**[VAMC HAZMAT DECON PLAN-2000]{.underline}**

**WASHINGTON DC**

**VAMC**

**HAZMAT OPERATION PLAN**

** (DECON)**

**2000**

######### CHAPTER 14

Revised April 2000

######## [NOT/ARE]{.underline}

This hospital is [not]{.underline} an "industrial" decontamination
facility!

We [are]{.underline} a "hospital" with the capability to provide
decontamination to patients for life saving medical intervention.

If an emergency event occurs and the hospital decontamination facility
was to be activated, the hospital would immediately notify the D.C.
water and sewer authority for guidelines and assistance.

### WASHINGTON DC

**VAMC**

### HAZMAT/DECON OPERATION PLAN

**(DECON)**

**2000**

### DICTUM

### Throughout any emergency incident, this VAMC will assume a proactive, **yet defensive**, operational posture.

### As a federal hospital and emergency responder, we are here to save lives but protocol dictates that in responding, **in [no case]{.underline} will we jeopardize** medical center staff or patients.

### *The Director*

### VAMC HAZMAT/DECON PLAN -- 2000

### DICTUM

### Throughout any emergency incident, this VAMC will assume a proactive,** yet defensive, **operational posture**.**

### As a federal hospital and emergency responder, we are here to save lives but protocol dictates that in responding, **in [no case]{.underline} will we jeopardize **medical center staff or patients.

### The Director

### [VAMC HAZMAT DECON PLAN -- 2000]{.underline}

### ALL FEMALE

### STAFF WITH THE

### REMOTEST

### POSSIBILITY OF BEING

### PREGNANT SHOULD BE

### PREVENTED FROM

### PARTICIPATING IN

### DECON ACTIVITIES

### [VAMC HAZMAT DECON PLAN -- 2000]{.underline}

### CONTENTS

### CHECKLIST/DECON TEAM LEADER.................................... pp 14-2

### INTRODUCTION............................................................... pp 14-5

### PROJECTED SEQUENCE OF EVENTS.................................... pp 14-7

### EXECUTIVE SUMMARY..................................................... pp 14-8

### ANNEX A -- DIRECTOR...................................................... pp 14-15

### POLICE........................................................... pp 14-15/18

### DECON MD..................................................... pp 14-19

### ANNEX B -- NURSING........................................................ pp 14-20

### ANNEX C -- RADIOLOGY................................................... pp 14-22

### ANNEX D - VAMC STAFF................................................... pp 14-24/46

### ANNEX E - PUBLIC AFFAIRS............................................ pp 14-47/49

### APPENDIX I -- DETERMINATION OF ADEQUATE FIELD DECON pp 14-51

### APPENDIX II -- ARRIVAL OF UNANNOUNCED PATIENT......... pp 14-52

### APPENDIX III -- PROCEDURE FOR DECONTAMINATION

PATIENTS ................................................. pp 14-53/54

APPENDIX IV -- PATIENT HOLDING AREA........................... pp 14-55

### APPENDIX V -- DECONTAMINATION CLINICAL PERSONNEL.... pp 14-56

### APPENDIX VI -- RADIATION RESPONSE PLAN........................ pp 14-57/58

### ATTACHMENT I -- OUTSIDE VAMC/DECONTAMINATION AREA pp 14-60

### ATTACHMENT II -- DECONTAMINATION AREA/ASSIGNMENTS pp 14-61/62

### ATTACHMENT III -- PERSONAL PROTECTIVE EQUIPMENT.......... pp 14-63/64

14-1

### CHECKLIST

### ATTENDING CHECKLIST

**VETERANS AFFAIRS MEDICAL CENTER (VAMC)**

**READ ME FIRST!**

#### [DECON TEAM LEADER]{.underline}

The purpose of any hazardous materials response is to remove a toxic
substance from a patient in a manner that is safe to both the patient
and the care provider. Realize that some toxic substances can be
transferred to you, the care provider, unless some form of protection is
worn. Also realize that some toxins may not be readily detectable. The
following checklist of questions should assist you, DECON Team Leader,
in determining what ***initial*** steps to take when confronted with a
potential hazardous materials incident and whether to use the rest of
this plan.

**I.) WHAT IS THE TOXIC SUBSTANCE AND METHOD OF EXPOSURE?:**

· Determines whether Hazardous Materials plan is even needed.

· Determines risk to hospital staff and thus level of protection needed.

· Ideally, EMS will have identified the toxin prior to patient arrival,
but if not, **no patient(s) are allowed into the hospital treatment area
until the agent has been identified and decontamination has occurred
(Appendix 1-5, attachment (1) & (2).**

**I.) WHAT TYPE OF EVENT HAS OCCURRED?:**

· A MULTI-CASUALTY INCIDENT WILL REQUIRE ACTIVATION OF THE **Full-scale
disaster plan** regardless of the toxin involved.

· How many victims are involved? A few people exposed to a minor
irritant (e.g., tear gas) can be effectively handled without the
disaster plan.

· Any Hazardous Materials event will require notification of police,
engineering, administration and environment management.

**I.) DIRECTOR/ASSOCIATE DIRECTOR/DIRECTOR, EMERGENCY OPERATION CENTER
(EOC):** With the above information you now have only one decision to
make.

· Do I need to use this HAZMAT plan to remove a toxic substance from
patients?

**ONCE YOU HAVE THIS INFORMATION, RESOURCES SUCH AS POISON CONTROL CAN
HELP YOU DETERMINE THE FOLLOWING.**

**I.) ARE THERE ANY RISKS OF SECONDARY CONTAMINATION?:**

· Some substances or the manner in which a patient was exposed (i.e.,
ingestion, vapor exposure) pose limited risk to the responder and
therefore this entire plan is not needed.

· Other substances are easily transferable to the responder or are so
toxic that this plan should be used.

14-2

**I.) WHAT ARE THE DANGERS AND CLINICAL SIDE EFFECTS OF THE TOXIC
SUBSTANCE?:**

· Is the substance flammable?

· Can the substance on the surface of the victim vaporize or be
re-aerosilized to affect hospital staff?

· Are there toxidromes to be aware of and what are the signs and the
symptoms of the exposure? Are the signs and symptoms immediate or
delayed?

**I.) WHAT KIND OF PROTECTION DOES ONE NEED TO HANDLE THESE PATIENTS?:**

· Some substances require only every day hospital garb for adequate
protection.

· Other substances require a higher level of protection. The maximum
level of protection available at VAMC is called **LEVEL C.** This
includes a suit, gloves, boots, and a face mask (rubber hood) with
breathing tube with respiratory cartridges. (Attachment 3)

**I.) WHAT TYPE OF DECONTAMINATION IS NECESSARY FOR THE PATIENT(S)?:**

· Most substances require washing the patient with water only.

· A few rare substances react violently with water and should be brushed
or vacuumed off the patient.

· Do you even need to decontaminate the patient?

**I.) IS THERE A SPECIFIC ANTIDOTE FOR THE TOXIN?:**

· If so, does the VAMC have antidote(s) available? If not, contact
Public Health Service/Metropolitan Medical Strike Team and request use
of the MMST Cache if the antidotal drug is on hand. **You cannot use the
MMST cache without official release (Phone \#'s 14-11, 12).**

Given the diverse nature of possible etiologic agents, it is impossible
to place on paper one single plan to encompass them all. In almost all
situations, patients will present in an irregular fashion at a delayed
time after their exposure (incubation period). Instead of a large number
of patients presenting at one time, several patients may present over a
period of days with similar infectious symptoms. The real trick will be
to recognize that there has been a biologic release at all. If an event
is recognized, coordination with the Department of Infectious Diseases
is necessary. Information regarding the incident must be directed to
hospital administration as soon as possible for coordination with the
D.C. Department of Public Health and the D.C. Emergency Management
Agency.

In rare cases, a pre-announced release or a rapidly detected release
will occur. In this instance, decontamination should occur as with other
HAZMAT contaminations. There may be some variations dependent on the
agent involved. If there are any questions,

14-3

consideration should be given to the quarantine of the exposed patients.
In most cases, regular hospital PPE (e.g., N-95 mask, gown, eye
protection and gloves) is adequate protection for the staff.

### 14-4**VAMC WASHINGTON**

**DECONTAMINATION PLAN**

**INTRODUCTION**

A. GENERAL.

1\. The Medical Center Director is responsible for the implementation of
this plan.

1\. The purpose of this plan is to provide guidance to the Washington DC
VA Medical Center (VAMC) in providing HAZMAT support to the Washington,
DC area.

1\. This plan has been coordinated with: Washington, DC Fire Department
(EMS), Washington, DC Emergency Management Agency Office and the
Washington, DC Office of Commissioner of Public Health, Emergency Health
and Medical Services and the Washington area MMST and US Public Health
Service/National Disaster Medical System (USPHS/NDMS), F.B.I. & the
Secret Service.

