police, fire fighters, ambulance staff and

the general public could all be

contaminated before the chemical was

Chemical incident identified.

casualties,
emergency
There could be mass
including personnel
services. How would
in the

planning: a review London A 8t E departments

with a chemical
cope, faced
disaster such as this?

of the literature
INTRODUCTION
The Tokyo subway attack is the largest docu-
J. C. Rodgers mented exposure of a civilian population by a
warfare nerve agent to date. Sarin is a nerve
agent designed to paralyse and kill within min-
utes. The sarin attack was apparently focused
on three rail lines which intersected under-
Chemical incidents cause problems for neath the Japanese National Government’s
Accident and Emergency (A & E) ministry offrces (Okumura et al 1996). There
departments which are different from were five sites of gas release; the method of gas
those recognized in other major release was thought to be a lunch basket with a
accidents. As well as possible trauma container of sarin, punctured by an umbrella
there is the added problem of (Stealey 1995).
contamination. A & E departments The main symptoms experienced by people
must be prepared for chemical directly next to the source of fumes were
disasters with a chemical incident plan, miosis, muscle twitching, uncoordinated
decontamination facilities and actions and convulsions (Okumura et al 1996).
protective clothing for all staff involved. Others more seriously affected had respiratory
The plan should include how to protect failure. Many more casualties complained of
the hospital from contamination and sore throats, hacking cough and varying
how to prevent its personnel from degrees of nausea and faintness.
becoming secondary casualties. The Six hundred and forty patients were admi-
results of a survey into the ted to St Luke’s Hospital on the day of the
preparedness of inner London A & E attack. Some victims attended other hospitals
departments were published in issue 6.2 but the majority of casualties were seen at St
of this journal, April 1998. Luke’s Hospital under the medical direction of
On 20 March, I995 a religious cult Dr Yamashina. One hundred and ten patients
released a nerve gas (sarin) into the were kept in hospital overnight, 80 of whom
Tokyo subway system. More than 5500 were discharged the following day. Of all the
people needed hospital treatment and casualties 984 were moderately unwell, 54 very
I I people died (Reuter News Service, seriously unwell and 11 died. Next day, some
22 March, 1995). The hospitals were patients had slight symptoms of poisoning
overwhelmed with casualties. Once including headache, nausea, fatigue and dysp-
chemical exposure of victims was noea; others had eye problems. Many of the
suspected, clothing was removed and victims are still in a vegetative state and some
patients were showered. Stretcher reported persistent ocular problems in July
patients were decontaminated by 1995 (Stealey 1995).
means of bed bathing and a change of St Luke’s clinical staff triaged sarin victims
bedclothes (Okumura et al 1996). into three clinical groups (mild, moderate and
Hospital contamination was a problem severe) on the basis of their signs and symptoms
during this incident due to the delay in (Okumura et al 1996). Once chemical exposure
recognising chemical exposure. This of victims was suspected, clothing was removed
Jane C Rodgers RGN, BSc
(Hons) Professional Practice resulted in staff contamination. Many from patients, ambulatory patients were given
(A & E Nursing). Sensor Staff lessons were learned from this disaster, showers and non-ambulatory patients were
Nurse, Accident and
Emergency Department, St. including the need to be prepared for decontaminated by means of bed bathing and a
Thomas’ Hospital, Lambeth all eventualities. change of bedclothes (Okumura et al 1996).
Palace Road, London SE I 7EH,
UK If a similar incident occurred in the When the chemical was identified as sarin, the
Manuscript accepted 2 I
London Underground system, it would Accident and Emergency (A & E) departments
January I998 be catastrophic. Underground staff, administrated the antidotes, Pralidoxime (PAM)
Acudent and Emergency Nursing (I 998) 6. I55- I59 0 Harcourt Brace & Co. Ltd I998
I56 Accident and Emergency Nursing
and Atropine, and supportive treatment, includ-
ing the use of diazepam in some cases (Stealey
1995). PAM must be injected almost immedi-
ately after exposure: it controls fasciculations
and convulsions. Atropine is used for symptoms
of excess salivation and bradycardia, and
diazepam for convulsions and anxiety.
Due to the delay in confirmation of chemi-
cal contamination, secondary contamination
