IntroductionTabun, soman, sarin and VX are potentnerve agents, all with the basic chemicalproperties of organophosphates. Theywere produced for use in war and suchusage has been reported. In the contextof terrorism, the agents have been usedin a variety of attacks, most notable wasthe use of sarin gas on civilians by aJapanese cult in 1995, resulting in 12deaths and a morbidity of about 6,000people. Malaysia has never experienced amass casualty incident involving nerveagents. This case describes a majorincident drill whereby 55 volunteerswere exposed to malathion, anorganophosphate insecticide.

CBRN preparedness in MalaysiaMalaysia has some experience indealing with chemical, biological,radiological and explosion incidents.Some of the more notable occasionsrelate to industrial ammonium gasexposures, pandemic flu and minorbomb scare and explosion events.Under the Malaysian response system,lead agencies for any mass casualtyincidents are the police, fire andrescue, and hospital emergencyservices. This list of lead agencies maybe expanded subject to the nature ofthe incident. For CBRN incidents, thespecialised hazardous material(HAZMAT) team ,which is under thepurview of the fire and rescuedepartment joins the respondingteams. For radiological or nuclearincidents the atomic energy licensingboard is also included. All these leadagencies work within Malaysia’sincident command system guided bythe prime minister’s Directive 20 underthe national security council.

For incidents involving terrorism,Directive 18 is used as the standardoperating procedure. As a measure ofpreparedness, a series of drills areconducted throughout the year. Thedrill scenarios are varied and someinclude terrorism as well as CBRNfeatures. Examples of past drills

involving CBRN situations haveincluded nerve gas, chlorine gas,pandemic flu, explosions, air crashes,radioactive situations and terrorism. Inconducting these drills, we havebenefitted from good support by privatesector entities like the airports,monorails and high rise buildings.These exercises have been carried outwith good interagency cooperation overthe years.

A valuable learning experienceOf the many exercises we have held, onewhich took place in 2010 provided asignificant learning opportunity as itprogressed to become a real incidentwithin the drill. The drill was organisedby one of Malaysia’s rescue agencies andmultiple responding agencies took part.To avoid any untoward problems, we arenot providing the name of the organiserwhile attempting to share this casepurely for its learning values.

The exercise scenarioMultiple incident scenarios were createdat a building on an abandonedconstruction site near a beach. Onescenario involved an ‘explosion’ of amakeshift lab operated by a group ofterrorists in the building. Following theexplosion a major fire spread throughthe building. The fire and rescue agencywas alerted and fire engines from anearby station arrived within fiveminutes and started to douse the flames,following their standard operatingprocedures. The police and a nearbyhospital were also alerted. The policecame and provided security around theincident site. The emergency medicalteam from the responding hospital sentan ambulance team to the site.

The initial medical responseThe first ambulance arrived at the sitewithin 10 minutes. The five-strongmedical comprised a medical officer, anassistant medical officer, a staff nurse, ahealth attendant and a driver. Themedical officer assumed the role of

medical commander and on arrivalreported to the forward fieldcommander, who was the chief of fireand rescue response. He quicklyassigned tasks to all team members andtwo of them started triaging at thecasualty collecting area (CCA). Heperformed the scene size-up, and basedon information from the forward fieldcommander he reported the status backto the hospital’s call centre. Moreassistance was requested. An adjacentsite was chosen for setting up anadvanced medical base station, and bythis time 20 simulated patients hadbeen evacuated. The fire and rescueagency doused the fire effectively.

Triaging victimsAt the CCA victims were triagedaccording to the simple triage and rapidtreatment (START) system. Criticalpatients were tagged red, semi-criticalas yellow and non-critical as green. Themedical commander initially called outto those who could walk to follow thetriageur to the base station and thesewere tagged green. Those who couldnot walk were then tagged as red,yellow or if dead as white, since white isthe colour associated with mourning inMalaysia. Patients brought to theadvanced medical base station were re-triaged according to Malaysian triagesystem. The patients’ personalinformation was collected and basicfirst aid was provided beforetransportation to medical facilities.Those with green tags were taken to thenearby health clinic for outpatienttreatment. Those who were either onred or yellow were transported to thenearest hospital according to priority,with the red-tagged patients going first,followed by the yellow tags. The processwent smoothly.