4\. A projected schedule of events is at Page 14-7.

A. ASSUMPTIONS.

1\. This plan is based on the premise that the VAMC, if requested to
activate the DECON unit, will have a time lag of at **least one hour**
before victims/casualties begin arriving for treatment.

1\. The VAMC will be responding to a Nuclear/HAZMAT type incident --
either natural or man made.

1\. Planning will be based on existing personnel.

1\. Most patients arriving from the disaster area will have undergone
some basic HAZMAT decontamination (gross) and agent (bio/chem) will have
been identified.

1\. All clinical DECON will take place in the VAMC DECON area
(Attachments (1) and (2)).

14-5

C. FACT.

1\. Unit is capable of Secondary and Definitive DECON.

**1. VAMC will not accept biological casualties unless agent is
identified and proper antidotal medicines are available for required
treatment**.

Gross Decon

1\. Evaluate the patient(s) from the high-risk area.

1\. Remove the patient's clothing

1\. Perform a one-minute quick head-to-toe rinse with water.

Secondary Decon

1\. Perform a quick full-body rinse with water.

1\. Wash rapidly with cleaning solution from head to toe.

1\. Rinse with water from head to toe.

Definitive Decon

1\. Perform thorough head-to-toe wash until "clean".

1\. Rinse with water thoroughly.

1\. Towel off and put on clean clothes.

D. DECON Pager Activation

1\. Effective April 7, 2000, the Medical Center activated **Code
Decon.** **Extension 6801** has been set up for the receipt of the DECON
Activation call.

1\. The responsibility of the switchboard operation will be to submit a
pager message through the "Quick Mate" paging device upon request from
the:

a\. Medical Center Director,

a\. Associate Director,

a\. Associate Director for Patient Service,

a\. Emergency Preparedness Officials: Phil Forbes, Chief Evans, John
Lewis, or Dr. Steadman.

1\. This message to be sent is **"All Decon Personnel Report to Your
Assigned Station"**

1\. The switchboard operator will annotate the request in the unusual
incident book. This note will provide the time and the name of caller
who requested the Decon emergency code to be sent. The switchboard
operator will also annotate her operator number to identify who received
the request.

14-6

**PROJECTED SEQUENCE OF EVENTS**

· Police/VAMC receives alert call.

· Police verify event. OBTAIN as much event information as possible.

· Police notify Assn. Director/Senior Clinician in Nursing Service

· Event is evaluated by senior management

· HAZMAT Plan activated -- hospital "closes."

· Activate DECON Pagers (X-6801)

· VAMC AEC commences mobilization.

· VAMC personnel report to assigned DECON stations.

· Patient arrival and treatment/DECON.

· Hospital personnel DECON.

· Hospital secures from event.

· Removal contaminated clothing/equipment.

· Clean DECON area.

· Critique.

· Resume normal routine.

14-7**EXECUTIVE SUMMARY**

###### AMBULATORY EMERGENCY CARE (AEC) HAZMAT PLAN

**[ACTIVATION OF PLAN:]{.underline}**

The decision to activate the DECON plan is made by the
**Director/Associate Director** in conjunction with the **AEC Attending
Physician** on duty in consultation with the **Charge Nurse **on duty
and the **hospital administrator** on call (as time permits). It is
presumed that, in most instances, District of Columbia Fire and Rescue
will be able to provide some warning of the delivery of exposed
patients. It is also presumed that these patients will have received
some form of decontamination (gross) in the field. It is important to:

· Determine if adequate field decontamination was performed. (see
Appendix I)

· Be prepared for the unannounced arrival of potentially contaminated
patients. (see Appendix II)

**[AEC MANAGEMENT:]{.underline}**

Once the DECON plan is activated, the next decision to be made involves
management of the AEC and its resources. **The regular AEC will remain
open to receive regular patients in that all Emergency HAZMAT procedures
will be performed in the DECON area.**

**[CALL LIST:]{.underline}**

Once the DECON plan is activated the VAMC's Emergency Plan, the
telephone cascade and DECON Pager system will be put into effect. This
will bring in back-up personnel and VAMC personnel from Police,
Resources Management, EMS and Engineering to assist with set-up of the
decontamination site.

**[PREPARATION:]{.underline}**

The specific toxin dictates what self-protection will be required as
well as what type of decontamination will be necessary. **In the
instance where the threat of secondary contamination or spread of the
toxin is a concern [or]{.underline} is unknown, all patients will remain
in the DECON unit area until adequate decontamination has been
performed.**

There is only one area for decontamination of patients. (See attachments
#1 and #2) As patients arrive, VAMC police, outfitted in prescribed
Personal Protective Equipment (PPE), will direct or transport them to
the DECON using an [outdoor]{.underline} route.

Preparation of the DECON site is covered in Annexes B, C, and D.

The DECON site will not be entered by VAMC staff unless proper
protection equipment (PPE) is worn. The site is referred to as the "hot
zone." (Staff use of personal protective equipment is covered on pages
63 and 64, (Attachment (3)).

All electronic detection equipment and PPE for decontamination is kept
in two places:

· DECON Equipment Room GD-243 & 247.

· Radiation Safety Survey Meters GD-213 (Radiology Department).

14-8

Currently, the VAMC has a supply of Mar Mac "C" level suits, surgical
gloves, boots, surgical masks/gowns and 16 Turbo PAPR (Powered Air
Purifying Respirator) Assembly and filter type masks.

In a situation with large numbers (20+) patients to decontaminate, a
maximum of 30 clinical VAMC personnel (Annex A, B, D, Appendix IV,
Attachment #2) in protective gear will be needed. Not all situations
will require this type of staffing. The following position assignments
(all of which will be wearing PPE) should be made by the AEC Attending
on duty in conjunction with the AEC charge nurse:

· 1 DECON officer (usually senior RN or AEC physician): briefs team,
oversees set-up of the DECON areas and performance of DECON. Assists
with safety issues. (Annex A, B, D, Appendix 3 and 4, Attachment 2)

· 1 DECON MD: acts as Hot Zone Supervisor, assists with safety issues,
provides emergency treatment only as needed (Attachment 2 & Annex A).

· See Annex D for VAMC staff assignments.

**[PATIENT ARRIVAL:]{.underline}**

The "Hot Zone" DECON physician will, upon arrival, assess the condition
of the patient as well as the degree of contamination. Triage procedures
should be initiated at this point, if necessary. During this initial
patient survey and stabilization, contamination reduction should be
simultaneously performed. This will include the removal of all clothing
and personal effects. Ambulatory personnel will be directed to the
proper DECON reception areas (Attachment #2, #8 and #10). Stretcher
patients will have their clothing removed by the Hot Zone DECON Team.
**An initial wash down will be performed before removal to the inside
DECON area**.

**[DECONTAMINATION:]{.underline}**

Each individual's duties are outlined in the tear-out sections Annex B,
C and D of this document. Instructions of how to decontaminate a patient
are provided on page 53/54, Appendix 3, with a flow diagram (Attachment
#2). DECON personnel should familiarize themselves with these procedures
during preparation for the arrival of patients.

The type of decontamination is determined by the specific toxin
involved. Patient flow should be in an orderly fashion. After
decontamination, flow should proceed out the other side of the "hot
zone." All hospital personnel in the "hot zone" must wear protective
gear. Once they have entered this zone, they themselves must be
decontaminated in their protective gear before exiting the area
(Attachment 3, Appendix 5).

#### [CHEMICAL RADIOLOGICAL AND RADIATION MONITORING STATION]{.underline}

Prior to any patient leaving the DECON AREA and being admitted to the
TRIAGE area (#18), he/she will be required to undergo a Chemical, &
Radiological survey.

This survey will be performed by a doctor/clinician from the Radiology
Department.

14-9

This survey will be performed in the hallway outside the DECON shower
units (#17) at station point (#5). The doctor/clinician will have a
radiological testing and CBR detection device (APD 2000) at station #5.
All patients will be halted at the station by a policeman and the
doctor/clinician will conduct a quick 'sweep' of the patient. If the
patient is 'CLEAN', he/she will be allowed to proceed to the TRIAGE
(#18) area. If the patient is judged to be no 'clean', they will be
returned to the respective DECON area for further decontamination.

#### [PATIENT INQUIRIES]{.underline}

Under no circumstances will anyone other than the Director, Associate
Director, Chief of Nursing and the Public Affairs Officer provide any
information concerning a patient's condition to an outside source. All
inquiries of this nature should be given to the PAO. The PAO is allowed
to verify that a patient is on board.

**[INCIDENT COMPLETION:]{.underline}**

After all patients have been decontaminated, a distinct set of steps
needs to be followed by the VAMC DECON Staff to prevent the spread of
the toxin from the "hot zone." These steps can be found in Appendix 3.
Engineering and EMS will assist with clean up efforts under the
supervision of the DECON officer and VAMC Safety officer.