occurred. There were reports from A & E staff
that they had symptoms of dim vision, rhinor-
rhoea, dyspnoea and chest tightness. Atropine
sulphate had to be given to six of the clinical
staff (Nozaki et al 1995).
Many lessons were learned from this attack,
not least that this incident could have happened
anywhere in the world including the UK, and
we would have been as unprepared as the
Japanese were. Hospital contamination was a
problem and resulted in staff contamination and
eye problems. Vigorous patient decontamina-
tion is of major importance. Other problems
included a large number of people to deal with
initially, and a vast amount of medical informa-
tion to be passed to other receiving hospitals.
Special hospital procedures were required, and
protocols for triage in relation to contaminated
casualties were necessary (Stealey 1995).
Okumura et al (1996) suggest that disaster
planning should include mass casualties from
chemical exposure.
INFORMATION ON CHEMICALS
AND ANTIDOTES
Chemical substances in the form of gas (or sub-
stances which can release a vapour) are termed
poisonous gases if they produce incapacitating
or toxic effects. Poisoning can result from war-
fare when gases are deliberately used as lethal
agents or as the result of inhalation of vapours
from industrial chemicals, mechanical or
chemical processes, or household substances.
For example, household products, such as
kerosene and oven cleaners, produce vapours
that have toxic effects if inhaled in significant
quantities. Gas masks are used in military and
industrial settings to provide protection against
poisonous gases. Other safety measures include
proper ventilation and the appropriate storage
of volatile chemicals.
Chemical weapons can be divided into three
groups: vesicants, blood agents and nerve
agents. Vesicants have a corrosive action on
body tissue causing blistering of the skin. They
are often referred to as blister agents. The most
common agent in this group is known as mus-
tard gas; no antidote exists, therefore treatment
is symptomatic. Decontamination may min-
imise the injury as blistering takes hours to
develop. Blood agents include hydrogen,
cyanide and cyanogen chloride. Blood agents
are poisonous to the body and a person exposed
will have an immediate increase in respirations,
followed by convulsions, respiratory and cardiac
arrest. The treatment includes inhalation of
amyl nitrate but prognosis is poor.
Nerve agents include sarin, taban and
soman. All these nerve agents produce the same
physiological effect: they act upon enzymes at
the myoneural (muscle-nerve) junction, caus-
ing immediate convulsions, paralysis and death.
They are capable of entering the body either
through the lungs or the skin and are deadly
in very small quantities. Treatment following
exposure is difficult. Some patients in Japan
were kept alive on ventilators with huge doses
of atropine for many months (Okumura 1996).
CHEMICAL INCIDENTS
A chemical incident is ‘an unforeseen event
leading to acute exposure of two or more indi-
viduals to any non-radioactive substance, result-
ing in illness or a potentially toxic threat to
health’ (Schonfield et al 1995). Major chemical
incidents cause problems for A & E depart-
ments which are different from those recog-
nized in other major accidents. Murray (1991)
suggests that special attention should be given
to preparation and planning. Baxter (1991)
observes that health professionals are more used
to planning for major trauma than for mass
chemical exposure. He suggests that as a result
of this, the level of preparedness of A & E
departments in the UK is variable with regard
to training, the use of chemical incident proto-
cols, the provision of protective clothing and
antidotes, and the availability of facilities for
decontaminating seriously ill casualties.
Most health care institutions have an emer-
gency plan aimed at coping with a disaster
scenario. However, this is usually directed at
casualties of a conventional nature. A plan for
chemical incidents must include treatment of
unfamiliar injury and protection of the hospital
from contamination and its personnel from
becoming secondary casualties. Hazardous
material incidents are unique in that the conta-
minating material may also be dangerous to the
personnel rendering care. If contaminated
patients are brought to an A & E department it
puts the staff at risk and also risks the closure of
the facility to the rest of the community.
A & E staff must be prepared to receive
injured and contaminated casualties, for in life
threatening cases it is not always possible to
decontaminate patients at the scene of an inci-

