). This guide is updated every 3 to 4 years and provides in-formation on approximately 4,000 chemicals. The US DOT and the Secretariat of Communications and Transportation of Mexico, along with Transport Can-ada, jointly developed the ERG. You can download a free copy of the ERG via the Pipeline and Hazardous Materials Safety Administration (PHMSA) website. Material Safety Data Sheets A common source of information about a particular chemical is the material safety data sheet (MSDS)(or safety data sheet [SDS]) specific to that substance (FIGURE 40-23).Essentially, the MSDS provides ba-sic information about the chemical makeup of a substance, the potential hazards it presents, appro-priate first aid in the event of an exposure, and other FIGURE 40-22 The Emergency Response Guidebook is a reference used as a base for your initial actions at a hazardous materials incident. Courtesy of the US Department of Transportation. pertinent data for safe handling of the material.The MSDS will typically include the following details: The name of the chemical, including any syn-onyms for it Physical and chemical characteristics of the material Physical hazards of the material Health hazards of the material Signs and symptoms of exposure Routes of entry Permissible exposure limits Responsible-party contact Precautions for safe handling (including hy-giene practices, protective measures, and pro-cedures for cleaning up spills or leaks) Applicable control measures, including per-sonal protective equipment Emergency and first-aid procedures Appropriate waste disposal DISTRIBUTORS: TANNER INDUSTRIES,INC. DIVISIONS: NATIONAL AMMONIA NORTHEASTERN AMMONIA HAMLER INDUSTRIES BOWER AMMONIA & CHEMICAL 735 Davisville Road, Third Floot, Southampton, PA 18966; 215-322-1238 CORPORATE EMERGENCY TELEPHONE NUMBER: 800-643-6226 CHEMTREC: 800-424-9300 DESCRIPTION CHEMICAL NAME: Ammonia, Anhydrous CAS REGISTRY NO:7664-41-7 SYNONYMS: Ammonia CHEMICAL FAMILY:Inorganic Nitrogen Compound FORMULA: NH3 MOL. WT: 17.03(NH3) COMPOSITION: 99+% Ammonia STATEMENT OF HEALTH HAZARD HAZARD DESCRIPTION: Ammonia is an irritant and corrosive to the skin, eyes, respiratory tract and mucous membranes. Exposure to liquid or rapidly expanding gases may cause severe chemical burns and frostbite to the eyes, lungs and skin. Skin and respiratory related diseases could be aggravated by exposure. Not recognized by OSHA as a carcinogen. Not listed in the National Toxicology Program. Not listed as a carcinoen by the International Agency for Research on Cancer. EXPOSURE LIMITS FOR AMMONIA:Vapor OSHA 50 ppm, 35mg/m3PEL 8 hour TWA NIOSH 35 ppm, 27 mg/m3 STEL 15 minutes 25 ppm, 18mg/m3 REL 10 hour TWA 300 ppm, IDLH ACGIH 25 ppm, 18mg/㎡3TLV 8 hour TWA 35 ppm, 27 mg/m3 STEL 15 minutes TOXICITY: LD 50 (Oral/Rat) 350mg/kg BOILING POINT:-28°F at 1 Atm. PH:N/A SPECIFIC GRAVITY OF GAS (air = 1): 0.596 at 32°F SPECIFIC GRAVITY OF LIQUID (water = 1):0.682 at 28°F (Compared to water at 39°F). PERCENT VOLATILE: 100% at 212°F APPEARANCE AND ODOR: Colorless liquid or gas with pungent odor. CRITICAL TEMPERATURE:271.4°℉ GAS SPECIFIC VOLUME:20.78 Ft3/Lb at 32°F and 1 Atm. VAPOR DENSITY: 0.0481 Lb/Ft3 at 32°F LIQUID DENSITY: 38.00 Lb/Ft3 at 70°℉ APPROXIMATE FREEZING POINT:-108°F WEIGHT (per gallon): 5.15 pounds at 60°F VAPOR PRESSURE: 114 psig at 70°F SOLUBILITY IN WATER (per 100 pounds of water):86.9 pounds at 32°F, 51 pounds at 68°F SURFACE TENSION:23.4 Dynes/cm at 52°F CRITICAL PRESSURE: 111.5 atm Revision: September 2005 FIGURE 40-23 An example of a material safety data sheet for anhydrous ammonia. Courtesy of Tanner Industries, Inc., Southampton, PA. All facilities that use or store chemicals are required by law to have an MSDS on file for each chemical used or stored in the facility. Many sites,especially those that stock many different chem-icals, may keep this information archived on a computer database. Although the MSDS is not a de-finitive response tool, it is a keypiece of the puzzle.The MSDS can also be obtained from the transport-ing vehicle. Shipping Papers Shipping papers are required whenever hazardous materials are transported from one place to an-other. They include the names and addresses of the shipper and the receiver, identify the material being shipped, and specify the quantity and weight of each part of the shipment. Shipping papers for road and highway transportation are called bills of lading or freight bills and are located in the cab of