#### [POST EVENT DEBRIEF AND SURVEILLANCE]{.underline}

All staff directly involved in the decontamination of patients will
participate in a post-event debriefing to be held within 72 hours under
the direction of the Associate Director. Participating staff members
will also be entered into a post-event surveillance system which will be
initiated by the AEC and then continued by Employee Health. Initial
entrance into the surveillance system will consist of a registered visit
to the AEC for a physical exam.

#### [DECEASED/DISPOSITION]{.underline}

Normal hospital procedures.

Body contaminated -- cover and place in the HOT ZONE area for pick up by
DC Fire/Police.

14-10**HELPFUL PHONE NUMBERS AND RESOURCES**

**DECON PAGER ACTIVATION 202-745-8000, X- 6801**

HOLDING AREA 202-745-8618/8534

**DECON UNIT **202-745-8000, x7695

(#17) X6473 (#23)

(GD-247)

**POISON CONTROL** 202-652-3333

CHEMTREC 202-425-4300

Useful for the identification of ingredients in many industrial
substances as well

As their properties.

EPA REGION III 215-566-3255

A 24-hour hot line number for use in a very large scale incident.

D.C. FIRE AND EMS WATCH OFFICER 673-3266 or 3267

D.C. FIRE AND EMS COMMUNICATIONS 673-3264 or 3265

INTERNET MSDS SHEETS

##### MILITARY RESOURCES

Chemical Biological Defense Command (CBDCOM) 800-368-6498

Military center for coordinated defense against chemical and biological
weapons.

Chemical Incident National Response Center 800-424-8802

Biological Incident, Medical Research Institute of Infectious Disease

1-888-872-7443

Armed Forces Radiobiology Research Institute 1-800-SKY-PAGE

PIN 801-0338

301-295-0316

REAC/TS (national radiation response) 423-481-1000 (beeper 241)

**Metropolitan Medical Strike Team (MMST)** can be accessed through
Arlington County EOC at:

703-558-2222

##### DC WATER AND SEWAGE

James McQueen, Security & Facilities Safety 202-645-6443

Claude Williams, Safety Director 202-645-0417

Pager: 202-668-6824

14-11**BIOLOGICAL HAZARDS**

Consideration should be given to the possibility of a biological
hazardous material incident when multiple patients with similar symptoms
present (e.g., rashes, flu-like symptoms, fevers)

Some helpful numbers:

1\. Military Research Institute of Infectious Disease: 1-888-872-7443

2\. CDC 24-hour hotline: 770-488-7100

Department of Infectious Disease: 8301 (Office)

8695 (Clinic)

3\. D.C. Poison Control: 202-625-3333

4\. D.C. Department of Public Health: 202-645-5628

5\. BIOLOGICAL/INFECTIOUS DISEASE

U.S. Army Research and Material Command

Fort Detrick, Maryland

301.619.2833

1.888.872.7443

14-12

**ANNEXES**

ANNEX A DIRECTOR.................................... pp 14-15

POLICE......................................... pp 14-15/18

DECON MD.................................\... pp 14-19

ANNEX B NURSING...................................... pp14-20/21

ANNEX C RADIOLOGY................................. pp 14-22/23

ANNEX D VAMC STAFF..............................\... pp 14-24/46

ANNEX E PUBLIC AFFAIRS........................... pp 14-47/49

14-13**ANNEX A**

**DIRECTOR**

**POLICE**

**DECON MD**

14-14**[ANNEX A]{.underline}**

1\. MEDICAL CENTER DIRECTOR will activate the VAMC's Emergency
Preparedness Plan (Medical Center Policy Memorandum 138-6, dated
October, 1995.) The Incident Command System (ICS) will be utilized.
**DECON Pager Alert X-6801**

2\. POLICE.

**a. Police service will act as the primary/initial point of contact
(POC) for the VAMC response.**

a\. In the performance of their duties, the police will have a key to:
the DECON area. The key will be kept in a secure location to be used
only in the event of an actual alert/drill. **(Key = AK MASTER)**

a\. Police Service will upon receipt of a phone call from a designated
Federal response agency, alert cognizant VAMC staff members. The alert
phone call will inform the VAMC that an incident has occurred and the
VAMC will/may be in receipt of victims.

a\. The police representative will, upon receipt of an alert request:

\(1\) Take caller/requester's name, **obtain a call back name, agency,
and contact number **for verification.

\(1\) Call requester back and verify alert. At this time find out as
much about the situation as possible:

· time of event

· location of incident

· type (HAZMAT/nuclear) of event/incident

· agent identified (?)

· probable number of victims for VAMC (ambulatory/stretcher)

· transportation mode of casualties (motor transport, walking, etc.).

· estimated time of arrival

\(1\) Alert the Director and Associate Director's Office, Nursing
Service and AEC.

\(1\) If authorized by senior management have all vehicular entrances to
hospital closed except the main gate (#1). Gate #1 will remain open to
normal traffic and a police officer will monitor the traffic flow. Clear
this action with Director's office. All police assigned to gate security
will put on appropriate PPE.

\(1\) Contact the AEM (745-8181/pager: 1-888-765-6497).

14-15

a\. \*Once the Director and AEC have been alerted, the police
representative will contact the following personnel:

\- Associate Director 745-8101-who may put the VAMC on "ALERT STATUS".

\- Chief of Staff 745-8225

\- Chief, A&MMS 745-8218/8216

\- Chief of Nursing 745-8219/7361

\- Chief of Police 745-8188/7462

\- Chief of Engineering (EPC) 745-8372

\- Director, Resource Mgmt Svc 745-8229

All cognizant Police on Duty

\- Police at Front Entrance Duty Box (if manned)

\- Administrative Officer of the Day (AOD) 745-8236/8360

**\*After hours/weekends** the police will call the VAMC personnel at
their **off duty phone numbers** including the **AEM**.

f\. If a HAZMAT/nuclear incident has occurred, the police will
immediately go to Gate 2 (Attachment 1) and take charge of traffic
control. All casualties will be directed to Gate 2 for processing.
Officers will be properly outfitted with the necessary DECON personal
protective clothing and equipment. Officers will have radio contact with
the DECON unit to advise the unit of the traffic/patient flow. Be
especially aware of the "unscheduled walk-on" patient (Appendix II).

g\. Other officers, if available, will be positioned at points '**A**'
and '**B**' #'s 3, & #23 (Attachment 1 and 2) to assist with
traffic/crowd control. **Secure DECON area from all unauthorized
personnel.**

h\. Carry out duties as stated in VAMC Emergency Preparedness Plan.

i\. Go to DECON AREA and unlock all doors inside and out (GD: 227, 237,
238, 243, 247, Hallway).

j\. Assist in moving PC (Room GD: 247) to DECON area \# 23.

k\. Open door to Room GD-227. Clear passageway to DECON area.

l\. Officers at points 'A' and 'B' will ensure that all vehicles
carrying patients, once the patients are unloaded, will be parked in
adjacent parking spaces to the DECON facility and not allowed to depart
the VAMC until properly DECON'd. Drivers of said vehicles will remain
with their vehicles unless their personal decontamination is required.

14-16m. If asked to provide a "bed status" report, police will contact
the AOD:

745-8236/8360.

n\. Radios are critical! Ensure, at the minimum, that the EOC, all
supervisory personnel in VAMC emergency plan and personnel in DECON
areas \# 3, 11, 17, 18, 24, 21 and "Holding Area" -- GC-217 are provided
radios.

