Chemical Protective Clothing; a Study Into the Ability of Stav to Perform Lifesaving Procedures

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J Accid Emerg Med 2000;17:115–118 115 J Accid Emerg Med: first published as 10.1136/emj.17.2.115 on 1 March 2000. Downloaded from Chemical protective clothing; a study into the ability of staV to perform lifesaving procedures

Mark J Coates, Ayman S Jundi, Mark R James

Abstract In 1997, a total of 931 “chemical incidents” Objective—To investigate the ability of were reported from hospitals, public health medical and nursing staV to perform cer- organisations, or other medical professional tain tasks while wearing a chemical pro- organisations, to the Chemical Incident Re- tection suit with a respirator. Tasks chosen sponse Service (CIRS)1 at the Medical Toxi- were those that would be required before cology Unit, Guy’s and St Thomas’ Hospital decontamination. Trust. The majority of these figures (584) rep- Methods—Ten experienced accident and resents incidents identified by CIRS from hos- emergency doctors (middle grade and pital inquiries. A large number of these consultants) and 10 nurses were asked to incidents aVected multiple casualties, and perform certain tasks that were judged to some involved dealing with highly toxic chemi- be life saving, relevant to triage, or neces- cals. sary to confirm death, on an advanced life The Ambulance Service Association has support manikin, while wearing a TST- produced Interim Guidance on Chemical Sweden chemical protection suit. The Incidents.23Three triage categories were identi- operators were objectively assessed by one fied: of the authors for achieving each task, x P1: require resuscitation during, or before, then asked to make a subjective assess- decontamination. ment of the diYculty experienced. x P2: treatment may be delayed until after Results—Medical staV were asked to ven- decontamination on a stretcher. tilate the manikin using a bag-valve- x P3: may be decontaminated in ambulant mask, intubate within 30 seconds, apply facilities. monitor electrodes and cables and check It is suggested that, for P1 category patients, cardiac rhythm, apply gel pads and defi- only immediately lifesaving procedures should 4 brillate safely, and finally, fold the cruci- be performed before decontamination. form triage card to show “RED”, and The accident and emergency (A&E) depart- attach it to the manikin. All the doctors ment at the Royal Preston Hospital is a desig- completed these tasks, except for one, who nated receiving facility for casualties from a could only intubate the manikin after sev- chemical incident. It has purchased a number http://emj.bmj.com/ eral attempts. Nursing staV were asked to of TST-Sweden chemical protection suits open and apply an oxygen mask, adjust (Textil Skyddsteknik AB, Kinna, Sweden; oxygen flow, size and insert an oropharyn- distributed in the UK by Airshelta, Hudders- geal airway, ventilate the manikin using a field; fig 1); each consists of a polyurethane bag-valve-mask, apply a pressure bandage coated polyamide overall (EN 465), and a to a limb, and fold the cruciform triage butyl coated polyester hood (EN 146). Ventila- tion is provided by a battery operated blower

card to show “YELLOW”, and attach it to the on September 25, 2021 by guest. Protected copyright. manikin. All the nurses completed these unit and a filter that meets CEN class A2 tasks. Operators reported varying degrees (organic gases and vapours), B1 (inorganic of diYculty, the most diYcult tasks were gases and vapours), E2 (acidic gases and those requiring fine movements or deli- sulphur dioxide), K1 (ammonia and its organic cate control. Generally, operators found derivatives), and P3 (toxic particles, bacteria, the butyl rubber gloves cumbersome. viruses). It comes with separate butyl rubber Communication diYculties were fre- boots, and butyl rubber gloves. The suits are quently reported. Although only intuba- designed for dealing with contaminated casual- tion was formally timed, tasks were ties in a clean environment. They meet or Accident and exceed the recommendations of the Ambu- Emergency perceived to take longer. Some operators 23 found the suits too warm and uncomfort- lance Service Association, and would provide Department, Royal protection against most agents encountered Preston Hospital, able. Sharoe Green Lane Conclusion—Should the need arise, the during decontamination of patients in a clean North, Fulwood, TST-Sweden chemical protection suits environment, including victims of nerve gas Preston PR2 4HT attack.56 They are not, however, designed for would enable experienced doctors and M J Coates use within