Get Naked, Get Wet

"If you fail to prepare, be prepared to fail."- M. Spitz


Of all the things that I teach in my CBRNE class, this is what my students remember most. "Get Naked, Get Wet". It's not a rallying cry for indecency. Not that they're unnaturally preoccupied with nudity, but hey, that's just what might save you from that nerve agent.

The class is more popularly known as Bioterrorism. Actually, it's more than just smallpox rashes and anthrax ulcers; more than just donning and doffing the Haz-Mat suits. It's CBRNE- Chemical, Biological, Radiological, Nuclear, Explosives.

It's a sign of the times. Terrorism is alive and well. The terrorist attacks on 9/11 had shaken the collective consciousness of Americans. It ushered in a new era of fear; "the "mighty has fallen". We are vulnerable, and we must be prepared. The better prepared the nursing workforce is, the better our chances are to mitigate the impact of disasters.

Unfortunately, most hospitals choose to bury their heads in the sand. In their mistaken notion that 9/11 would not happen again and that somehow the man who ran away with the missing vial of smallpox would not even know what to do with it. There is no urgency in training front-line workers in recognizing and responding to a CBRNE emergency. What a damn shame.

As I had written before, on September 11, 2001, I stood on the platform of a Manhattan-bound E train to spend my birthday morning at the bookstore cafe in the World Trade Center. Just as the train was pulling into the station, something inexplicable gripped me. I turned around, crossed to the westbound platform to the train back home, to safety. Divine Providence.

I have taught CBRNE classes for about 13 years now; even before the World Trade Center attacks. I had gone to several emergency preparedness classes, even to faraway Alabama in a long-abandoned military barracks, just to be fully immersed in a full-scale disaster drill with 'disaster victims' in realistic moulage.



So, in all my classes, these are the highlights:

1. IF YOU SEE SOMETHING, SAY SOMETHING

The reminder is everywhere. The Metropolitan Transit Authority has even taken radio ads: "If you see a suspicious package or activity on the bus, on the train, or in the subway, don't keep it to yourself."

I preach Healthy suspicion without paranoia. Recognize when something is out of the ordinary. Be suspicious if patients flock to the ER with Flu-like symptoms in the middle of summer.

Dead birds outside your window? Don’t panic. Don’t imagine an apocalyptic scenario. The 3,000 red-winged blackbirds that dropped dead from the Arizona sky on January 1, 2011, were reportedly felled by trauma from the fireworks for the New Year's Eve celebration. That's what the National Geographics wrote. Uh, okay.

2. S-I-N

I teach my students to sin. That they should not rush into action unless they know what they're getting into. Only fools rush in.

S-I-N: Safety first, Isolate the problem, and Notify the authorities.

Knowledge is power. But how can you protect yourself and the people around you if you cannot recognize that you are looking at a patient with descending paralysis from botulism toxicity? How can you effectively treat your patients when you yourself have succumbed to the nerve agent? How can you ring the alarm when you don’t even recognize that something is so completely wrong?

3. ISOLATION FOR SMALLPOX, PLAGUE AND VIRAL HEMORRHAGIC FEVER (VHF)

Common presentation of fever, general malaise, and body aches can fool even the most astute triage nurse. The index of suspicion should be raised with the following: synchronous formation of rashes that start in the face and extremities (smallpox), hemoptysis, and rapid progression to acute respiratory failure (pneumonic plague), and bleeding (VHF). Thanks to those TV movies on Ebola, the public is aware of the devastating effects of the disease.

The most important takeaway is that these diseases can be transmitted from person to person. ISOLATE, ISOLATE, ISOLATE. Immediately.

4. PERSONAL PROTECTIVE EQUIPMENT (PPE)

In 1995, cult members in Japan released the nerve gas Sarin in the subway station. Twelve people died, but thousands more of the "worried well" rushed to the nearest hospital. Well-meaning nurses and doctors ran to meet the patients. No masks, no gloves, no gowns. Like soldiers running to the battlefield without guns. They did not S-I-N.

5. TRIAGE- THE GREATEST GOOD FOR THE GREATEST NUMBER

In normal times, the dying gets the most attention and the ED staff works hard just to prevent the patient from being another statistic. Disasters nullify what we hold dear in emergency nursing. Suddenly, the dying gets passed by. The limited resources demand that the rescuers spend time with those with a reasonable chance of survival, whether they're young or old. It would be devastating to turn your back on somebody, but what can you do if your resources are scarce?

6. GET NAKED, GET WET

As slogans go, this one just makes everybody smile. The light-heartedness is just a defense mechanism for the sobering fact that nerve agents kill. Modesty be damned. Get those clothes off and get wet, right now.

Decontamination is the physical process of removing debris, harmful substances, and chemical agents from the skin, clothing, and other items. Knowing that the clothes and the exposed areas of the body get the most contamination, it makes sense to undress right away and flush the debris with water.

Do not worry about the water run-off if your decontamination chambers are not equipped with such. Let the water run off to the sewer. The alligators will just glow in the dark. Who cares?



At the end of the class, there's that photo opportunity of posing in that Haz-Mat suit complete with the hood and the powered-air-purifying respirator (PAPR). Cool!