**[SPECIAL INSTRUCTIONS FOR GATE 2]{.underline}**

**[THE OFFICER BE ASSIGNED TO THIS CRITICAL AREA MUST BE THOROUGHLY
COGNIZANT OF THE DUTIES AND RESPONSIBILITIES OF THE
POSITION.]{.underline}**

**[THE GATE TWO (2) POSITION IS ONE OF THE MOST CRITICAL AREAS OF THE
HOSPITAL IN TIMES OF CRISIS/EMERGENCY DEALING WITH A WMD OR OTHER TYPE
OF MASS CASUALTY EVENT. ALL CASUALTIES WILL BE ROUTED THROUGH THE GATE 2
POSITION.]{.underline}**

**[GATE 2 IS THE PATIENT FLOW ]{.underline}["]{.underline}[CHOKE
POINT]{.underline}["]{.underline}[ FOR THE ENTIRE HOSPITAL. YOU HAVE THE
RESPONSIBILITY OF PATIENT FLOW INTO THE DECON TREATMENT AREA. IN ORDER
TO DO YOUR JOB ]{.underline}["]{.underline}[YOU
MUST]{.underline}["]{.underline}[ BE IN CONSTANT COMMUNICATION WITH THE
OIC DECON/EMERGENCY MANAGEMENT PHYSICIAN/CLINICIAN LOCATED IN THE DECON
TREATMENT AREA. THIS WILL BE ACCOMPLISHED BY RADIO.]{.underline}**

14-17

**[WHEN CASUALTIES ARRIVE!!! YOUR JOB IS TO STOP THE VEHICLE/PERSONNEL,
THEN CONTACT THE DECON OIC, AND INFORM HE/SHE OF THE ARRIVAL OF
CASUALITIES]{.underline}[...]{.underline}[YOU WILL INFORM THE OIC OF THE
NUMBER OF CASUALITIES AND IF POSSIBLE THEIR CONDITION I.E.: AMBULATORY,
STRETCHER ETC]{.underline}[...]{.underline}**

**[AT THIS POINT THE DECON OIC WILL TELL YOU TO EITHER RELEASE TO DECON
TREATMENT AREA OR DETAIN THE CASUALTIES/PATIENTS AT GATE
2.]{.underline}**

**[REMEMBER YOU DO NOT RELEASE ANY VEHICLES/PATIENTS TO THE DECON
TREATMENT AREA UNTIL YOU ARE SPECIFICALLY TOLD TO DO SO BY THE DECON
OIC!!!]{.underline}**

**[SPECIAL INSTRUCTIONS FOR GATE 1]{.underline}**

**[POLICE AT THIS LOCATION WILL BE ALERT FOR THOSE PERSONS
]{.underline}**

**[COMING TO ]{.underline}[PICK-UP PATIENTS]{.underline}[ WHO ARE IN THE
]{.underline}[HOLDING AREA]{.underline}[.]{.underline}**

**[ THESE PERSONS WILL BE DIRECTED TO THE PARKING AREA NEAR
]{.underline}**

**[THE ]{.underline}[NURSING HOME CARE UNIT (NHCU)]{.underline}[
ENTRANCE. THEY WILL BE ]{.underline}**

**[TOLD TO PARK THEIR VEHICLE AND SEEK OUT A POLICE/SOCIAL
]{.underline}**

**[WORK SERVICE REPRESENTATIVE WHO WILL DIRECT THEM TO THE
]{.underline}**

**[NHCU RECEPTION AREA FOR PATIENT PICK-UP]{.underline}.**

14-18

**[DECON MD]{.underline}**

The AEC in charge/DECON MD will, in coordination with the Nursing
Service, perform and assist in the following protocol/procedures.

· Take charge of the situation.

· Put on personal protective gear.

· Act as safety officer for all DECON personnel

· Assure personnel are not fatigued

· Assure suit integrity of PPE

· Monitor personnel for signs of illness

· Monitor ambulatory patients for signs/symptoms of illness

· Medically intervene only when emergent (avoid invasive medical
procedures in decontamination area unless necessary to save a life.)

· Assist in patient flow.

· Assure that no contaminated material (clothing, etc.) is allowed to
enter the hospital.

· Ensure patients are washed down (#7, 8 & 10) outside prior to entering
DECON shower areas.

· In conjunction with the Incident Command System/VAMC Safety Officer,
assist with the preparations of the DECON areas. (Attachment 2)

· Based on agent identification (chemical/biological) contact Pharmacy
and arrange for delivery of pharmaceuticals (if available) to DECON
area.

· Initiate prescreening of staff prior to dressing in protective gear.

· Brief ambulatory and critical care teams on how to perform DECON.

· Perform visual triage of patients as they arrive.

· Direct ambulatory patients to one of two areas (male/female &
children) for DECON, assuring patients are logged in and given/have
triage tags.

· Ensure that a DECON monitoring station is set up in Area #5.

14-19**ANNEX B**

**NURSING**

14-20**[ANNEX B]{.underline} NURSING**

1\. Upon alert by VA Police, Nursing Service will provide:

a\. Two (2) clerical personnel trained in self protection procedures to
position (4) (See Attachment 2) to assist the DECON physician in
directing casualties to the DECON unit.

b\. One personnel (each) to positions (7) & (8) to "WASH DOWN"
casualties. Outside hoses will be used in the 'spray' mode. Ensure that
nozzles are on all the outside hoses. ALL PERSONNEL entering the DECON
area will be WASHED DOWN.

c\. Two personnel (each) to positions (7), (8), and (10) for the
removal, collection, disposal and tagging of patient clothing/personal
items. All clothing that is removed will be placed (double bagged) in a
DECON marked receptacle.

d\. Two critical care nurses for Hot Zone triage/medical care (11).

e\. One supervisor to positions (10), (13), (17) and to supervise the
HOT ZONE corridor, HOT ZONE triage/DECON showers/PPE distribution and
patient disposition respectively.

f\. Personnel to area (18) to assist (as required) in CLEAN ZONE medical
triage.

g\. Personnel to Decon station #15 as requested by Decon supervisor.

h\. Personnel to Patient Holding Area (GC-217) as required.

i\. Contact Central Processing Distribution (CPD), X8601, to deliver
medical supplies to DECON area. The supplies would be available to
support "minor" injuries i.e.: band-aids, surgical wraps, pain
medication (tylenol, asprin...).

j\. Personnel to positions (5), (23) to commence patient tracking.

k\. Call Engineering Control Panel (X-7700 or X-8405) and direct "Cut
off all air handler in MER 2)".

ALL PERSONNEL WILL WEAR LEVEL C PERSONAL PROTECTIVE EQUIPMENT WHEN
PERFORMING THESE DUTIES IN THE DECON HOT ZONE/DECON SHOWER AREAS
(ATTACHMENT 3).

14-21

**ANNEX C**

**CHEMICAL, BIOLOGICAL**

**&**

**RADIOLOGICAL MONITORING**

**STATION**

14-22**[ANNEX C]{.underline}**

**[RADIOLOGY]{.underline}**

INTRODUCTION. CHEMICAL, BIOLOGICAL & RADIOLOGICAL (CBR) EXPOSURE
INCIDENTS ARE BY THEIR NATURE COMPLEX. ONE OF THE FIRST ACTIONS TAKEN IN
RESPONSE TO THE EVENT IS THE INVOLVEMENT OF THE HOSPITAL'S RADIOLOGICAL
SAFETY OFFICER (RSO) (EXT. 7546: BEEPER 3115).

· Upon activation of this plan, the RSO and Chief, Nuclear Medicine
Technologist will proceed immediately to the DECON unit. Upon arrival
the RSO will establish a CBR monitoring station (#5) in the hallway
(#17).

· The CBR monitoring station will be staffed by the RSO, and a staff
nuclear medicine technologist, and a nurse who will assist the RSO with
monitoring each patient following decontamination and initiate patient
tracking.

· The RSO will use one or more microroentgen per hour (micro R/h) survey
meters, which are stored in room GD-213, and a chemical agent detector,
which is stored in room GD-244, adjacent to the CBR monitoring station
(#5).

· Following a DECON shower each patient will proceed down the hallway
and stop at the CBR monitoring station (#5). Here each patient will be
surveyed by the RSO for effective removal of chemical, biological,
and/or radiological (CBR) agents. Patients free of CBR contamination
will proceed to Triage at hallway (#17) or return to the DECON shower
for further decontamination.

· Patients free of external contamination but internally contaminated
will be monitored after Triage, since external shower will not remove
internal radiological contamination. Patients' waste will be
individually sampled and evaluated for internal "exposure" by the RSO.
Access to a group private room and bathroom is recommended to minimize
spreading contamination from patients' excreta. Internally contaminated
patients may be treated using standard/universal precautions as
applicable to a patient's undergoing therapeutic radioiodine treatment.

14-23

**ANNEX D**

**VAMC STAFF**

**ALL STAFF COMING IN CONTACT WITH DECON PROCEDURES [WILL BE
]{.underline}DRESSED IN APPROPRIATE LEVEL PROTECTION CLOTHING -- NO
EXCEPTIONS!**

### 14-24**[ANNEX D]{.underline}**

### STAFF ASSIGNMENTS

### AEC Attending........................................................................ pp 26

### AEC Charge RN...................................................................... pp 27

### Ambulatory DECON Personnel...................................................\... pp 28

### Acquisition and Material Management Service................................... pp 29

### Canteen Service........................................................................ pp 30

### Chaplain Service....................................................................... pp 31

### Chief of Staff........................................................................... pp 32

### Dental Service.......................................................................... pp 33

### Central Dental Laboratory............................................................ pp 34

### Engineering Service/Safety Officer................................................. pp 35

### Environmental Management Service................................................ pp 36

### Medical Service........................................................................ pp 37

### Neurology Service..................................................................... pp 38

### Nutrition and Food Service........................................................... pp 39

### Pathology and Laboratory Service................................................... pp 40

### Pharmacy Service...................................................................... pp 41

### Physical Medicine and Rehabilitation............................................... pp 42

### Psychiatry Service..................................................................... pp 43

### Psychology Service.................................................................... pp 44

### Resource Management................................................................ pp 36a

### Social Work Service/Volunteer Service............................................ pp 45

### Surgical Service........................................................................ pp 46

### ANNEX D

### 14-25**AEC ATTENDING**

· Using the initial questionnaire (pp 14-2, 3, 4) at the beginning of
this document, determine the nature of the event and decide whether
decontamination will be necessary.