the high risk contaminated exclu- nurses to perform lifesaving measures A S Jundi sion zone, where only firefighters wearing M R James eVectively, without significant impair- chemical protection suits equipped with self ment to their skills. Tasks would be easier contained breathing apparatus can operate. Correspondence to: to accomplish with better fitting gloves. Mr Jundi, Specialist In the course of staV training on chemical (J Accid Emerg Med 2000;17:115–118) Registrar (e-mail: incident management in the A&E department [email protected]) Keywords: chemical incidents; protection suits; con- at the Royal Preston Hospital, concern was Accepted 23 October 1999 taminated casualties expressed as to whether lifesaving procedures 116 Coates, Jundi, James J Accid Emerg Med: first published as 10.1136/emj.17.2.115 on 1 March 2000. Downloaded from x Ventilate the manikin using a bag-valve- mask apparatus. x Apply a pressure bandage to a forearm, using a 5 inch roll of wool, and a 5 inch roll of crepe bandage, then secure it using adhesive tape. x Fold the cruciform triage card to show “YELLOW”, starting from a standard preset position, reinsert it into its pouch, and attach it to the manikin. All participants were also asked to feel for the carotid and radial pulses of the authors while wearing the butyl rubber gloves. The operators were objectively assessed by one of the authors for achieving each task. StaV were then asked to make a subjective assess- ment of the diYculty experienced in performing these tasks, on a scale of 1 to 5, with 1 being as easy as performing the task without the suit, and 5 being so hard as to make the task unach- ievable. StaV were also given the opportunity to make general comments about the suits Figure 1 TST-Sweden chemical protection suit. afterwards. could be carried out safely and eVectively while StaV were familiar with all the equipment wearing the chemical protection suits that are used, with the exception of the chemical available in the department. protection suit, and were not given the oppor- The aim of the study was to establish tunity to practice any tasks in the suit. whether medical and nursing staV would be capable of performing lifesaving procedures, or Results confirming death, while wearing the TST- Ten doctors and 10 nurses participated in the Sweden chemical protection suits. We also study, each performing the required tasks in tried to convey staV perceptions of the sequence, after putting on the chemical protec- diYculty of achieving these tasks while wearing tion suit. the suits. The first task given to the doctors was to ventilate an advanced life support (ALS) mani- Methods kin using a bag-valve-mask apparatus. This was Twenty medical and nursing staV were invited achieved by all 10 participants the mean to perform a number of tasks that were deemed diYculty rating being 1.8 (range 1–3). The immediately life saving, relevant to triage, or main diYculty was in sensing the eVectiveness necessary to confirm death, while wearing the of the mask seal around the face of the http://emj.bmj.com/ chemical protection suits. These tasks were manikin. selected to represent interventions that might All but one middle grade doctor managed to be required before decontamination of P1 intubate the manikin in the allocated time; a patients. second middle grade doctor failed the first This was carried out as part of the A&E attempt, but managed the task on the second. department’s ongoing training on chemical This was scored as “achieved”, as it would be incident management. considered a “pass” under ALS test condi- on September 25, 2021 by guest. Protected copyright. Medical staV were asked to perform the fol- tions. The diYculty rating ranged from 2–5, 5 lowing tasks: being given by the person who failed to achieve x Ventilate the manikin using a bag-valve- the task. The mean rating for this task was 2.8. mask apparatus. Tying the endotracheal tube in place was x Intubate the manikin within 30 seconds. reported as the most diYcult part of this task. x Apply electrocardiographic monitor elec- Applying the electrodes to the chest, while trodes, connect the cables, and check cardiac achieved by all doctors, was found to be the rhythm. most “fiddly” task, particularly peeling the x Fold the cruciform triage card to show back oV the self adhesive electrodes. The mean “RED”, starting from a standard preset position, diYculty rating was 3.7 (range 3–4). Folding reinsert it into its pouch, and attach it to the the cruciform triage card and applying it to the manikin. manikin was successfully achieved by all x Open the gel pad packet, apply gel pads to participants, with a mean diYculty