the vehicle (FIGURE 40-24). Drivers transporting chemicals are required by law to have a set of ship-ping papers on their person orwithin easy reach in-side the cab at all times. CHEMTREC Located in Falls Church, VA, the Chemical Transportation Emergency Center (CHEMTREC),now operated by the American Chemistry Council,is an agency that provides invaluable technical in-formation for first responders of all disciplines who CARRIER:NORFOLK SOUTHERN Date: 12/23/2008 Shipper: RSI LOGISTICS, INC (OKEMOS, MI US) understood throughout this contract as meaning any person or corporation in possession of the property under the contract) agrees to carry to its usual place of delivery at said destination,if on its route,otherwise to of the Uniform Domestic Straight Bill of Lading set forth (1) in Offeial, Southem, Western and lilionis Freight Classifention in effect on the date hereof, if this is a rail or a ral-water shipment,or(2)in the applicable motor carrier elassifeation or tarift if this is n motor carier shipment Shipper herby certifie that he is familiar with all the terms and conditions or the said bill of lading, Including those on the back thereof, set forth in the classification or tariff which governs the transportation of this shipment,and the said terms and conditions are hereby agreed to by the shipper and necepted for himself and his assigna. Consignee Information: CONSIGNEE DEER PARK, TX Address:City: DEER PARK, TX US Route:NS-ESTL-BNSF Origin Switch Route: Destination Switch Route: HUSTN-PTRA Rail Car No: GATX290861 , , For assistance in anytransportation emergency involving chemicals, phone CHEMTREC, dayor night,oll Free 1-800-424-9300 DESCRIPTION *THGIEW ONE TANK CAR Contains: Methyl Esters STCC#2899415 BIODIESEL-15, Biodiesel Sales Order Contract No: RSI82715 Sales Order Contract No: AAT122308-4 Purchase Order Contract No: AAT122308-4 (Sub. To Correction)204400 Lbs. SEAL NUMBERS: Gross Tare Net Weighed By: If charges are to be prepaid, write or stamp here, "To be Prepaid" Prepaid Subject to Section 7 of the conditions of applicable bill of lading, if this shipment is to be delivered to the consignee witho ut recourse on the consignor,the consignor shall sign the following statement:: The carrier shall not make delivery of this shipment without payment of freight and all other lawful charges.Not In Effect * This is to certify that the above named materials are properly classified, described, packaged, marked, and labeled,and are in proper condition for transportation, according to the applicable regulations of the Department of Transportation. FIGURE 40-24 A bill of lading or freight bill. Courtesy of RSI Logistics. are called on to respond to chemical incidents. The toll-free number for CHEMTREC is 1-800-262-8200.CHEMTREC can provide you with technical chemi-cal information via telephone, fax, or other electronic media. It also offers a phone conferencing service to connect you with thousands of shippers, subject matter experts, and chemical manufacturers. When you call CHEMTREC, be sure to have the following basic information ready: The name of the chemical(s) involved in the incident(if known) Name of the caller and callback telephone number Location of the incident or problem from the incident. After rapidly sizing up the scene,call for a hazmat team. If you are already too close by the time you first recognize the danger, immedi-ately leave the area. Once you have reached a safe place, try to rapidly assess the situation and provide as much information as possible when calling for the hazmat team,including your specific location, the size and shape of the containers of the hazardous material, and what you have observed and have been told has occurred. Do not reenter the scene, and do not leave the area until you have been cleared by the hazmat team, or you may contribute to the situation by spreading hazardous materials. Finally, do not al-low civilians to enter the scene, if possible. No one should enter the area without the proper protective equipment, respiratory protection, or training. Above all, avoid any contact with the material! Hazmat Scene Operations Once you have recognized the incident as one in-volving hazardous materials and have called for the hazmat team, focus your efforts on activities that will ensure the safety and survival of the greatest number of people. Use the ambulance's public ad-dress system to alert people who are near the scene and direct