· In consultation with the AEC administrative RN on duty and hospital
administration (if time permits), determine if disaster full activation
or intermediate activation is necessary. NOTIFY DIRECTOR ASAP!

· **Determine level of personal protection that will be necessary for
decon staff.** Several sources may be used to assist in this
determination including persons on the call list or resources on the
helpful numbers list (pages 14-11/12).

14-26**AEC CHARGE RN**

· Receive briefing from AEC Attending on nature of incident and level of
DECON required.

· Activate call list. (As appropriate).

· Assign DECON duties to available personnel.

· Brief DECON team on incident, patients, safety issues, and DECON
procedures.

· Supervise DECON area preparation and ensure that:

· Police has secured perimeter.

· Engineering Service has assisted with H20 and electricity.

· DECON teams have obtained appropriate materials from closets and
report to designated areas.

· Assist teams with donning of personal protective gear.

14-27

**AMBULATORY DECON PERSONNEL**

· Receive briefing from charge RN about toxin, patients, and DECON
procedure.

· Assist with establishment of DECON areas.

· Obtain prescreening from DECON officer.

· Put on personal protective gear.

· Assist patients with removal of personal belongings and entrance into
alley behind curtain (Attachment #2)

· Assist patients with instructions on disrobing and putting clothes in
DECON barrels.

· Assist in initial patient wash down in hot zone.

· Facilitate adequate patient flow -- patients are not to spend
excessive time in shower facility.

· Monitor patients for signs of illness.

· Assist patients with instructions after DECON complete.

14-28

### ACQUISITION & MATERIAL MANAGEMENT SERVICE

# [RESPONSIBILITIES]{.underline}

1\. Service Chief will assume Logistics Chief position

2\. Provide support to the Personnel Pool.

3\. Initiate emergency procurement procedures as needed.

4\. Support Engineering Service as requested.

# [PROCEDURES]{.underline}

1\. As required, initiate emergency procurement from nearby VAMC's or
community.

2\. Coordinate issuance, delivery and receipt of supplies and equipment
to affected services.

3\. Send four employees to the Personnel Pool -- DECON area (Attachment
2, #20).

4\. Have two of the large portable warehouse blowers/fans standing by
for removal to the DECON area upon request.

5\. Send two employees to Escort Pool Area (Attachment 2, #25).

14-29

**CANTEEN SERVICE**

# [RESPONSIBILITIES]{.underline}

1\. Provide emergency meals for patients, casualties and employees in
conjunction with Canteen Service

# [PROCEDURES]{.underline}

1\. Activate Service plan to provide emergency food service in
coordination with Food and Nutrition Service.

2\. Liaison with Patient Holding Area (GC-217). Extension: 8618/8534.

14-30

CHAPLAIN SERVICE

# [RESPONSIBILITIES]{.underline}

1\. Administer to religious needs of casualties.

2\. Assist the Director, Social Work with needs of patients/relatives at
the Casualty

Holding Area (GC-217).

# [PROCEDURES]{.underline}

Chief, Chaplain Service will:

1\. Initiate notification of the Chaplain Service staff.

2\. Report to Patient Holding Area, GC-217.

14-31**CHIEF OF STAFF**

# [RESPONSIBILITIES]{.underline}

1\. Maintain adequate level of medical care personnel throughout the
medical center and to provide medical care for emergency situations.

2\. Inform Medical Center Director regarding progress of medical aspects
of the plan.

# [PROCEDURES]{.underline}

Chief of Staff will:

1\. Report to EOC in person and operate from this location.

2\. Ensure Patient Holding Area (GC-217) is functional.

14-32**DENTAL SERVICE**

# [RESPONSIBILITIES]{.underline}

1\. Be prepared to send a maxillofacial trauma team to the triage area
(Attachment 2, #19).

2\. Be prepared to send emergency supplies and equipment to support the
trauma team.

3\. Provide one employee to DECON Personnel Escort Pool. (#25)

# [PROCEDURES]{.underline}

1\. Mobilize oral surgeon and other necessary staff to meet emergency
needs.

2\. Minimize routine patient treatment to maintain integrity of the
Dental Service.

3\. Detail liaison person to Personnel Pool to be dispatched to the
DECON area (Attachment 2, #25).

14-33

**CENTRAL DENTAL LABORATORY**

# [RESPONSIBILITIES]{.underline}

1\. Provide support to Dental Service.

2\. Provide manpower to Security Service to serve as Auxiliary Security
Officer.

# [PROCEDURES]{.underline}

1\. Assign auxiliary security officers.

2\. Assign a liaison to the Escort Pool in DECON area (Attachment 2,
#25).

14-34

**ENGINEERING SERVICE/SAFETY OFFICER**

# [RESPONSIBILITIES]{.underline}

1\. Provide ICS support to the EOC. Safety Officer will assume ICS
Coordination duties.

2\. If directed, deliver stretchers to area #20, GC-227. Open doors to
GD-227. Clear corridor and open door to corridor #17. Duct tape vents as
appropriate.

3\. Restore building integrity.

4\. Control panel will call and inform DC Water and Sewer of chemical
drainage (pp 14-11).

5\. Send two (2) employees to DECON area (#6, Attachment 2) for
stretcher bearers and two (2) employees to Resource Management/personnel
pool in main lobby.

6\. Send two (2) people to DECON Supply Rooms (#22, Attachment 2)
(GD-243) to assist in distribution of supplies.

7\. Secure elevators 5 & 6 for patient movement.

8\. Deliver four (4) dollies to DECON area #16.

9\. Secure all air intake/out-take diffusers as required to prevent
contamination. Call Engineering Control Panel X7700/8405 "Cut off all
Air Handlers in MER 2". Cover air filters in Hallway (#17) with plastic
and duct tape.

10\. Send one person to ensure outside hoses are connected (#7, #10, #8)
and water turned on. (Nozzles for all hoses are in DECON supply room and
should be fitted on [all hoses]{.underline} to include those in
GD-238/#15 at this time).

11\. Roll out plastic hall cover -- located in closet outside women
DECON area -- cover passageway #17 through TRIAGE hallway area. After
incident, safety staff will direct removal of plastic sheeting.

12\. Two personnel will duct tape all door frames except the one
opposite women DECON to prevent air leakage in corridor (#17).

13\. Duct tape all ventilation ducts in Supply Rooms (#22, GD-243 & 247)
and Room GD-227.

14\. Coordinate with RMS/EMS for personnel support.

15\. Assist in area cleanup as needed. Cleanup proceeds only after
consultation with safety officer/staff on contamination and protection
concerns.

14-35

16\. Collect patient valuables. Take valuables (in baggie):
slit/puncture holes in bag, emmerse in Clorax solution for 5-8 minutes,
remove valuables place in new baggie, place inside manila envelope
w/patient name on outside, seal -- deliver to Social Work Service.

14-35a

**ENVIRONMENTAL MANAGEMENT SERVICE**

# [RESPONSIBILITIES]{.underline}

1\. Assist in emergency sanitation activities.

2\. Distribute DECON area linen, towels, bathrobes to (#13, #16) meet
emergency needs.

3\. DECON tubs and barrels in place.

4\. DECON sign placed/hung on outside wall.

# [PROCEDURES]{.underline}

1\. Supervisor to station #20/#21 to coordinate EMS support (w/radio).

2\. Assign sufficient staffing to cover linen re-supply and refuse
removal.

3\. Provide six (6) employees to DECON area to assist stretcher bearers
(Attachment 2, #6). **Employees will have PPE.** Four (4) stretcher
bearers will suit up initially.

4\. Send staff to the DECON area as requested.

5\. Move DECON barrels to stations #4, #10, #13, #16, #8 and #7. Ensure
there are plastic bag inserts.

6\. Put up DECON sign stored in GD-243 on outside wall area.

7\. Put out "saw horses" in area #10.

8\. Move plastic tubs to areas #7, #8, and #10.

9\. Send two (2) personnel to Holding Area (GC-217).

[NOTE:]{.underline}

EMS personnel will constitute a valuable manpower resource supply prior
to, during and post emergency procedures.

It is important that all EMS personnel are aware of the intricacies of
this plan.

14-36

### RESOURCES MANAGEMENT SERVICE

#### [RESPONSIBILITIES]{.underline}

1\. Establish personnel pool.