dent. Protective clothing should be worn at all
times, and, as a minimum, should include eye
protection, impervious gloves, boots and over-
alls. Persons without protection will create sec-
ondary casualties and compound the size of the
incident. Betts-Symonds (1994) suggests that
there should be designated contaminated and
clean areas and personnel should not move
between these areas. Suitable rooms with ade-
quate ventilation, extraction systems, showers
and trolley baths are also important according
to Hines (1980).
Specialized A & E nurses have sophisticated
triage skills. However, when patients are conta-
minated, other considerations need to be taken
i into account. For example, a casualty with
~ severe nerve agent poisoning will die without
immediate management. He may also have a
serious injury, but the priority is to give the
nerve gas antidote, manage the airway and then
treat the injury. In contrast, a patient with a
serious injury and mustard gas poisoning may
require emergency treatment of the injury first
because the gas is not usually fatal. A & E
nurses must be able to respond appropriately in
each case (Betts-Symonds 1994).
Betts-Symonds (1994) suggests that staff
training should include ‘knowledge and use of
special protective clothing; emergency manage-
ment of chemical injury; limitations of staff
in full protective clothing and application of
chemical triage over medical triage’. It is also
important that A & E nurses know how to care
for patients who have a wide range of chemical
injuries, for example, chemical burns of the
eyes and skin. A & E nurses must also know
about inhalation injuries caused by irritant
gases from toxic releases and fires, and know
how to treat these patients (Baxter 1991).
Poison centres, like Guy’s Poisons Unit in
London, are ideally placed to act as focal points
for advice on management of chemical inci-
dents and for planning prevention. The data
bases available at the unit contain chemical haz-
ard toxicity data with an emphasis on informa-
tion about diagnosis and management of
poisoning, based, as far as possible, on clinical
experience (Murray & Wiseman 1992). In the
event of a chemical incident, the Unit will
assess the nature of the chemical hazard and
provide advice on decontamination, treatment,
case registration and follow-up (Kulling 1990).
Poisons units also contain emergency stores of
antidotes and are responsible for emergency
provision and distribution (Murray & Wiseman
1992). A & E departments should ensure that
the telephone number of the local poisons unit
is readily available, and that all nurses are aware
of its location.
Other valuable contacts in the event of a
chemical incident are the National Chemical
Chemical incident planning I57
Emergency Centre (NCEC), Harwell and
CHEMET. NCEC runs a 24-hour service
providing advice on chemical incidents. It has a
chemical information database which includes
details of products carried by specific compa-
nies. CHEMET is a meteorological office at
Brize Norton that will supply weather-based
information on-the likely dispersion of vapour
under current weather conditions. These tele-
phone numbers must also be readily available in
the event of a chemical incident.
DECONTAMINATION
Many chemicals can cause burns and be
absorbed, resulting in toxic effects leading to
kidney or liver failure. Chemicals can damage
the skin by severe change in the pH, defatting
the skin, a hydroscopic action and coagulative
necrosis. The first and essential treatment for all
chemical contamination is the removal of con-
taminated clothes and copious irrigation with
water (English 1990). Gases will stay on cloth-
ing and uncovered skin (such as the face) until
washed off, so the priority is to remove cloth-
ing. All contaminated clothing must be double-
bagged and labelled.
The DHSS Health and Building Notes 22
for Accident and Emergency Departments in
1969 and 1986, respectively, gave advice on
decontamination facilities for victims of chemi-
cal incidents. The 1969 Building Notes recom-
mended that a room should be set aside for
patients whose clothing has been contaminated
by chemicals. The room should include shower
facilities for patients to stand in. The 1986
Building Notes are more specific. They specify
that this room should be near the entrance to
A & E and should be large enough to allow
decontamination of stretcher patients. The
room should have a special drainage system
installed so that irrigation fluid will not conta-