them to move to a location where they will be sufficiently far from danger. With the aid of others on your team, try to set up a perimeter to stop traffic and people from entering the area. Establishing Control Zones Setting control zones and limiting access to the incident site helps reduce the number of civilians and responders who may be exposed to the re-leased substance. Control zones are established at a hazmat incident based on the chemical and physical properties of the released material,the en-vironmental factors at the time of the release, and the general layout of the scene. Of course, isolating a city block in the busy downtown area of a large city presents far different challenges than isolating the area around a rolled-over cargo tank on an in-terstate highway. Each situation is different, requir-ing flexibility and thoughtfulness. Securing access to the incident helps ensure that no one will acci-dentally enter a contaminated area. If the incident takes place inside a structure,the best place to control access is at the normal points of ingress and egress (entry and exit)-doors. Once the doors are secured so that no unauthorized personnel can enter, appropriately trained emer-gency response crews can begin to isolate other areas as appropriate. The same concept applies to outdoor incidents.The goal is to secure logical access points around the hazard. Begin by controlling intersections,on and off ramps, service roads, and other access routes to the scene. Law enforcement officers should as-sist by diverting traffic at a safe distance outside the hazard area. They should block off streets, close in-tersections, and redirect traffic as needed. During a long-term incident, highway depart-ment or public works department employees may be called on to set up traffic barriers. Whatever methods or devices are used to restrict access,they should not limit or prevent a rapid withdrawal of re-sponders from the area. It is not uncommon to set large control zones at the onset of an incident, only to discover that the zones may have been established too liberally.At the same time, control zones should not be defined too narrowly (FIGURE 40-25). As the IC gets more infor-mation about the specifics of the chemical or ma-terial involved, the control zones may be expanded or reduced. Ideally, the control zones will be estab-lished in the right place the first time. Wind shifts are a common reason why control zones are modified during the incident. If there is a prevailing wind pat-tern and you are in the area, that should be factored into any decision making when it comes to control zones. Typically, control zones at hazmat incidents are labeled as hot, warm, or cold. You may also discover that other terms are used, such as exclu-sionary zone (hot zone), contamination reduction zone(warm zone), and outer perimeter (cold zone).In any case, make sure you understand the ter-minology used in your jurisdiction. Be aware that FIGURE 40-25 Control zones spread outward from the center of a hazardous materials incident. Jones& Bartlett Learning. different jurisdictions may use terminology and setup procedures unlike the ones used in your agency. As long as you understand the concepts behind the actions and remember that safety is the main focus, the act of setting up and naming zones can remain flexible. The hot zone is the area immediately surround-ing the release, which is also the most contamin-ated area. Its boundaries should be set large enough that adverse effects from the released substance will not affect people outside of the hot zone. An incident involving a gaseous substance or a vapor,for example, may require a larger hot zone than one involving a solid or nonvolatile liquid leak. In some cases, atmospheric monitoring, plume mod-eling, or reference sources such as the Emergency Response Guidebook may prove useful in helping to establish the perimeters of a hot zone. Specifi-cally trained responders, in accordance with their level of training, should be tasked with using these tools. Keep in mind that the physical characteris-tics of the released substance will significantly af-fect the size and layout of the hot zone. In addition,all specifically trained responders entering the hot zone should avoid contact with the product to the greatest extent possible. Adhering to this important policy makes the job of decontamination easier and reduces the risk of cross-contamination. Personnel