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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. OSHA Respiratory Standard Medical Evaluation: Challenges from the World Trade Center US&R Operations .

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OSHA Respiratory Standard Medical Evaluation: Challenges from the World Trade Center US&R Operations

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  1. 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 OSHA Respiratory Standard Medical Evaluation:Challenges from the World Trade Center US&R Operations

  2. 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 • NIOSH-approved APR/SCBA/SAR • Medical Evaluation • Fit testing • Training/maintenance/program evaluation/records

  3. 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

  4. 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)

  5. 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

  6. 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

  7. 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

  8. 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

  9. Vision effects • Usually no problem for successful long-term 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

  10. Skin effects • Shave areas contacting the sealing surface

  11. Thermal effects • Especially when used in combination with impermeable clothing

  12. Psychological effects • Claustrophobia; fear of exposure

  13. 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.

  14. 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

  15. 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

  16. 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

  17. 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

  18. Asbestos insulation fireproofing Concrete Portland cement Crystalline silica glass concrete Inorganic acids Freons chiller plant Mercury fluorescent lights H2S sewer Combustion products Potential structural toxic hazards

  19. CO structure fire powered equipment vehicles PCBs PAHs diesel exhaust VOCs fuel oil/diesel fuel Heavy metals building materials batteries oxy-acetylene steel cutting Particulates fibrous glass gypsum cellulose Potential structural toxic hazards (con’td)

  20. Particulates • 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

  21. Particulates • 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)

  22. 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

  23. Asbestos • 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

  24. 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

  25. Afternoon 0.638 f/cc Afternoon 0.662 f/cc Early evening 0.430 f/cc Evening 0.196 f/cc Evening 0.150 f/cc Late evening 0.032 f/cc Asbestos-WTC • 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)

  26. 9/12 AmEx Building (NW) 0.131 f/cc Broadway x Murray (NE) 0.204 f/cc WTC perimeter 0.054-0.660 f/cc Murray x West (NW) 0.296-2.114 f/cc (heavy debris) 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

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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* US&R Interdeployment Medical Screening Labs * based on history, physical & risk factors

  34. MMR OPV* Hepatitis A & B follow up HBsAb Varicella* PPD (annually)** Influenza (seasonal)** Tetanus toxoid (Td) Vaccinations & TB Screening ** unless otherwise provided by employer * vaccination history or history of disease ok CONUS deployments only

  35. 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

  36. 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

  37. 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

  38. Applicability to Other FEMA Response Teams • US&R Section • Type I Task Force • Type III Task Force • NDMS Section • DMAT, VMAT • NMRT, MMRS/MMST • NPRT, NNRT

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