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Haz Mat "Specialist Course"

Mortuary Response to VHF - 2

During the actual response of the 2014 Ebola Outbreak, there were many operational issues and problems that needed to be solved as they presented themselves. Now, these issues can be completely reviewed and adapted for future responses. Evaluating these issues and making corrections, will provide for a more competent response in future generations. Not evaluating and inserting corrections into your operational plan will deteriorate the response and possibly cause needless deaths.

One operational infrastructure adaptation that shall be needed in future responses is that of STAGING. In the 2014 incident medical facilities were initially created to handle low patient/victims. This caused a quick overflow of victims to the point where patients were literally dying in the streets outside the initial hospital facility activated for treatment. Ask yourself; “How many patients can my current plan accommodate”? Is this the probable or possible amount/flow of patients I can expect? Or, is this number/flow inadequate? If it is likely to be inadequate, you have two (2) choices.

1] Expand equipment, personnel, and resources for a response or,

2] Partner with other same resources.

Both of these are obviously a full time position for many months for the emergency manager. In the first choice, your budget needs to be drastically increased as well as permanent employees. Equipment expansion will require additional storage space and or facilities on-site in a secure manner. Additionally, equipment maintenance will increase and require additional support personnel. Response personnel increases stress your total hiring and training infrastructure so there may be increases needed in these departments as well. When deployed to a response, support and supply personnel and resources will also need increasing to accommodate a smooth operation once activated.

Partnering with like organizations for a smooth organized response requires inter-departmental training on a regular basis. As changes occur, multiple groups must be all included as being, on-the-same-page. If geographical distance is an issue, how will you coordinate multi-group training? Is employee transportation possible? Can regular group training be done at simultaneous locations? Can training information be accomplished across an internet medium?  These are some of the considerations that must be taken into account, just for staging but true for all areas of operations!

Another problem was the breakdown (in the initial stages) of ICS between the government and medical staff. This was somewhat political and can be expected when dealing with foreign Nations, but more so in this situation due to the fact that the governments in question did not rely on their SME (Specialists Material Expertise). This is a common failure of the ICS staff and one in which when corrected, can quickly increase the effectiveness of any operational team.

Contract tracing was absent before the WHO/CDC was in a mode of full mobilization. This is a problem directly related to the UN and its medical guidelines but can also be instigated by localized Team directive. Your response group can identify this issue at the initial stages and continue to emphasize to the bigger picture until you receive confirmation that contact tracing protocol has been activated and is functioning. This is a good objective to insure by your Team Leaders and after all, your team members ARE affected by this practice. So this is really a safety issue for your Team. Study has proved that not activating a solid “Contact Tracing” protocol shall increase victim mortality.

Local custom conspiracy theories hampered many objectives from being successful (see film for details).  A cultural attaché is needed for all response groups operating outside of their local geographical operating area. In many cases, an interpreter must be included. If Team members cannot communicate properly with victims or local responders, this will increase cultural conspiracy theories thus making your response more difficult and success questionable.

During the 2014 incident DWB (Doctors Without Borders) staff experienced a high degree of PTSD (Post Traumatic Stress Disorder). Response Teams and the Military have to realize that physicians in general are not used to emergency situations. Their world is usually a controlled environment with disassociation from patients as human beings and looked at as “conditions”. This too, is a coping mechanism for Doctors having to deal with the emotional aspect of invasive patient treatment. Making sure that part of your “personnel” upgrades includes trained counselors in this type of trauma counseling. The goal of your operation is to have all parts flowing functional at the same time. Any one of these mentioned elements have the capability to derail your operational effectiveness.

Finally; an excellent time-line of this operation can be found through the PBS Frontline News group at

Haz Mat Mike




Mortuary Response to VHF 1

The Mortuary Program was developed because of the need to limit contamination by viral attacks upon a geographic location through disease. The mortuary response of the 2014 West Africa outbreak was found to be a major contribution towards the control of large scale pandemics. The rate of disease spread became so fast that increased safe burial protection was found to be a major contributor towards controlling this disease platform.

When a large scale epidemic of a VHF (Viral Hemorrhagic Fever) outbreak presents itself, a mortuary team shall be needed. This will involve safe burial techniques. There is a HIGH risk of transmission in the health care facility when a VHF patient dies as the bodily remains and body fluids of deceased VHF patients remain contagious for several days after death. Family and community members are also at risk if burial practices involved touching and washing the body. Therefore the body must be safely prepared for the actual burial procedure. The Mortuary Team must be made aware of general concepts to keep in mind before the procedure is actuated.

The Mortuary Team members shall need to be trained in the proper “Donning, Doffing and Decontamination Techniques” as the actual patient care members were during our former series of articles on VHF Response Techniques. (See archives). To develop a long term strategy, Mortuary Team members should be included in the base training and all operational training long before deployment. This will mean inclusion in the “Team” operations, training, and general upkeep of a response organization. Do not include contractors that have not participated in your response organizations structure. Inclusion into your Team structure will insure adequate resources and deployable entities that are practicing your “safe” operations throughout the incident.