2\. Register all employees and/or volunteers as they report for duties.

3\. Provide supervision and control to assure maximum manpower pool
utilization.

#### [PROCEDURES]{.underline}

1\. A Personnel Specialist will activate and staff the personnel pool in
the Main Lobby for assignment to DECON area.

2\. Establish registration and control procedures to assign employees to
emergency.

3\. Supervisor to report to stations #20 and #21.

4\. Supervisor to Director's Command Center.

#### [ICS DUTIES]{.underline}

1\. Staff two (2) predetermined telephones to give and/or receive
information and instructions from the Emergency Operations Center (EOC),
one (1) in the Fiscal Section and one (1) in the Human Resources
Section.

14-36A

### MEDICAL SERVICE

# [RESPONSIBILITIES]{.underline}

1\. Provide professional services to victims.

2\. Continue care and treatment of inpatients.

3\. Provide support to Surgical Service.

# [PROCEDURES]{.underline}

1\. Establish Medical Service Coordinating Center.

2\. Assign two physicians to triage team in DECON area (Attachment 2,
#19).

3\. Implement emergency staffing plan for casualties admitted.

4\. Establish professional and nonprofessional personnel pool.

5\. Assign a liaison to the Personnel Pool in DECON Area (#25).

6\. Assign personnel to Patient Holding Area (GC-217) as required
(Appendix 4).

7\. Assign one (1) person as Hall Supervisor (#24).

14-37

**NEUROLOGY SERVICE**

# [RESPONSIBILITIES]{.underline}

1\. Provide professional services to casualties with head injuries.

2\. Provide support to other medical services.

# [PROCEDURES]{.underline}

1\. Send a neurologist to each of the following sites or assign a
neurologist to assess the needs of the respective sites: (a) AEC
lobby/triage areas (#19), (b) Recovery Room, (c) Holiday Area GC-217,
(d) 4BW, and (e) Room 2A-123 and Ward 2BW.

2\. Assign a liaison to the Personnel Pool in DECON area #25.

14-38

**NUTRITION AND FOOD SERVICE**

# [RESPONSIBILITIES]{.underline}

1\. Coordinate with Canteen Service to provide emergency food service
for patients and casualties.

2\. Send three (3) employees to Personnel Pool area in Main Lobby to be
assigned as patient escorts (Attachment 2, #24).

# [PROCEDURES]{.underline}

1\. Deliver goods upon request to the Patient Holding Area, Room GC-217.

14-39

**PATHOLOGY AND LABORATORY MEDICINE**

# [RESPONSIBILITIES]{.underline}

1\. Provide emergency laboratory procedures.

2\. Provide emergency blood bank.

3\. Operate temporary morgue.

# [PROCEDURES]{.underline}

1\. Activate service plan to mobilize staff, supplies, and equipment.

2\. Alert appropriate blood bank(s).

3\. Direct staff to carry out priority laboratory functions.

14-40

**PHARMACY SERVICE**

# [RESPONSIBILITIES]{.underline}

1\. Emergency distribution of medications.

2\. Deliver and distribute medications at the treatment areas upon
authorized requests.

# [PROCEDURES]{.underline}

1\. Await taskings.

2\. Personnel will support normal medication requests.

3\. Send one person to Holding Area (GC-217).

14-41

**PHYSICAL MEDICINE AND REHABILITATION SERVICE**

# [RESPONSIBILITIES]{.underline}

1\. Provide room for Non-Immediate Major Surgery Team.

2\. Provide two staff to the Escort Pool (Attachment 2, #25).

# [PROCEDURES]{.underline}

1\. Prepare Physical Therapy Room (GC-217) (Holding Area) to receive
casualties from triage area.

2\. Chief of PT and therapists will assist the Non-Immediate Major
Surgical team in GC-217.

14-42

**PSYCHIATRY SERVICE**

# [RESPONSIBILITIES]{.underline}

Provide emergency psychiatric triage and treatment and disposition to
incoming victims of the emergency in DECON/Triage Area (Attachment 2),
#18.

# [PROCEDURES]{.underline}

1\. Send psychiatrist to Patient Holding Area -- GC-217.

2\. Arrange for transfer or discharge of patients, if necessary.

3\. Identify and clear ward areas for incoming casualties.

4\. Detail liaison person to personnel area #25.

14-43

**PSYCHOLOGY SERVICE**

# [RESPONSIBILITIES]{.underline}

1\. To provide psychological assessment and intervention when necessary.

2\. To serve as backup to the Casualty Information (Public Affairs)
Officer.

# [PROCEDURES]{.underline}

1\. Each Psychology Service staff member will report to his/her major
area of clinical responsibility. Staff will provide appropriate
psychological support as needed and be available to be called upon by
the Chief, Psychology Service or designee.

2\. A liaison will be provided to Social Work Service in the Patient
Holding area, GC-217.

3\. PPE as required.

14-44

**SOCIAL WORK SERVICE**

# [RESPONSIBILITIES]{.underline}

1\. Report to Patient Holding Area

(GC-217) and take charge.

See Appendix IV for details.

**VOLUNTARY SERVICE**

**[RESPONSIBILITIES:]{.underline}**

1\. To coordinate use of volunteers in emergency situations.

**[PROCEDURES:]{.underline}**

1\. Report to Director/Supervisor Social Work Service and receive
taskings.

2\. Determine what duties volunteers can **safely **perform during
emergency situation.

3\. Maintain a list of volunteers who could be called into action when
an emergency preparedness situation exist. These list should include but
not limited to:

a\. 4-wheel drive vehicle operators

b\. HAM Radio operators

14-45

**SURGICAL SERVICE**

# [RESPONSIBILITIES]{.underline}

1\. Provide staffing to cover DECON/emergency treatment location.

2\. Maintain effective care of essential inpatients.

# [PROCEDURES]{.underline}

1\. Establish the Surgical Service Coordinating Center.

2\. Assign two surgeons to the triage team (Attachment 2, #19 & #11).

3\. Implement emergency staffing plans for casualties admitted.

4\. Implement relocation and/or controls over supplies and equipment.

5\. Detail liaison person to DECON area (#25) for escort duty.

6\. Surgical Team, non-immediate, to Holding Area (GC-217) (Appendix 4).

14-46

**ANNEX E**

**PUBLIC AFFAIRS**

14-47

Public Affairs Contingency Plan

Decontamination Unit

1\. Purpose. To establish policies and procedures pertaining to public
affairs issues at the Washington DC VA Medical Center during contingency
or emergency operations regarding the use of the decontamination
facility.

2\. Mission. To establish a system to disseminate information to news
media and other concerned groups and provide coordination between media
representatives, the local community, the VA Central Office Public
Affairs Office and disaster victims admitted to the medical center
during mass casualty situations.

3\. Responsibilities. The responsibilities of the Public Affairs Officer
are:

a\. Be the sole individual responsible for collecting and releasing any
and all information that is pertinent.

b\. Report to the Command Post. Keep the Command Post informed as the
number and type of media on site and informed of any problems concerning
media coverage of the situation.

c\. Ensure that a Public Affairs Specialist is stationed in the Public
Affairs Office to answer the phone and log media calls that will be
turned over to the Public Affairs Director.

d\. Designate an area on or off the VAMC installation as a temporary
press center, from which interviews can be conducted and the media
representatives may contact their stations/editors.

e\. Designate an individual to be stationed by the press center.

f\. Establish means of communications with nursing, security and other
areas as appropriate.

g\. Maintain close coordination with the American Red Cross Office, DC
Office of Emergency Preparedness, VA Central Office Public Affairs, and
other organizations as required.

h\. Refer media to DC Office of Emergency Preparedness or the American
Red Cross to obtain names of individuals.

i\. Arrange, as necessary, through newspapers and over radio and
television outlets, the recall of VAMC personnel.

j\. Be prepared to use appropriate radio and television media to
disseminate information about clinic closure, general appointment
cancellations, traffic

14-48

flow changes, and other information of general interest to assigned
personnel, employees and patients of the VAMC.

k\. Liaison with Patient Holding Area -- GC-217 (Appendix 4).

14-49

**[APPENDICES]{.underline}**

APPENDIX I

\- DETERMINATION OF ADEQUATE FIELD

DECONTAMINATION.......................................... pp 51

APPENDIX II

\- ARRIVAL, UNANNOUNCED PATIENT..................\... pp 52

APPENDIX III

\- CLINICAL DECON PERSONNEL.....DUTIES.............. pp 53-54

APPENDIX IV

\- PATIENT HOLDING AREA ....................................pp 55

APPENDIX V

\- WHAT TO DO WHEN DECON OF PATIENT IS

COMPLETE.........................................................pp 56

APPENDIX VI

\- RADIATION RESPONSE PLAN............................... pp 57-58

14-50

*[APPENDIX I ]{.underline}*[-- DETERMINATION OF ADEQUATE
FIELD]{.underline}

####### [DECONTAMINATION]{.underline}

It is possible that an event will occur in which the patients will have
received adequate decontamination in the field and will not require
further decontamination at the VAMC. This determination can only be made
after adequate consultation with the D.C. Fire Department Hazmat team
and appropriate resources, such as Poison Control or Chemtrec. The
following information must be obtained before the decision can be made
to forego decontamination at VAMC. When in doubt, contact outside
sources: Phone #'s 14-11/12.