minate the main drainage system. Adjacent to
this room should be a decontamination equip-
ment store. The document advises that the
Health and Safety Executive should be con-
sulted in the event of a major chemical incident
(Health Building Note 22 1986).
HOW WELL PREPARED IS
LONDON FOR CHEMICAL
EXPOSURE?
The incident in Japan alerted the UK to the
risk of a similar catastrophic incident in the
London Underground system. The British
Transport Police have taken this risk very
I58 Accident and Emergency Nursing
seriously and have begun to make preparations
in case a similar incident occurred. However,
there is no unified plan among all emergency
services, including the A & E departments
should an incident occur.
In the event of a chemical spillage the fire
brigade is responsible, at the scene, for contain-
ing the hazard and making safe the area. The
police would co-ordinate the emergency ser-
vices (Baxter 1991). The fire brigade has its
own chemical advisors and access to computer
databases. Most casualties are decontaminated
before being brought to the A & E department,
but there are occasions when this is not possi-
ble. When contaminated casualties are brought
to A & E departments, there must be facilities
for decontamination and protective clothing for
all staff involved.
The use of nerve gas has introduced a new
dimension to terrorism. The incident in Tokyo
has shown that use of such chemicals is deadly
in confined areas such as Tube stations and
trains. If an incident did occur in the London
Underground there would be the possibility of
the general public, underground staff, police
and ambulance staff being contaminated before
the chemical was identified. There could
be mass casualties including the emergency
services personnel. Many of the emergency
services personnel, including railway, fire,
ambulance and hospital staff were contaminated
and some died, during the sarin incident in
Japan (Okumura et al 1996).
The British transport police (BTP) who
guard the London Underground take the threat
of a nerve gas incident very seriously and have
already taken measures to protect the under-
ground and its staff. Two and a half million
people use the Underground every day. Each
train can carry up to one thousand people, so
the potential for large numbers to be involved
in a chemical incident is significant. Keeping
the stations clean and tidy is the first action
taken by the BTI? This reduces the possibility
of hiding anything. At selected stations there
are hourly searches of the platforms. In time,
patrolling officers will be educated about the
signs and symptoms of chemical release, such as
smell. Gas detectors are available which can be
in use within minutes following alert, e.g. if a
platform of people were to begin coughing.
The BTP also have respirators and
nuclear/chemical suits for their staff to wear
(Operation Alert 1991).
The government’s Review of Peacetime
Emergencies (1989) concluded that the prime
responsibility for handling particular disasters
should remain at the local level. A national dis-
aster squad would not be established. A guid-
ance document from the NHS (1990) provides
essential information on communication issues,
ambulance service operation arrangements,
hospital service requirements, plus information
for civil defence and local authority links with
the NHS. In addition guidance is given in rela-
tion to radiation and chemical incidents.
After the incident in Japan the author
became concerned about how her own A & E
department could cope in a similar disaster.
London has been involved in many terrorist
incidents in the past years, e.g. IRA bombings,
so there is the possibility of a terrorist incident
involving chemicals. As a specialist A & E nurse
the author finds the lack of decontamination
facilities, protective clothing, and training
around the UK worrying.
There is limited information available on the
preparedness of London hospitals for a chemical
disaster, which is why the author feels this is an
area requiring attention. Research needs to be
undertaken to provide evidence on the level of
preparedness of all A & E departments for
chemical incidents, and if they are unprepared,
suggestions need to be made on how this
situation can be improved.
Human activity may well cause the
emergency in the first instance but at the end
of the day human resourcefulness will
probably prove to be the salvation in
managing the emergency to a proper
conclusion.
(Stealey 1995)
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