When highly infectious agents are released epidemics (highly infected local areas) will require a mortuary team to prevent a pandemic (globally infected area) from resulting. Global incidents such as the 2014 West Africa pandemic can stress world-wide resources beyond their limits leading to historic changes. A mortuary team can limit these global changes from becoming world affects.

Local response is generally the best practice for this, as they already have a positive relationship with the general population. This becomes critical during an incident when consoling and passing needed information onto this citizenry. Local “Teams” generally have a much more positive affect with the local patients when the transfer of critical information regarding VHF is needed to insure containment of a possible pandemic.

Safe burial techniques are paramount to limit further contamination and death to the remaining population. Since the infection rate continues after death, due to the high rate of still infectious bodily fluids remaining after death, the need for rapid burial practices need to be implemented by the mortuary team members. In the coming months we shall demonstrate the proper techniques for all Mortuary Team members to follow.

To begin this process, there are three major rules to adopt into your Team structure for the concept process when interacting with the local citizenry. First and foremost the Teams’ emphasis should always be focused on the burial taking place as SOON as possible AFTER the body is prepared. To accomplish this goal, there are three (3) main concepts that should form the basis of a Mortuary Team’s response;

1] Be aware of the family’s cultural practices and religious beliefs. Help the family understand why some of their traditional practices cannot be done because they place the family and citizenry at risk for exposure.

2] Counsel the family about why special steps need to be taken to protect the family and community from illness. If the body is prepared without giving information and support to the family and community, they may not want to bring other family members to the health facility in the future. They may think that if the patient dies, the body will not be returned to them.

3] Identify a family member who has influence with the rest of the family and who can make sure family members avoid dangerous practices such as washing or touching the body.

Next month; Ebola 2014 West Africa “Outbreak” Issues lessons learned for future responses.

Haz Mat Mike



VHF - Dress-out Doffing and removal of CPC

Once we have reached the point where the patient has become momentarily stable, the patient care worker can decontaminate, and dress-out or “Doff” his/her CPC for a break or for a treatment worker rotation. To do this, last month’s step of decontamination inside the treatment/isolation area is completed and the worker can now move out of this zone. In traditional format, realize that the care worker would technically be now moving into the “Warm” zone of decontamination. After gross (or heavy) contamination is reduced the worker leaves the Hot Zone.

Many different formats can be employed that are particular to your location, equipment, isolation wards, etc.  But almost everyone can use the simplest and effective of waste handling procedures for infectious waste materials. Have your worker leave the hot zone and step into a large sized bio-hazard waste bag.

At this point, the concept is to leave all contaminated CPC inside this waste bag. So, respiratory protection will need to have been pre-evaluated for your desired result. If you choose re-useable long wearing full face APRs’ (recommended), a separate container will be needed for further decontamination before the APR is returned to its user. While this affords additional personnel/practices in your hazardous waste/laundering team, it does provide better personnel protection. The waste team will need full previously discussed CPC protection to decontaminate fully, the used APRs’ on or off-site depending on your facility plan for this type of incident.

After this step has been provided for, the worker must spray its’ inner gloves with bleach solution from another 1:100 spray bottle. The health care worker can then remove their level “B/C” protective suit into the bottom of the bio-hazard bag. IMPORTANT: the inner gloves will be removed as the final portion of the suit is stepped out of and the wearer MUST not touch the inner surfaces of the “B/C” protective CPC. Liken this to peeling a banana without touching the inside fruit. This is a procedure known as “Dry Decon” and requires separate team instruction and practice.

Once the CPC suit has been successfully “peeled” down to the bottom inside of the bio-hazard bag, the remaining protective clothing and or respiratory protection can be removed. You individual techniques are dependent upon the CPC/PPE chosen and accepted by your facility. Separate techniques in training with a practiced professional should be taken by your facility to make sure personnel can perform these tasks to remain contamination free.

When all these steps are successful, the patient care worker can now step out of the bio-waste bag into the “cold/clean zone”. At this point the waste/laundry team should move in and secure the bio-hazard waste bag as out-lined in the incineration steps for safe securement of VHF infected waste. It can then be transported to the waste team staging or processing area.

The health care worker should then move to the secured locker room area. Inner scrubs should be deposited into an additional bio-hazard waste bag that will be secured as previously mentioned and sent to the laundry to be processed by the waste team.

The health care worker should now body shower and dry off with a clean towel. He/she can now safely re-dress in “new” scrubs and footwear to return to the hospital area or break room. All workers must wash their hands before leaving the locker room.

Next month we shall continue on with the VHF of a mortuary team for large scale pandemics.