rating of the manikin, and defibrillate safely, using a Zoll 2.4 (range 2–3). PD 1400 defibrillator. The final task, applying the gel pads and Nursing staV were asked to perform the fol- using the defibrillator safely, was also success- lowing tasks: fully achieved by all the doctors. It was, x Remove a non-rebreathing oxygen mask however, rated at a slightly higher rating, with a from its packet, apply the mask to the manikin, mean of 2.7 (range 2–4). Operators com- connect the tubing to an oxygen source, and mented on the diYculty in opening the gel pad adjust the oxygen flow to 10 l/min. packets, the lack of tactile feel to determine x Select, size, and insert an oropharyngeal paddle contact with the chest, and diYculty in airway. communication to warn colleagues to stand Lifesaving procedures in chemical protection suits 117 J Accid Emerg Med: first published as 10.1136/emj.17.2.115 on 1 March 2000. Downloaded from 5 Bearing in mind that the authors were, presumably, in a normal cardiovascular condition, it would be conceivable that detecting the 4 pulse of a moribund, seriously injured casualty would be considerably more diYcult. All the tasks were essentially achievable. 3 However, they varied in diYculty. This seemed to be related to the degree of fine movement and tactile feedback that were involved in the 2 execution of the task. Most operators have

Difficulty rating expressed that they found the gloves to be too big and cumbersome, resulting in impairment 1 of fine movement performance, and loss of tactile feedback. Communication diYculties were also frequently reported by participants, 0 B-V-M ventilation Intubation ECG monitoring Defibrillation Triage card mostly due to background noise from the Figure 2 Means and ranges of diYculty ratings for tasks given to medical staV (B-V-M = blower unit. Visual field restrictions also added bag-valve-mask; ECG = electrocardiography). to communication diYculties. Most participants felt that tasks took longer to achieve, and 5 many felt that the suits became warm and uncomfortable, even in the relatively short time that they wore them. 4 Discussion Chemical incidents pose a particular problem 3 for the emergency services and health care workers. Casualties presenting for treatment 2 might be a source of dangerous, or even fatal, contamination to staV. Casualties should Difficulty rating always be decontaminated before treatment if 1 their condition allows it, and they should be presented to the ambulance and hospital staV “as clean as possible”.23 That, however, may 0 not necessarily mean that they are totally safe Oxygen mask Guedel airway B-V-M ventilation Pressure bandage Triage card to handle without protection. In addition, Figure 3 Means and ranges of diYculty ratings for tasks given to nursing staV (B-V-M = some casualties may be in urgent need of bag-valve-mask). lifesaving treatment before they can be safely clear. Several participants experienced diY- decontaminated. The adequate protection of culty in hearing the change in the defibrillator’s staV, under these circumstances, must take the http://emj.bmj.com/ audible tone, indicating completion of charg- first priority, and the TST-Sweden suits can ing. In general, the safety of nearby colleagues provide that protection, against most agents, in was an important concern for operators (fig 2). a non-contaminated atmosphere. The first task given to the nurses was to pro- Several studies, mostly from the military vide oxygen to the manikin at a flow rate of 10 medical literature, have looked at the physi- ological e ects of wearing protective clothing l/min, through a non-rebreathing mask. All V for prolonged periods.7–9 Other studies have nurses could manage this task, with a mean analysed exercise tolerance in soldiers wearing diYculty rating of 1.8 (range 1–2). Sizing and on September 25, 2021 by guest. Protected copyright. such clothing,10 11 or the eVects of such clothing inserting an oropharyngeal airway was, simi- on psychomotor and cognitive performance of larly, achieved by all; the mean diYculty rating troops.12 These studies have investigated such being 1.9 (range 1–2). eVects on army personnel trained to operate All nurses managed to ventilate the manikin while wearing chemical protective suits almost using a bag-valve-mask apparatus. The mean as a matter of routine. One study looked at skill diYculty rating was 2.7 (range 2–4). As was the decay after prolonged wearing of protective case for the doctors, the main diYculty clothing among army paramedics13 and sug- reported was the inability to sense the ad- gested that while tasks took longer to achieve, equacy of the mask seal around the