DHSFEMA Urban Search _ Rescue Interdeployment Health Screening

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					OSHA Respiratory Standard Medical Evaluation:Challenges from the

World Trade Center US&R Operations

Ken Miller, M.D., Ph.D. Medical Director, Orange County Fire Authority Assist. Medical Director, Orange County EMS Team Leader DMAT CA-1 Medical Team Manager US&R CA TF-5

Fire Service Respiratory Program
• OSHA 29 CFR 1910.134
– Program Administrator – No cost to employee – Identify respiratory hazards:
• IDLH atmospheres
– NIOSH-approved SCBA/SAR, Rapid Intervention Team

• Non-IDLH atmospheres

– Medical Evaluation – Fit testing – Training/maintenance/program evaluation/records

Medical evaluation requirements
• Must be done before fit testing and use • Information must be obtained as per 1910.134: OSHA Respirator Medical Evaluation Questionnaire • Includes ability to use respirator:
– ENT, pulmonary, cardiovascular, musculoskeletal

• Employer must obtain written recommendation regarding the employee’s ability to use respirator

Medical evaluation requirements (cont’d)
• Additional evaluations if:
– – – – – symptoms/signs related to respirator use physician/administrator/supervisor recommends observations during fit testing/program change in conditions/physiological burden Deemed necessary by the evaluating clinician (i.e., tailored medical surveillance after a known exposure – WTC)

OSHA Respirator Medical Evaluation Questionnaire
• • • • • • Job title Type of respirator Tobacco use General health Specific pulmonary problems (e.g. TB, emphysema) ROS: pulmonary, cardiac, vision, hearing, and musculoskeletal • Known workplace chemical hazards, or high humidity or temperature conditions • Occupational/military/recreational/hobby history

Cardiovascular effects
• By virtue of weight – SCBA alone = 35 lbs. • May worsen hypertension • Thermal stress (in conjunction with impermeable clothing) • Restrict if IHD, or being evaluated for IHD

Pulmonary effects
• Healthy individuals can usually compensate for respiratory effects • May decrease maximal exercise capability at higher exercise levels • Restrict if moderate-severe respiratory disease • Chronic productive cough might cause noncompliance

Musculoskeletal effects
• By virtue of weight or ability to put on certain types of respirators • Also consider use of respirator: degree of handling and lifting, performance time, implications of loss of balance (e.g. from a height), shoulder and back fatigue, and risk of lower back injury

Vision effects
• Usually no problem for successful longterm soft contact lens users (i.e. 3 months or more) • Full-face respirators may fog • Limit visual fields • Special insert spectacles might be required in order to fit in the mask

Skin effects
• Shave areas contacting the sealing surface

Thermal effects
• Especially when used in combination with impermeable clothing

Psychological effects
• Claustrophobia; fear of exposure

DHS/FEMA US&R Program
• 28 FEMA US&R Task Forces
– TF Leader, Safety Officer – Search, Rescue, HazMat, Medical, Logistics, Plans

• 3 FEMA Incident Support Teams
– – – – ESF 9 Liaison IST Leader, IST Safety Officer, IST Medical Officer Operations Plans
• Sit/Sat, Structures Spec., US&R Spec., HazMat Spec.

– Logistics
• Communications, Transportation, POA/Mob Spec.

DHS/FEMA US&R Program
• FEMA Program Office
– Advisory Committee
• policy decisions

– Operations Working Group
• US&R Program Staff • Multidisciplinary Working Groups
– including Medical, WMD, Legal, Training

• National, East, Central, West TFL Reps

Toxicology of structural collapse
• Experience from WTC & Pentagon
• Probably no new hazards at the World Trade Center collapse compared to other structural collapse sites • Just a lot greater quantity than experienced at prior US&R missions:
– large number of responders – large debris pile & collapse zone – prolonged search, rescue & recovery operations

US&R medical mission
• Victims:
– – – – – – – Blunt & penetrating trauma, burns Crush syndrome/traumatic rhabdomyolysis Inhalation injury, dust impaction Hypo-/hyperthermia Dehydration Exacerbation of chronic illness Field critical care with prolonged extrication

The changing medical mission
• • • • • • • • No survivors recovered after Wed. 9/12 Void space searches Massive trauma to non-survivors Void spaces contain fire gases Rubble pile continues to burn Lower sub-basements flooded Focus now or rescuer health & safety Occupational & environmental toxicology

Potential structural toxic hazards
• Asbestos
– insulation – fireproofing

• Freons
– chiller plant

• Mercury
– fluorescent lights

• Concrete
– Portland cement

• Crystalline silica
– glass – concrete

• H2S
– sewer

• Combustion products

• Inorganic acids

Potential structural toxic hazards (con’td)
• CO
– structure fire – powered equipment – vehicles

• Heavy metals
– building materials – batteries – oxy-acetylene steel cutting

• PCBs • PAHs
– diesel exhaust

• Particulates
– fibrous glass – gypsum – cellulose

• VOCs
– fuel oil/diesel fuel

• Inorganic dusts
– mineral dusts
• silica, silicates: glass, brick & tile • asbestos • concrete: silicates, CaCO3 & MgCO3

– metallic dusts & fumes – synthetic crystalline fibers
• fiberglass, mineral wool, ceramic fiber • insulation

• Pneumoconioses
– nonmalignant pulmonary fibrosis • + functional compromise – silicosis • glass or stone dust aerosol – asbestosis – particulates NOS: “non-toxic” •  clearance of toxic particulates • respiratory irritation • alveolar proteinosis (rarely)