Haz Mat Mike



VHF - 12 "Doffing" procedures for Dress-out and Decontamination

To collectively reach the phase of your incident where final disinfection/decontamination takes place and removes the patient treatment personnel from the Hot Zone involves two (2) concepts;

1] Technical Decontamination

2] Disinfection BEFORE removal

Technical decontamination first involves the removal of major or heavy volumes of projectile vomiting or other bodily fluid discharge from the patients which have contaminated the health care worker. These volumes must be wiped off as completely as possible and treated in the previous months’ post with 1:10 bleach solution, soaked towels, and the listed time limits. Once this has been accomplished, technical decontamination blends into “disinfection before removal” both inside the isolation area (Hot Zone) and outside this zone depending on the operational set-up you decide will work best for your facility given the physical room limitations.

Disinfection BEFORE removal involves conditions where either the massive discharges did not occur, or have been mitigated as previously noted. Unless major projectile discharge occurs, or has been mitigated, the outer gloves and booties are likely to have the most contact with VHF agents and therefore the heaviest contamination (VHF fluids during patient care) at this point.

Ideally, before leaving the Hot Zone (isolation area/patient isolation room) the procedure must follow these steps;

1] After the final 3 to 5 minute soaking of gloves in the 1:100 bleach solutions, wash in a separate bin/sink the outer gloved hands with soap and water.

2] In a clean solution or “spray” dip or soak the gloved hands in a 1:100 bleach solution for one (1) minute.

3] Step into (or keep moist with a spray) a solution bin of 1:100 bleach solution enough to cover the outer soles of your footwear. The best way to accomplish this is to begin this procedure while these other processes are taking place. This way a longer time period will and should be realized for footwear. This is because additional contamination will be accumulated on the footwear. Therefore, a longer time period should be considered for footwear saturation.

4] While this is ongoing, spray the outer CPC garment with 1:100 bleach solutions. When the entire CPC has been covered with the spray solution outer decontamination has been completed. When finished,

5] Step out of the bin/pan onto one of your clean, bleach soaked towels to dry off more completely the CPC booties soles. This clean bleach soaked towel should have been previously placed inside a bio-hazard bag or waste transportable vessel of your choice.

6] While standing on this bleach soaked cloth, remove your outer booties, remove outer gloves, and slide this ensemble down around you and into the bio-hazard waste container IN THIS ORDER

7] Lastly; step out of this area into a clean area located outside the patient treatment isolation area (Hot Zone). Deposit remaining Inner gloves into a separate bio-waste container (bio-waste bag).

Personal hygiene should be managed at this point before laundering used inner clothing and re-showering before being released from the contaminated site area.

Haz Mat Mike



VHF - 11 First Aid Exposures for Treatment Workers

In last month’s post we looked at the decontamination of large spill/patient discharges and how they affect decontamination issues for hospital treatment staff. But what if the treatment staff becomes injured as a result of patient discharge/struggle? We need to consider treatment staff injuries while in the isolation/Hot Zone treating patients. Once treatment staff becomes injured/a breach of his/her skin, he/she becomes downgraded in their operational capabilities.

First, if an injury occurs, your treatment/isolation area/ Hot Zone will need some type of another vessel or bin to immerse the injured site for 20 to 30 seconds in a 70% alcohol solution. Immersion is the best approach but due to size of your isolation areas a spray system could be considered. This site area of the injury would need to remain wet and saturated with the 70% alcohol solution for the entire 20 to 30 seconds.

Second, have the injured patient care worker flush this injured site with running water for 20 to 30 seconds. At this point, the injury can be treated with an appropriate bandage or dressing for the type of wound delivered. The dressing/bandage will then need to be wrapped with some type of cover or saran wrap arrangement as the treatment personnel will need to proceed through the decontamination/disinfection outlined for all team members at a later date.

Next, report this incident to your Team Leader for the proper corrective action. He/she will need to make arrangements after the injured worker proceeds through the decontamination process. At this point, the injured worker becomes a monitored patient. Where will he go? Can you place him in another isolated area of the hospital for an extended time? Will he go home? These are all decisions the Team leader must be prepared for, in other words it’s all about what is next? Team Leaders should be taught like Emergency Managers that whatever is happening now is already done. It’s all about what is next? These decision makers must be a step ahead of an ongoing incident.

The injured treatment worker can now proceed through the decontamination process after these decisions have been made and the appropriate steps/systems are in place.

Once this step is completed, the injured treatment personnel now become a monitored patient for VHF. Whatever the incubation period of your VHF (Ebola is 7 to 21 days) is the length of time to restrict the patient for observation. If no symptoms show themselves, additional testing is done to insure non-exposure/contamination to the VHF. Once this monitoring is completed, the health care worker can be placed back into normal rotation or return to normal duties.

Haz Mat Mike

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