Setting up the medical base station Assistant medical officers and healthattendants erected a tent as a medicalbase station. Areas for red, yellow andgreen tagged patients were created for

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Dr Alzamani Mohammad Idrose, emergency physician and disaster medicinespecialist, and Dr Shah Jahan Mohd Yusof, emergency physician, Kuala Lumpur

General Hospital, Malaysia, on the time an exercise went ‘live’

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critical, semi-critical and non-criticalpatients respectively. A mobile logisticsteam provided water and food aroundthe clock while the health personnelwere stationed there.

Functioning under Directive 20 The multiple agencies responding at thesite were coordinated under the primeminister’s Directive 20. This documentfrom the national security councilmakes it mandatory for the police, fireand rescue and medical departments towork together under the command of

the police who provide the on-scenecommander (OSC). According to thisdirective, the police set up a commandpost and liaison officers from allagencies assemble there. In the absenceof the police, the top officer from thefire and rescue department is thecommander. During this drill, thecommander was from the fire andrescue department as the police did notparticipate in the command of theexercise. The drill ran smoothly and thestation could be utilised well to treatsimulated patients.

Next phase: the chemical elementOn completion of the multiagencyresponse for the ‘fire’ victims from thelab explosion, the exercise controllersinitiated the next phase of drill whichinvolved a chemical element.Nonetheless, the exercise judges werenot informed of the type of agent used.This was a deliberate decision as thecontrollers wanted to avoid bias in teamresponse and judgment. In fact theprogression of the scenario was kept asecret in order to keep the exercise ‘real’.

At this stage, the medical teamcompleted the set up of the medicalbase station and it was fully functional.The station had areas for triage, apatient information board andtreatment areas for red, yellow andgreen category patients. Subsequently,the fire and rescue respondersummoned the HAZMAT team since‘nerve gas’ was detected on theirequipment. While waiting for theHAZMAT team to arrive, they performeddecontamination using the water hose.At this time, patients were extracted oneby one. The HAZMAT team then arrived,set up field-decontamination facilitiesand started to decontaminate non-walking victims.

Drill goes wrong - the real incident After decontaminating five simulatedpatients, it was suddenly noted that agroup of 55 people ran out of thebuilding towards the beach. They lookedsickly – some were in a state ofdizziness, nauseous and walking in arather unsteady manner. Someone washeard shouting: “Real incident! Realincident! Exercise abort! Exercise abort!Patients to go to medical base station!”In a panicky situation with the drillturning into a real incident and‘patients’ manifesting real symptoms,the exercise controller immediatelydirected all patients to the medical basestation. Everyone bypassed the HAZMATdecontamination station and headed tothe medical base station.

All 55 patients suddenly appeared atthe advanced medical base station. Themedical judge who was an emergencyphysician changed roles and joined theteam as the medical commander tohandle the situation. Only then did one“Didn't think we'd be needing you today!” ©Alzamani

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of the controllers inform the medicalcommander that malathion had beenused to mimic nerve gas. Malathion isan organophosphate and was detectablewith a device used by the HAZMATteam. A change of wind direction andmisinformation as to the amount of themalathion used in the exercise wereblamed for the spread of more than theexpected level of malathion gas. Theorganiser did not reveal the exactamount used.

Actions takenThe medical commander directed themedical team to perform triage,collect patient information, provideinitial medical treatment andcoordinate transport to the hospitalbased on priority. A quick visualassessment was done on all patientsswarming in front of the medical basestation. Those who seemed alright andcould walk steadily were directed tothe green zone and those who couldnot walk were distributed between thered and yellow zones with the moresevere cases in the red zone. Triagingwas largely done by visual observationas all 55 patients appeared at themedical base station at once.

As soon as they were all in theirrespective zones, they were asked toremove their clothes. Medical personnelwere instructed to wear masks andavailable personal protective equipment(PPE). They did not have perfect PPE,however, as no goggles were available.They used surgical masks, plasticaprons and surgical gloves.Nonetheless, they proceeded to helpundress those who were weak and couldnot walk.

Everyone undressed down to theirunderwear. They were not stripped offtotally naked in respect of localculture. Moreover, from the incidenthistory provided by the exercisecontrollers, no splashing was involved.Therefore, it was thought that onlyexterior garments were affected by thegas. Fortunately all patients were maleand there were no gender issues. Allclothes were collected and sent off fordisposal. We decided to only use a drydecontamination method as thecontamination was more of gas thanof splashes. We ask the receivinghospital personnel to wear PPE andwipe patients with wet towels if fullwet decontamination in a shower wasnot possible.

