Hazardous Materials/ WMD Recognition and Safety in the Healthcare Environment

1. Hazardous Materials/ WMD Recognition and Safety in the Healthcare Environment

2. EOC ICS ICS IC TLA’s Three Letter Acronyms RRT PPE WMD WMD CIA CP CIA OSC PPE PPE Glossary OSHA OSHA Nomenclature and Accuracy HHS SIN WMD NRT

3. Internal Powder Actuated Cartridges External Commercial explosives Fireworks Ammunition Fertilizer bombs (Ammonium nitrate & fuel oil) Hydrazine (A flammable liquid. Forms explosive mixtures [hypergolic] - a high energy rocket fuel, corrosive and poisonous) Explosives (Class 1)

4. Internal Acetylene Propane Oxygen Nitrogen Nitrous Oxide Carbon Dioxide Anesthetic Gases Medical Air Argon External Hydrogen Sulfide Phosgene Methyl Bromide Ammonia Compressed Gases (Class 2)

5. Internal Diesel Alcohols Xylene Methyl Methacrylate Methyl Ethyl Ketone External Gasoline Hydrazine Methanol Diesel Acetone Flammable/Combustible Liquids (Class 3)

6. Internal Barium External Aluminum phosphide Naphthalene Sodium Carbon Magnesium Flammable Solids (Class 4)

7. Internal Oxygen (actually a compressed gas or cryogenic liquid) Peroxyacetic Acid External Red Fuming Nitric Acid (a corrosive) Nitrogen Tetroxide Ammonium Nitrate Methyl Ethyl Ketone Peroxide Fluorine, Chlorine (also poison, compressed gas, corrosive) Oxidizers & Organic Peroxides (Class 5)

8. Internal Phenol (Carbolic Acid) Chemotherapy drugs Biohazardous Waste Blood Borne Pathogens Solvents Sewage Vesicants (blistering agent, Doxorubicine, Vincristine) Mercury ETO (ethylene oxide) Glutaraldehyde & Formaldehyde External Pesticides WMD (Sarin, VX) Solvents Bioterrorism Tear Gas Vesicants (mustard, Lewisite) Poisonous & Infectious Materials (Class 6)

9. Internal Nuclear Medicine External Terrorist use Military Facilities Nuclear Reactors Commercial/Research facilities Industrial x-ray material Radioactive Materials (Class 7)

10. Internal Lab acids (e.g., Hydrochloric Acid) Boiler treatment caustics Floor stripper External Pool chemicals Sulfuric acid Nitric acid Muriatic acid Sodium Hydroxide Chlorine, Fluorine Corrosive Materials (Class 8)

11. Internal Hazardous waste Asbestos Anesthetics External Pepper spray/mace Molten Sulphur Miscellaneous. Hazardous Materials(Class 9)

12. Incidental Spill Spill that can be cleaned up in first 10-15 minutes without risk of overexposure (above Cal/OSHA short-term or Ceiling Limits) to employees under normal conditions. (May be FRA.) Emergency Response Spill Requires Haz Mat Response if risk of overexposure to employees. (Tech) Definition of Spill Types

13. Internal External • Most of these are known Limitless Unknown Chemicals ?

14. What kinds of hazardous materials incidents can you realistically expect in the hospital? Most Common Type of Release is the Hazardous Materials Spill

15. Haz Mat Spills Bottom line is to minimize the risk to employees and to patients. For example, let’s look at a class of chemicals: the Aldehydesisters…. Formaldehyde Form and Glutaraldehyde Glut Thanks to Kaiser Permanente Western Environmental Health & Safety Service Hub for permission to modify their aldehyde presentation.

16. Introduction • Aldehydes are used throughout hospitals and pose unique hazards. The most common aldehydes, formaldehyde and glutaraldehyde, can be bad actors. Responding to spills of these chemicals requires pre-planning and an effective understanding of the hazards.

17. HCHO • Formaldehyde - • Aliphatic (straight-chain) monoaldehyde • Vapor density of 1.01 (similar to air) • Moderate vapor pressure • Exhibits a pungent odor at a threshold of between 0.05 - 1.0 ppm. • Full-Strength formalin: 37% HCHO, 10-15% methanol, 48-53% water • 10% formalin: 4% HCHO + methanol + buffer

18. Dermal: Skin Irritant (dermatitis, cracking, scaling) & Sensitizer. Inhalation: Direct irritant at 1.0 ppm. Sneezing, coughing, sore throat. Chronic exposures may cause asthma and increase risk of pneumonia and bronchitis. Can cause olfactory fatigue. Eye Contact: Transient discomfort to severe, corneal clouding/loss of vision. Ingestion: Burning of mouth, pharynx, stomach. 37% causes severe irritation, inflammation, and even death. Formaldehyde Potential Adverse Health Effects

19. Healthcare Uses of Formaldehyde • Tissue Fixation and Preservation • Dialysis equipment disinfection • Stool specimen preservation • Reticulum staining • Biological Safety Cabinet decontamination • Pharmacy compounding • Pathology / Morgue • Operating Room • Labor and Delivery • Hemodialysis • Emergency Room • Waste Storage • Shipping & Receiving Formaldehyde Use Areas

20. Formaldehyde Potential Adverse Health Effects • Dermal: Skin Irritant (dermatitis, cracking, scaling) & Sensitizer. • Inhalation: Direct irritant at 1.0 ppm. Sneezing, coughing, sore throat. Chronic exposures may cause asthma and increase risk of pneumonia and bronchitis. Can cause olfactory fatigue. • Eye Contact: Transient discomfort to severe, corneal clouding/loss of vision. • Ingestion: Burning of mouth, pharynx, stomach. 37% causes severe irritation, inflammation, and even death.