· WHAT IS THE CONTAMINANT AND WHAT TYPE OF EXPOSURE HAS OCCURRED?

· **IS IT THE ONLY CONTAMINANT OR IS THERE THE POTENTIAL FOR MORE THAN
ONE CONTAMINANT?**

· WHAT WAS THE LENGTH OF EXPOSURE?

· WHAT TYPE OF FIELD DECONTAMINATION WAS PERFORMED? (i.e., GROSS,
SECONDARY, ETC)

· WHO PERFORMED PRE-HOSPITAL DECONTAMINATION?

This information may not be available or it may be of questionable
value. In these instances, one should err on the conservative side and
activate the Hazmat plan to further decontaminate the patients. Further
clues can be sought for inadequate decontamination. For instance, if
transporting personnel have developed symptoms from the contaminant, one
could presume that the pre-hospital DECON was inadequate.

14-51*[APPENDIX II ]{.underline}*[-- ARRIVAL OF THE UNANNOUNCED
PATIENT]{.underline}

· Contaminated patients who arrive at the VAMC without warning must be
immediately isolated **[outside]{.underline}** of the VAMC and
directed/escorted to the DECON area by the Police -- Gate 2 (Attachment
(1)).

· Any vehicle used to transport a contaminated patient onto the VAMC
grounds must be isolated until appropriate decontamination has been
carried out. (Police.) **[Under no circumstances will a contaminated
vehicle be parked in or adjacent to the VAMC garage.]{.underline}**

IF THE PATIENT HAS ENTERED THE VAMC GROUNDS INADVERTENTLY:

· Isolate the patient outside immediately. Designate personnel to place
on protective equipment and then care for patient in appropriate DECON
area.

· Staff members and others who were inadvertently exposed to the patient
should be isolated as well. Depending on the contaminant, these staff
personnel may require decontamination as well.

14-52*[APPENDIX III ]{.underline}*[-- CLINICAL DECON OF
PERSONNEL]{.underline}

[Hospital Personnel:]{.underline}

· Receive brief from charge RN about toxin, patients, and DECON
procedure.

· Assist with setup of DECON area.

· Obtain prescreening from DECON officer.

· Place on personal protective gear.

· Medically intervene only when emergent (avoid invasive medical
procedures in decontamination area unless necessary to save a life).

[Decontamination Procedure:]{.underline}

I. Decontamination of patients will occur in three stages and be divided
into three groups by the Hot Zone Supervisor (#10)/Hot Zone Triage
Supervisor (#12):

A. Group I -- Non-ambulatory patients.

B. Group II -- Ambulatory males.

C. Group III -- Ambulatory females and small children less than 10 y/o.

II\. Stage I -- Patients will disrobe and/or be disrobed at:

A. Station 10 (group 1).

B. Station 7 (group 2).

C. Station 8 (group 3).

\- Clothes will be placed in plastic bags then in large community
containers (large gray trash cans) and disposed of. Personal articles
will be bagged in zip lock bag w/patient ID inside/on, tagged and placed
in small colored tubs.

Assist patient in removing clothing.

Begin at the head and move downward.

Do not pull t-shirts over head. Cut them off.

Buttoned shirts should be rolled off carefully leaving contaminated
portion inside.

Pants should be rolled down inside out to ankles and slipped off feet.

Have patient remove underwear starting at the top and work downward.

III\. Stage II -- Patients will be first rinsed outside doors adjacent
to disrobing stations (#7, 8, 10). Patients will then enter their
respective DECON units (male/female) for a complete soap wash down.
After a brief rinse, patients (if applicable) are to be sponged with 5%
bleach solution. Patients will then rinse for two-three minutes at
posted rinsing showers.

· Decontamination [should begin]{.underline} at the head of the patient
and proceed downward with initial attention to contaminated eyes and
open wounds. Once wounds have been cleaned, care should be exercised so
that the wounds are not recontaminated. This can be aided by covering
the wounds with a

14-53

waterproof dressing. For some chemicals, such as strong alkali, it may
be necessary to flush exposed skin and eyes with water or normal saline
for an extended period of time.

· External decontamination should be performed using the least
aggressive layer methods. Mechanical or chemical irritation to the skin
should be limited to prevent damage to the epidermal layer, which would
result in increased permeability. Contaminated areas should be gently
washed under a spray of water. Care should be taken so that contaminants
are not introduced into open wounds.

· The first priority in the process of decontamination should be
contaminated open wounds. These areas allow for rapid absorption of
hazardous materials. Wounds should be irrigated with copious amounts of
normal saline, and deep debridement and excision should be performed
only when particles or pieces of material have been embedded in the
tissues. Decontamination of eyes should also have high priority. Gentle
irrigation of the eyes should be performed with the stream of normal
saline diverted away from the medial canthus so that it does not force
material into the lacrimal duct. Contaminated nose and ear canals should
also be gently irrigated with frequent suction to prevent any material
being forced deeper into those cavities. Washing with soap and tepid
water is usually all that is needed to remove contamination. **Hot
water, stiff brushes, or vigorous scrubbing should never be used because
they cause vasodilation and abrasion.** This increases the chances for
absorption of hazardous materials through the skin.

IV\. Stage III -- Patients will be given towels, robes and slippers at
positions 13, 14 and 15 per groups 3, 2 and 1 respectively and
proceed/taken to medical triage (position 18/19).

· Assist patient in removing clothing.

· Begin at the head and move downward.

· Do not pull t-shirts over the head. Cut them off.

· Buttoned shirts should be rolled off carefully leaving contaminated
portion inside.

· Pants should be rolled down inside out to ankles and slipped off feet.

· Have patient remove underwear starting at the top and work downward.

14-54

APPENDIX IV

PATIENT HOLDING AREA

This attachment will contain:

1\. Holding Area (HA) and discharge procedures.

2\. Return of valuables.

3\. GC-217

Ext. 8618

Ext. 8534

#### [BACKGROUND]{.underline}

**THE SOCIAL WORK SERVICE WILL BE IN CHARGE OF THE HA AND ITS
FUNCTIONS**

The Patient Holding Area (HA) will be located in room GC-217.

The Ambulatory/Outpatient Physical Therapy Area (OPTA) will be used as a
Outpatient/Ambulatory Holding Area (HA) for patients who are being
released.

Remember these people are functioning in a highly emotional state and
while in the

Holding Area it is our mission/responsibility to "bring them back to
normalcy" as soon as possible.

**1. [SOCIAL WORK SERVICE]{.underline}**:

Upon alert the senior Social Work person/supervisor will report to the
HA (GC-217) with his staff and assume the responsibilities as the HA
Officer-in-Charge (HAOIC). Those responsibilities being:

a\. Activate a log/mechanism (computer) to log patients in-out of the
HA.

b\. Make patient welcome and as comfortable as possible.

c\. Provide patient with a **"call out form**" and allow the patient use
of a telephone to notify outside source to come and pick he/she up for
transport away from VAMC.

d\. Contact Canteen Service to provide nourishment for patients.

e\. Have personnel at Nursing Home Reception Area to meet patient
transport personnel -- notify HA to send patient for pickup.

14-55

f\. Provide escort to take patient to Nursing Home Reception Area for
transport. Ensure that prior to leaving HA that patient is "logged out"
and provided with a **Symptom Sheet** to be used by the patient in case
he/she becomes ill after arriving at their destination.

g\. Patients should be advised that they need to leave a **phone
number** where they can be contacted to come back and pick up their
valuables or an **address** where they can be mailed.

h\. Be prepared to receive patient valuables from **Engineering
Service**. Upon receipt of valuables, contact patient for pickup or be
prepared to mail.

**2. [ESCORTS]{.underline}**:

The hall Director (Att.2 #24) will contact the Re-supply Staging Area
(Att2,#20/21) to report to position #24. Upon reporting, the **escort**
will accompany the patient(s) to the Holding Area (GC-217). After
delivering the patient(s) the escort will report back to position #24
for further assignment.

**3. [POLICE]{.underline}**:

Personnel coming to pickup patients will be routed through Gate #1. From
Gate #1 Police will direct transport parking area near NHCU. At this
time instruct personnel to look for Police Office for directions to
NHCU.

A Police personnel will be positioned in the vacenity of the NHCU to
direct transport personnel to the NHCU reception area for patient
pick-up.

