Medical Air Solutions, LLC

RBC Terrorism Preparedness and the Emergency Department
 

Terrorism was in the news again when ricin was discovered in a senator’s mailroom in the Senate office building in Washington, D.C. Ricin is manufactured by processing waste of castor beans in a lab and then grinding the beans into a powder, aerosol or pellet form. It is a deadly toxin in very small quantities and there is no known cure or antidote. Luckily, the grinding equipment that is commercially available cannot make the particles small enough to be in the sub-micron range to where it can become airborne and stay airborne for extended periods of time.

There does exist such equipment, but usually “poor” terrorists do not have the funds to purchase what is necessary to make the finer particles needed to make ricin more than a very localized threat. It possibly came in the mail and, unfortunately, processing ricin with ionizing or microwave radiation does not deactivate this compound. This chemical compound cannot be transmitted from one person to another unless the compound is embedded in a person’s clothing and is generating the ricin dust from normal movement.

The terms for different kinds of terrorist/warfare attacks are sometimes described as RBC (Radiological, Biological, Chemical), NBC (Nuclear, Biological, Chemical) or CBR (Chemical, Biological or Radiological). They all mean the same thing. Here is a brief description of each:

Radiological Attacks

These can be manifested in two (2) forms. A nuclear detonation or the spread of radioactive particles from radioactive material by means of conventional explosives.

A nuclear detonation will cause massive casualties. Survivors may experience blindness (from the flash of the detonation), physical trauma (from the blast/shock wave), thermal related burns, radiation burns, radiation poisoning (hours to days after) and many long term effects such as cancer, etc.

The “dirty bomb” would probably be the terrorist’s choice due to the fact that nuclear detonation devices tend to be difficult to acquire and hard to transport and hide. This type of attack occurs when an explosive is used to fracture radioactive material into small particles. The area is usually small and their may be casualties from the blast, but, the idea is to spread the particles in a specific area to instill terror in the local populace. Survivors near the blast may become contaminated with radioactive particles and the threat of long term health problems are increased.

Biological Attacks

This is far and away the most serious of the three types of attacks that would be initiated by terrorist organizations. Many countries have stores of biological agents such as smallpox and anthrax already produced, and, while acquiring these elements may sometimes be difficult, it can be accomplished, making this type of attack is a definite possibility.

Dissemination of these agents can be specific to buildings or can be spread by mechanical devices in large areas (crop dusters, aerosolizers, etc.). In the case of widespread dissemination, aerosolization would probably occur on a clear day just after sunset in the summer or fall with a light breeze. High winds and severe weather would not be conducive to a good “spread”. The light winds would keep the agent suspended and moving for an extended period of time.

Casualties from this type of attack may not appear for days depending upon the incubation period for the pathogen used. In a large number of cases, most people will go to the Emergency Department (ED) of their closest hospital. The ED could quickly become inundated with patients.

Chemical Attacks

Chemical attacks can be as dangerous to the attackers as it can to the intended victims. In WW 1, their were many instance of a sudden change of wind that blew the chemical released back to the soldiers that released it. For this reason, most terrorists will probably use chemicals in buildings or enclosed places. The casualty count may not be as high but the effect is usually to instill terror which usually succeeds.

Another form of chemical attack would be to poison a water or food supply. This type of attack would usually require a large amount of chemical and, while possible, is not as easily accomplished as targeting a specific building or area. Ricin, which is water soluble, is a prime candidate for this type of attack.

E. R. Preparedness

The consequences of a bioterrorist attack may not be apparent for days after the attack has occurred. With many weaponized pathogens, the symptoms may cause people to go to their primary physician or, if after office hours, they will go to the local Emergency Room. The Department of Health and Human Services (DHHS/HSRA) has allocated $20,000 per hospital through individual state health departments for training and to purchase equipment (air purification systems and related equipment) to prepare for this type of event. Those funds were allocated in 2002 and must be spent by March 31st, 2004. The money which is allocated for 2003, will be based on hospital size, and present state of preparedness. Those monies have been identified as being between $30,000 and $55,000, but not yet funded by Congress as of this writing. .

There are a number of engineering precautions that can be taken to reduce the threat of airborne pathogens in the E.R. Of the two (2) methods of pathogen reduction, dilution and removal, removal is the “best practice” for preventing the transmission of contagious diseases. HEPA filters are the primary and preferred way to remove viruses, bacterial and spores from airstreams and inhabited areas. Another method is the utilization of UVGI (Ultraviolet Germicidal Irradiation) which cannot be used in place of HEPA filtration, but does make a cost effective second line of defense.

HEPA filters are 99.97% efficient at 0.3 microns. Larger particles and smaller particles (down to 0.001 microns) are captured at virtually 100% efficiency. HEPA filters which are used in healthcare applications must be “certified”. This means that each filter is individually tested at the factory and is issued a certificate stating it has passed the standard D.O.P. test (Mil-Std 282 Dioctylphthalate test, or the Potassium Chloride KCL test). The certificate is usually affixed to the frame of the HEPA filter. The HEPA filter should also be sealed in its frame in the APS.

The E.R. waiting room is a “critical area” that should have a minimum of 15 HEPA filtered air changes with airflow dynamics positioned to move air from supply to exhaust in one pass. There may not always be a perfect configuration for this room, but the use of UVGI can greatly extend protection for this area.
Medical grade air purification systems (APS) can be installed permanently as part of the HVAC system or portable APS can be utilized to provide this air change per hour (ACH) requirement.

JCAHO is requiring (as of October 1, 2003) that at least one treatment room in the E.R. be capable of maintaining a monitored negative pressure environment and that all infectious isolation rooms have a permanent monitoring device. The APS for the waiting room and treatment room plus monitoring devices can be purchased with the bioterrorism funds available.

Upper room UVGI, properly specified, has been shown in recent studies to be highly effective by dramatically reducing the pathogen count in a specific area. A six (6) year study for NIOSH (National Institute of Occupational Safety and Health) by the University of Colorado and findings at Harvard Univ. Medical School stated in “Public Health Reports”, March-April 2003, Volume 118, pp 99-114 has determined that upper room UVGI should be installed in all infectious isolation rooms (Univ. of Colorado) and be used to counter weaponized pathogens which are as susceptible to UVGI as the non-weaponized varieties (Public Health Reports).


For more information, call Medical Air Solutions at 800-645-1059 or our engineering dept. at 770-377-3884.
 

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