mouth of the quality of the soldiers’ performance did not the manikin. suVer as a results of wearing the suits for eight Applying a pressure bandage to the mani- hours. Again, this study looked at highly kin’s forearm was successfully carried out by all trained personnel used to working in chemical the participating nurses. The mean diYculty protection suits as part of their every day rating was 2.9 (range 2–4). The main problem activities. was pulling out the end of the adhesive tape Our study looked at a small number of expe- used to secure the bandage. Folding and rienced medical and nursing staV, all from applying the cruciform triage card was per- within our department. It showed that experi- formed successfully by all participants, with a enced medical and nursing personnel who may mean diYculty rating of 2.5 (range 1–3) (fig 3). have to treat contaminated casualties while Participants were able to feel the carotid wearing chemical protection clothing can, to a pulse of the authors, but two thirds of them large extent, perform most essential lifesaving found it impossible to feel the radial pulse. procedures safely and eVectively. It also 118 Coates, Jundi, James J Accid Emerg Med: first published as 10.1136/emj.17.2.115 on 1 March 2000. Downloaded from showed that confirmation of death by assessing TST-Sweden chemical protection suits would pulse is likely to be unreliable, and the use of a be able to perform emergency lifesaving meas- stethoscope is, clearly, impossible with the ures eVectively, and without significant impair- hood. On the other hand, it showed that opera- ment to their skills. Further studies would be tors can use a defibrillator/monitor to confirm required to determine the feasibility of other the presence or absence of myocardial electri- essential procedures, such as obtaining venous cal activity when confirmation of death is access. required before decontamination of the casu- After communication of the above findings alty. However, the study highlights certain to TST-Sweden, they have informed us that the issues, such as the need for better fitting gloves. butyl rubber gloves will be available in a full It also demonstrated that the alien environ- range of glove sizes. ment of the suits imposes communication diYculties, mostly caused by the background Contributors noise from the blower unit and the auditory Dr Mark Coates contributed to the conception of the original idea of the project and the selection of the tasks to be tested, insulation caused by the hood. The hood also helped design the data collection proforma, and participated in greatly restricted the visual field, making visual data collection. He also helped in revising the paper before sub- communication diYcult as well. StaV need to mission for publication. Mr Ayman Jundi helped in the selection of the tasks to be tested, helped design the data collection pro- be aware of these problems, and to take the forma, carried out most of the data collection, carried out the necessary steps to minimise their eVect. One analysis and interpretation of data, and the formulation of conclusions. He carried out the literature search and the writing of interesting observation was that a small the paper. Mr Mark James contributed to the conception of the number of staV found the suits very uncom- original idea of the project and the selection of the tasks to be fortable, to the degree of experiencing claus- tested. He helped in revising the paper before submission for publication. trophobic feelings, and those staV members Mr Mark James acts as a guarantor for the contents of the could not tolerate the suits for more than a few paper. minutes. The study, and the ongoing training, Conflict of interest: none. helped identify those members of staV who found the suits intolerable, and allowed them Funding: none. to be assigned alternative tasks in the depart- 1 Medical Toxicology Unit, Guy’s and St Thomas’ Hospital mental chemical incident plan. Trust. Chemical incident report. No 7. London: Medical We did not make any attempts to test Toxicology Unit, Guy’s and St Thomas’ Hospital Trust, January 1998. participants’ ability to obtain venous access 2 Chemical Incident Procedures Working Group. The Ambu- while wearing chemical protection suits. We lance Service Association: interim guidance on chemical felt that the cannulation manikins currently incidents. London: Ambulance Service Association, August 1996. available are so unrealistic as to make any com- 3 Walker RJ. The Ambulance Service Association: interim parison with human subjects invalid. Plans are guidance on chemical incidents. 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