Cement & Concrete
• Portland cement
– < 1% crystalline silica • tri- & dicalcium silicate • principle risk of pneumoconiosis – aluminum oxide, tricalcium aluminate, calcium carbonate, calcium hydroxide • alkaline in solution, pH 13
– cutaneous, ocular, upper airway injury

– iron oxide – OSHA PEL: 10 mg/m3 total dust • 5 mg/m3 respirable dust

• Concrete: cement + binders

• Hydrated magnesium silicates
– insulation, heat & fire-proofing – binder in cement pipes & panels – workplace regulation since 1970

• Asbestosis
– acute & chronic lung inflammation – interstitial pulmonary fibrosis

• Mesothelioma, lung cancer

Asbestos (con’td)
• ACM in collapsed structures
– banned in construction since 1970’s – ACM still allowed
• pipeline wrap • asbestos-cement corrugated sheet, flat sheet & shingle • roofing felt & roof coatings • vinyl-asbestos floor tile

• Bulk dust: 0.48 - 4% (Phase Contrast Microscopy) – EPA defines asbestos-containing (ACM) as >1% – polarized light microscopy detection limit, not health-based
– Ambient air: 9/11/01 (PCM,  48-hr turnaround)

Afternoon Afternoon Early evening Evening Evening Late evening

0.638 f/cc 0.662 f/cc 0.430 f/cc 0.196 f/cc 0.150 f/cc 0.032 f/cc

Asbestos-WTC (con’td)
• OSHA PEL: 0.1 f/cc 8-hr TWA • OSHA STEL: 1.0 f/cc 30-min • Indoor clean air standard: <0.01 f/cc 9/12 AmEx Building (NW)
Broadway x Murray (NE) WTC perimeter Murray x West (NW)

0.131 f/cc
0.204 f/cc 0.054-0.660 f/cc 0.296-2.114 f/cc (heavy debris)

Combustion Gases
• Irritant gases-high water sol.
– aldehydes, acrolein, HCl, HF

• Irritant gases-low water sol.
– phosgene, PAHs, VOCs – isocyanates

• Tissue asphyxiants
– CO, HCN, H2S

• Particulates

Combustion Gases-WTC
• Public health vs. work space environment • Void space vs. surface gases

– Detected
• CO 100-1000 ppm (EPA verbal report)
– IDLH 1200 ppm, REL 35 (NIOSH), PEL 50 (OSHA) ppm – relative gas density 0.97

• H2S one site (below grade, Verizon Bldg), 50 ppm
– PEL 10 ppm

• COCl2 (US EPA monitoring)
– relative gas density 3.48

Oxyacetylene Cutting
• Burning C2H2 + high-velocity O2
• Metal oxides: metal fume fever
– fever, cough, dyspnea, myalgia, arthralgia – self-limited after removal from exposure

• Nitrogen oxides • Particulates: TLV-TWA 5 mg/m3 • Small airway injury
– interstitial pneumonia

Volatile Organic Compounds (VOCs)
• Chiller plant (200,000 lb. freon-22 at WTC) – chlorofluorocarbons (freons)
• cryogenic, simple asphyxiant • CNS depressant, hypotension • myocardial catecholamine sensitivity
– dysrhythmias

• combustion & pyrolysis products
– phosgene, HF, HCl, CO

• Solvents, paints, paint thinners • Diesel fuel, cleaning products

Respiratory Protection
• Real-time atmospheric monitoring
– O2, CO, LEL, H2S, + VOCs (PID)

• Dust mask & N-95 inadequate • Disposable P-100 (formerly HEPA) – First available – Not NIOSH-approved for asbestos (fit) – Inadequate for gases • Half-face APR, P-100/OV/AG + AM/MA • SCBA or SAR – Judged on individual void space monitoring

Hazardous Waste Operations & Emergency Response
• OSHA 29 CFR 1910.120 • Medical surveillance
– medical & work history/exam every 1-2 yr. – includes Respiratory Standard requirements
• ENT, pulmonary, cardiovascular, musculoskeletal • liver, kidney, neurological, hematological, skin
– plasma & RBC cholinesterase – urine heavy metals

US&R Interdeployment Medical Screening Labs
• CBC, diff, platelets • AST, ALT, GGTP, AlkPhos, bilirubin • Creatinine, BUN • Na, K, Cl, CO2, Ca • Total protein, albumin • UA, heavy metals • RBC cholinesterase • HBsAb • • • • Spirometry CXR* resting ECG stress ECG*

* based on history, physical & risk factors

Vaccinations & TB Screening
• MMR • OPV* • Hepatitis A & B
– follow up HBsAb

• PPD (annually)** • Influenza (seasonal)** • Tetanus toxoid (Td)

• Varicella*
* vaccination history or history of disease ok ** unless otherwise provided by employer CONUS deployments only

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Research and operational challenges
• Integration into existing programs
– Occupational Medicine – IAFF/IAFC Fitness/Wellness Program

• Task Force members not employed by sponsoring or participating agencies
– canine handlers, structural engineers, physicians

Research and operational challenges (con’td)
• Frequency of examinations
– annually, biannually – annual post-deployment follow-up for x-years

• Content of laboratory tests
– regulation/recommendation/evidence-based

• Continued funding

Research and operational challenges (con’td)
• Health screening vs. fitness for duty
– US&R Legal Working Group – Fitness for duty determined by sponsoring and participating agencies

• Interdeployment health screening vs. Mobilization Point Medical Check-In
– acute vs. maintenance evaluation

• Postdeployment medical surveillance

Applicability to Other FEMA Response Teams
• US&R Section
– Type I Task Force – Type III Task Force

• NDMS Section

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