accountability is important, so ac-cess into the hot zone must be limited to only the responders necessary to control the incident. All personnel and equipment must be decontaminated when they leave the hot zone. This practice ensures that contamination is not inadvertently spread to clean areas of the scene. The warm zone is where personnel and equip-ment transition into and out of the hot zone. It contains control points for access to the hot zone as well as the decontamination area. Only the min-imum number of personnel and the equipment necessary to perform decontamination or support those operating in the hot zone should be permit-ted in the warm zone. A patient's skin and clothing may contain haz-ardous material, so the decontamination area is set up in the warm zone. The decontamination area is the designated area where contaminants are re-moved before an individual can go to another area.Decontamination is the process of removing or neu-tralizing and properly disposing of hazardous materi-als from equipment, patients, and rescue personnel. FIGURE 40-26 Patients should be decontaminated before they are taken to treatment areas. ©ZUMA Press Inc/Alamy Stock Photo. The decontamination area must include special con-tainers for contaminated clothing and special bags to isolate each patient's personal effects safely until they can be decontaminated (FIGURE 40-26).The area will also contain several special facilities to thor-oughly wash and rinse patients and backboards.The water that is used must be captured and delivered into special sealable containers. Anyone who leaves the hot zone must pass through the decontamination area. Firefighters'and hazmat team members' outer protective gear is rinsed and washed in the decontamination area be-fore it is removed (FIGURE 40-27). To prevent need-less contact and transmission of splash or residues,different personnel are used in the decontamination and treatment areas. Do not move into the decon-tamination area unless you are properly trained and equipped.Wait for the patients to be brought to you. Beyond the warm zone is the cold zone.The cold zone is a safe area where personnel do not need to wear any special protective clothing for safe operation. Personnel staging, the command post,EMS providers, and the area for medical monitor-ing, support, and/or treatment after decontamina-tion are all located in the cold zone. Role of the EMT As an EMT, your job is to report to a designated area outside of the hot and warm zones and provide tri-age, treatment, transport, or rehabilitation when hazmat team members bring patients to you. FIGURE 40-27 The decontamination zone is where firefighters' and hazmat team members' outer protective gear is rinsed and washed before removal. Courtesy of Airman 1st Class Scherrie Gates/US Air Force. Classification of Hazardous Materials The National Fire Protection Association (NFPA)704 hazardous materials classification standard is a system for the identification of hazardous materials according to health hazard or toxicitylevels,fire haz-ard, chemical reactive hazard, and special hazards (such as radiation and acids) for fixed facilities that store hazardous materials. Toxicity protection levels are also classified according to the level of personal protection required. For your safety, you must know the type and degree of health, fire, and reactive haz-ard protection you need to operate safely near these substances before you enter the scene. Toxicity Level Toxicity levels are measures of the health risk that a substance poses to someone who comes in contact with it.There are five toxicity levels: 0, 1, 2, 3, and 4.The higher the number, the greater the toxicity, as follows: ·Level 0 includes materials that would cause little, if any, health hazard if you came in con-tact with them. Level 1 includes materials that would cause irritation on contact but only mild residual in-jury, even without treatment. Level 2 includes materials that could cause temporary damage or residual injury unless prompt medical treatment is provided. Both levels 1 and 2 are considered slightly hazard-ous but require use of self-contained breath-ing apparatus (SCBA) if you are going to come in contact with them. Level 3 includes materials that are extremely hazardous to health. Contact with these mate-rials requires full protective gear so that none of your skin surface is expose

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