\*NOTE: **" CALL OUT FORM"** will contain hospital phone numbers and
directions to

the VAMC for pickup.

\*NOTE: **"SYMPTOMS SHEET"** will contain a list of: symptoms, probable
agents,

recommended treatment and VAMC/LOCAL response phone numbers for

assistance

14-55a

APPENDIX V

*[APPENDIX V ]{.underline}*[-- WHAT DO YOU DO WHEN DECON OF PATIENTS IS
COMPLETE]{.underline}

At the close of the incident, the decontamination area must remain
isolated and secured until the area is adequately cleaned and the
contaminated clothing, and disposable equipment have been appropriately
removed. Appropriate clean up is the responsibility of the hospital's
Safety Department and Plant Operations/Environmental Services. To hold
contaminated items for possible investigative use (e.g., Clothing) the
hospital safety officer may be contacted through the page operator. All
contaminated clothing receptacles will be staged in the DECON hot zone
(attachment #2) until removed by the Engineering Safety Officer.

Vehicles used to transport contaminated patients must be decontaminated.
This is the responsibility of the Engineering Safety Officer. If vehicle
DECON is not readily available, the Police Chief will designate a
vehicular hot zone and position the vehicles.

STAFF DECONTAMINATION

· Wet Rinse: All team members wearing PPE must rinse off in the outside
DECON triage area (Attachment 2) while wearing full protective gear.
EMS/Engineering will put down plastic sheeting in area #10. The order of
removal of gear is the following:

· Boot Removal: Step out of one boot. Step out of the second boot. At
this point, both feet should be on the plastic sheeting.

· Outer Gloves: Outer, chemical resistant gloves should be removed and
placed in the containers provided in the hot zone. (Area #10)

· Suit Removal: Using the inner gloves, the suit should be unzipped and
rolled down the body so that the suit will eventually be inside out.
(Males will de-suit in Area #7/Females in Area #8)

· Respirator Removal: Remove the respirator and drop it into the
container provided.

· Inner Gloves: Remove the inner gloves and drop them in the same
container as the suit.

Showering: The DECON team member is now ready to move from the hot zone
into the DECON for showering and post entry monitoring.

14-56

**APPENDIX VI**

**RADIATION RESPONSE PLAN**

What is different about radiation accidents compared with other Hazmat
incidents?

We can detect most types of radioactivity.

Some symptoms of exposure are often delayed (unless severe).

In the worst case of radioactive contamination on record in this
country, the patient gave off a level of radiation not immediately life
threatening to rescuers. This level was reduced by 2/3 after disrobing
of the patient.

Extra equipment needed above what is required for regular decon
activities:

A.) Radiation counter (can be found in AEC/Radiation Safety -- Nuclear
Medicine, GD-213).

B.) Q-tips and baggies with labels.

C.) Tide/cornmeal mixture (found in hazmat closet).

This is an absorbent/cleansing substance that may be applied to the
patient.

D.) Film badges (get from RSO).

· THE MONITOR (WE HAVE ONLY TWO) SHOULD BE CARRIED BY A DECON STAFF
MEMBER IN THE HOT ZONE. ONE SHOULD BE USED TO SCAN PATIENTS AFTER GROSS
DECON FOR THE PRESENCE OF RADIOACTIVITY AND THE OTHER USED TO SCAN THEM
AFTER DECONTAMINATION (TO ENSURE PROPER CLEANING) PRIOR TO TRIAGE.

**RADIATION SURVEY:**

· DO NOT ALLOW PROBE TO TOUCH PATIENT AS THIS MAY CONTAMINATE THE SENSOR
AND GIVE FALSE READINGS. A THIN PLASTIC BAGGY SHOULD BCOVER THE PROBE AS
WELL.

· BATTERIES GO INTO PANEL ON TOP OF METER. TURN TO 1X POSITION AND PLACE
PROBE FLUSH WITH CHECK SOURCE ON SIDE OF METER. METER SHOULD READ 4K.

· TURN AUDIO BUTTON TO ON. NOW YOU WILL HEAR A CLICKING SOUND THAT
CORRELATES TO METER READ OUT. AS CLICKING INCREASES, IT IS INDICATING AN
INCREASED RADIATION COUNT

14-57

### APPENDIX VI

**RADIATION RESPONSE PLAN**

(NOTE: A FEW CLICKS CAN BE HEARD AWAY FROM PATIENT. THIS IS BACKGROUND
RADIATION AND IS NORMALLY PRESENT.)

· ALL SURFACES OF THE BODY SHOULD BE CHECKED.

· IF A "HOT SPOT" OF RADIOACTIVITY IS FOUND, MARK IT WITH A PEN AND
RECHECK IT AFTER DECONTAMINATION.

**PERSONAL PROTECTION EQUIPMENT (PPE)**

· LEVEL C PROTECTION AT MAXIMUM

· RESPIRATORY FILTERS WILL BE DETERMINED BY TYPE OF ISOTOPE INVOLVED
(MAY ONLY NEED SURGICAL MASK)

· FILM DOSIMETER TO BE ISSUED TO EACH PERSON BY DECON OFFICER (WORN ON
COLLAR, PROT4CT FROM RINSE SPLASH).

· ANY PERSON WITH THE REMOTEST CHANCE OF BEING PREGNANT SHOULD BE
EXCLUDED FROM DECON TEAM.

14-58

[ATTACHMENTS]{.underline}

ATTACHMENT 1:

· DECON/TRIAGE Site Plan...................................... pp 60

ATTACHMENT 2:

· DECON/Triage Response Positions............................ pp 61-62

ATTACHMENT 3:

· Personal Protective Equipment.................................. pp
63-64

14-59**ATTACHMENT 3**

**PLEASE**

PRIOR TO REPORTING FOR DECON "SUITING UP", YOU SHOULD LEAVE ALL PERSONAL
ITEMS AT YOUR WORK STATION. REMEMBER, EVEN RINGS CAN BECOME CONTAMINATED
AND SHOULD BE REMOVED.

Follow these steps when "suiting up":

1\) All jewelry should be removed.

2\) Light scrubs should be worn under the outfit and should be put
donned first.

3\) Don a pair of surgical latex gloves.

4\) Don a surgical mask.

5\) Don a body suit -- These suits protect against most substances in
the concentrations found on patients. Inspect the suit quickly for holes
and tears prior to donning it.

6\) Use duct tape to seal the areas where the top of the boot comes into
contact with the body suit.

7\) Don chemically resistant outer gloves. Seal opening between the cuff
and the glove near the wrist with a piece of duct tape.

8\) DECON Officer should check all personnel for proper suit assembly.

9\) To remove suits after performing DECON, see page 41.

DECON SUIT COLOR CODE:

SILVER....................POLICE

CREAM/WHITE.........CLINICIANS

YELLOW..................ALL OTHER

ATTACHMENT 3

63

**[STATION]{.underline} [TASKINGS]{.underline}**

+\*1. Police at Gate 2 Traffic Control

\* 2. Police to direct traffic at parking lot/DECON alley intersection.

\+ 3. Six stretcher personnel (EMS/ENG)

Police (on call)

\+ 4. Casuality Directional Personnel (Nursing)

\* 5. Radiological/Bio/Chemical "CHECK" point (COS/Radiology)

Initial Patient Tracking (Nursing)

6\. Clean entry entrance/stretcher bearers (ENG/EMS)

\+ 7. Two personnel for collection/tagging of ambulatory male
clothing/articles, also responsible for placing tubs/barrels/bags/tags
for #7, #8. (Nursing)

\+ 8. Two personnel for collecting/tagging of ambulatory female/children
clothing articles. (Nursing)

\+ 9/10. Two personnel for collecting clothing/tagging of stretcher
patients. (Nursing)

+\*10. Hot zone supervisor. (Nursing Supervisor)

\+ 11. Two docs/four nurses for Hot Zone triage/Med. Care. Also
responsible for acquiring medical supplies/PPE, etc. (AEC/Nursing)

+\*12. One hot zone triage supervisor. (AEC Physician)

\+ 13. One female nursing personnel for shower traffic direction. Also
responsible: Placement buckets/soap/clorox, etc....distribute towels and
clothing.

\+ 14. One male as per 13. (AEC/Nursing)

\+ 15. Stretcher patient DECON area (Nursing)

+\*16. " "

+\*17. Hall supervisor (Nursing Service)

\*18. Triage (AEC Physician)

19\. " "

20\. Manpool/resupply staging area (RMS)

62

\*21. Supervisor -- manpower/resupply control (RMS)

\*22. Supervisor to hand out supplies (ENG)

\*23. Computer registration (Nursing)

\*23/24. Police supervision

\*24. Supervisor/director

25\. Escort staging area (Services/Nursing)

26\.

\* Radios issued

\+ PPE Worn.

62a