Managing the ambulancesWhen the real incident occurred, wewere fortunate in having eightambulances from multiplegovernmental agencies and non-governmental organisations at the site.One assistant medical officer becametransport manager and lined up theambulances to efficiently move patientsto the hospital, taking the more severecases first. In a matter of 15 minutes, 15patients were sent to the hospital. Thecritical ones were accompanied at leastby staff nurses or assistant medicalofficers. A few were accompanied bydoctors. The non-critical patients weresent with paramedics.

Communication was made with thehospital medical commander and thesituation was updated. Fortunately, thehospital was prepared since ‘red alert’was declared by the hospital directorearlier on for the simulated patients.Upon arrival, all patients were wipedclean with wet towels and provided withfresh hospital garments. Vital signswere checked and examinations wereperformed. Blood investigationscomprised full blood counts, renalprofiles and acetylcholinestrase levelmeasurement. Atropine and

Got to love it when patients are rushed past decon because it is an 'emergency.' ©Alzamani

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pralidoxime were administered to 11patients, they were admitted and urinewas sent off for cholinestrase tests.Three were observed for six hours andsubsequently discharged, while onepatient was badly affected.

Resuscitating the badly affected patientThis person was stationed close to themalathion canister during the drill andhad a large amount of exposure. Hepresented with watery eyes, nausea andmuscle fasciculation, was consciousand had no seizure. At hospital heappeared anxious. Subsequently, hisblood pressure dropped to 90/50mmHg and he started to developprofound bradycardia after 30 minutesat Port Dickson hospital. A total of12mg of atropine had to beadministered and 1g of pralidoxime wasinfused over 30 minutes. He becamemuch more anxious thereafter and theGlasgow coma scale score droppedfrom 15 to 8/15 (E2V2M4). He wassubsequently intubated and washospitalised in the intensive care unitof a tertiary centre some 30 kilometresaway. The patient was in the intensivecare unit for four days and thendischarged to a normal ward where hestayed for another two days. He wasfinally discharged well.

Managing the green triage patientsAll patients were asked to remove theirclothes leaving only underwear. The

clothes were collected and put intorubbish bags for disposal. A makeshiftshower area was created using a waterhose and all patients were asked toshower. They were given cheap new t-shirts and pants. After decontaminationthey were assessed by a doctor. All ofthem were well after decontamination,reassured and discharged.

Internal hospital responseThe responding hospital set off a redalert, which effectively activated itsmajor incident response plan. Allhospital staff including specialists,medical officers, assistant medicalofficers, staff nurses, health attendantsand general workers were summoned toreport at the operations room.Treatment areas for critical, semi-critical and non-critical patients wereopened and staff were allocatedaccording to their functions. Thehospital director took the role ofhospital medical commander.

DiscussionThis incident generated a total of 50real patients. Of these five were redcases, 10 were yellow and 35 greencases in terms of severity. Eventually allpatients were discharged well withoutany subsequent morbidity.

What we learntThis was our first experience of masscasualty organophosphate (or nerve

gas) poisoning via malathion. Despitecausing low human toxicity, malathioncan implicate serious morbidity andmortality if not detected and treatedearly. Communication with medicalpersonnel is therefore essential for thesafety of all responders. Dangerousagents used must be discussed withthe medical team so that preparationcan be made for coping with anyuntoward incidents. Medicalresponders need to be flexible in theirapproach, use what they have and faceeach CBRN situation with scientificprinciples while respecting localcultural and religious values.Decontamination procedure needs tobe improved so that for mass casualtysituations, walking patients candecontaminate themselves. This caseprovided our responders with greatand valuable lessons.

From this experience allresponding agencies re-evaluated theirstandard operating procedures andmade improvements for CBRNresponse. The subsequent drills weremade safer with more open discussionwith multiple agencies. Respondingagencies also increased their capacityto handle mass casualty CBRNincidents by acquiring moreequipment such as massdecontamination tents but also vianetworking with other governmentalbodies such as the military to enhancetheir response effectiveness.

We'll be needing a lot of these! ©Alzamani