21. Healthcare Glutaraldehyde Uses • Cold sterilizing and disinfecting solution • As a component of X-ray film processing chemicals • Histology & Pathology Fixative ingredient • Gastroenterology (GI) • Operating Room or Ambulatory Surgery • Respiratory Therapy • Urology • Sterile Processing • Obstetrics/Gynecology • Ultrasound/Radiology • Histology/Pathology Glutaraldehyde Use Areas

22. Glutaraldehyde Health Effects - • Eyes: Clear dose-response relationship for conjuctival and corneal injury. Lowest concentration producing minor corneal injury is 1%; 0.2% for conjunctival irritation. • Skin: Function of site on body, time of contact, concentration, and condition of skin. Threshold concentrations for primary dermal irritation under occlusive conditions on sensitive skin is about 0.4% solution. However, concentrations of up to 5% may not induce an irritant effect when applied briefly to bare skin. • Respiratory: The threshold for peripheral sensory irritation of the respiratory tract is 0.3 ppm. Short-term repeated exposure to Glutaraldehyde vapors in concentrations from 0.2 to 3.0 ppm shows a steep dose-response for toxicity and moderately severe irritation effects.

23. Summary of Health Hazards • In spill situations, both formaldehyde and glutaraldehyde have the potential to pose a significant threat to the respiratory system, skin or eyes. • Proper selection of respiratory protection and protective clothing is key to mitigating risk to personnel during spill clean up. (Covered in FRO.)

24. Spill Clean-up Options • Let it evaporate if operational downtime not a problem and no recirculating exhaust to adjoining departments. (FRA) • Departmental staff to apply spill control product and work fast to minimize exposure. (FRA?) • Internal or external spill clean-up team (will be haz mat after first 10-15 minutes if no spill control product applied). (Tech) • Implement permanent engineering controls that will reduce exposure risk - could be floor exhaust, increased over-all exhaust, emergency exhaust fan.

25. Spill Response OptionsNeutralization/Absorption Products • Neutralizers react with the aldehyde and convert it to a non-hazardous product. • Inert Absorbents capture the aldehyde but it still possesses its hazardous qualities.

26. Multiple Hazards & Health Effects • Regulations are performance standards • More than one hazard class • Markings don’t show all hazards • Think of multiple hazards always!

27. Lets talk about… TERRORISM External Events Most external events, both small and large, are accidents …. but some are not.

28. Types of Weapons of Mass Destruction (WMD) C - Chemical B - Biological R - Radiological N– Nuclear E - Explosive

29. Introduction to Haz Mat & WMD • Types of Weapons of Mass Destruction (cont’d.) • Others • Incendiary (arsonist) • Explosive (bomber) • Firearm (assassin) • Common Hazards • Typical Hazardous Materials - You May Encounter • Potential Weapons of Mass Destruction - You Will be Directed To

30. Chemical TerrorismIs a Haz Mat Event Types of Agents • Nerve - Sarin VX • Blister (vesicants) - Mustard Lewisite • Blood - Cyanide • Choking - Chlorine Phosgene • Irritating - Tear Gas Pepperspray

31. Biologic TerrorismIs an Infectious Disease Event Types of Agents • Bacteria Anthrax Plague Tularemia • Viruses Smallpox Hemorrhagic Fevers (Ebola) Venezuelan equine encephalitis (VEE) • Toxins Botulism Ricin

32. Scene Clues • People running from area • People collapsed in the area • Evidence of a leak • Fire • Vapors • Unusual colors/ odors • Loud roar or increased pitch of a valve

33. Do not rely on only one source of information. Be skeptical!! Information Resources • Container Labels • SDS’s • Poison Control • ERG • ATSDR • Agency for Toxic Substance & Disease Registry • Computer programs • People 2008

34. Importance of Recognition • Any responder can encounter WMD or hazmats • Any responder can get hurt Percent of responder injured at hazmat incidents.

35. Senses • Last resort! • Highest danger!

36. “Clues” are “Clues”! • They are a, • Warning • Note of caution • Indication of things to come • But not always all the answers!

37. Need to recognize and act fast Hospital Triage Clues • Liquids or powders on the patient • Odors • What were they doing when this happened? • Where were they? • How long ago did the accident occur?

38. SDS Diforsuranol Make out your will. It’s all over.Death imminent. No hope for you pal! Bad stuff! Touch this and you die. Call 911 now! Safety Data Sheets • Should be available for each Hazmat in the workplace • Required by OSHA Hazard Communication Regs • Provides valuable information

39. Know Your… • Level of Training • Role • Responsibility • Limits