Emergency response to environmental toxic incidents: The role of the occupational physician*

Transcription

1 Occup. Med. Vol. 46, No. 5, pp , 1996 Copyright 1996 Rapid Science Publishers for SOM Printed in Great Britain. All rights reserved /96 Emergency response to environmental toxic incidents: The role of the occupational physician* R. J. McCunney Environmental Medical Service, Massachusetts Institute of Technology Cambridge, MA, USA A survey of accidental environmental releases of hazardous chemicals conducted by the Agency for Toxic Substances and Disease Registry indicates that fixed facility events accounted for 77% of the episodes whereas 23% of the releases were related to transportation activities, such as loading or unloading materials. In nearly all the events (88%) only one chemical was released. Volatile organic compounds, chlorine, herbicides, acids and ammonia were the most common substances involved. In nearly one out of six reported events, an injury occurred. To prepare for emergencies associated with the accidental release of hazardous materials, the federal government, industry and professional organizations including the medical community have all been involved. In the United States, the Superfund Amendment Reauthorization Act (SARA) Title III passed in 1986 addresses the need to establish local emergency planning committees, to report and collect data, and a number of other matters. Professional societies, including the Joint Commission for the Accreditation of Health Care Organizations, the American College of Occupational and Environmental Medicine (ACOEM), and the American Industrial Hygiene Association, have all attempted to ensure proper education and training of those professionals called to assist in such emergencies. The occupational physician can assume numerous roles in the challenge related to emergency response, by becoming familiar with computerized information available to promptly determine the type of hazard released and its appropriate antidote, advising on the proper personal protective equipment, awareness of secondary contamination and participation on local emergency planning committees among many others. Emergency release of hazardous materials continues to occur with a frequency in the United States that deserves active vigilance and planning. Key words: Emergency response: environmental chemical releases; occupational physician. Occup. Med. Vol. 46, , 1996 Received IS January 1996; accepted in final jorm 7 May INTRODUCTION Emergency response to environmental incidents continues to arouse the attention and demand the expertise of health officials in many industries, local communities and professionals. As a result of one 'Based on presentations made at the 1994 Annual Medichem Congress, Melbourne, Australia and the 1995 Annual Meeting of the American College of Occupational Medicine, Las Vegas, Nevada, USA. Medichem is a scientific advisory committee of the International Commission on Occupational Health. Correspondence and reprint requests to: R. J. McCunney, Environmental Medical Service, Massachusetts Institute of Technology, 77 Massachusetts Avenue, 20B-238, Cambridge, MA, USA. Tel: (+1) ; Fax: (+1) particular episode, the 1984 release of methyl isocyanate gas in Bhopal, India, 1 a watershed of activity occurred worldwide, ranging from the government to the medical community to professional societies, and the chemical industry itself. 2 ' 3 The point of this paper is to (1) summarize reports related to the consequences of acute releases of hazardous materials; (2) describe appropriate United States regulations; and (3) propose how physicians can be instrumental in both the planning and implementation of related emergency measures. Previous reports Despite the recent emphasis on planning for emergency response, as well as requirements of certain laws,

2 398 Occup. Med. Vol. 46, 1996 including the Superfund Act Reauthorization Amendment (SARA), 2 reporting systems appear in need of improvement. 4 Presently, 14 state health departments collect and transmit information regarding emergency events to the Agency for Toxic Substances and Disease Registry (ATSDR). This information includes the names of the substances released and the public health consequences including illness, injuries and the need for evacuation. When instituted by the ATSDR in January, 1990, the programme included five states. At the completion of December, 1992, an additional nine states were enrolled. In the most recent summary, from January 1990 through December 1992, 33,125 events were reported, 5 with fixed facility events accounting for 77% of the episodes, and releases related to transportation activities making up the remaining 23%. Only one chemical was released 88% of the time. Volatile organic compounds, herbicides, acids and ammonias were the most common substances described. In approximately one out of six reported events, injuries occurred; 11 deaths were noted. The most frequently reported symptoms were respiratory and eye irritations. At least one out of six of these events resulted in an evacuation. Earlier, a Centers for Disease Control Report described accidental releases of hazardous materials that resulted in deaths, injuries or evacuations. 6 As part of the report, the three largest national databases, the National Response Center, the Department of Transportation Hazardous Materials Information System and the Acute Hazardous Events Database were reviewed. Of the 587 episodes described in 1986, 115 deaths, 2,254 injuries and 111 evacuations occurred. Since only eight (1%) of these 587 events were common to all three of the reporting systems, the author conducted an additional review of articles in the NEXIS Search System of Mead Data Central. 7 This survey of the general literature uncovered an additional 210 deaths, 6,490 injuries and 533 evacuations, which yielded an average of 3.3 acute chemical releases each day resulting in serious consequences. These releases were not reported to customary agencies, but were noted by the author through a review of newspaper accounts. The most common substances released were natural gas, gasoline and chlorine. These results indicate that the unexpected release of hazardous materials occurs with some frequency in the USA and often results in death, injuries and evacuations. As evidenced by the Binder study, many releases are not being reported through appropriate channels. HOW THE USA HAS RESPONDED Four major sectors have become more involved in responding to the accidental release of hazardous materials, including the federal government, the chemical industry, the hospital sector, and professional societies of industrial hygienists and physicians, among others. In 1986, the Federal Government passed the Superfund Act Reauthorization Amendment (SARA) (Title III), 2 which requires manufacturing facilities to report the identity and quantities of materials that they use to the local government. The Environmental Protection Agency establishes a list of extremely dangerous substances (approximately 400) that must be reported. After an unexpected release of a hazardous substance, the community emergency coordinator of the Local Emergency Planning Committee (LEPC) and the State Emergency Response Commission must be notified. The LEPC has specific roles that are outlined in Table 1. The Local Emergency Planning Committee (LEPC), consists of representatives of organizations that may respond in an emergency, including police, fire and medical professionals. The Act mandates the need for medical treatment protocols, among other healthrelated activities. Many sectors, including the chemical industry, hospitals and professional societies of industrial hygienists and physicians have responded directly to their role in preventing adverse health effects from the accidental release of hazardous substances. The chemical industry, through its trade association, the Chemical Manufacturers Association (CMA) developed a community awareness emergency response (CAER) programme. This programme includes guidelines for health and safety representatives of manufacturing facilities for participation in emergency planning procedures (see Table 2). The hospital community addresses emergency preparedness primarily through the Joint Commission for the Accreditation of Health Care Organizations (JCAHO). 8 These extensive requirements specify how hospitals must respond to the accidental release of chemical materials, including maintaining suitable medical references, providing access to specialized professionals and administering antidotes for treating exposure to certain hazards. 9 Failure to meet these dictates has serious ramifications for a hospital's eligibility for receiving third party funding, especially Medicare and Medicaid. In the aftermath of an unexpected release of a hazardous chemical, practical questions invariably surface about the safety of re-entry, especially in a confined area. To develop a scientific basis for addressing these Table 1. Role of the local emergency planning committee Identify facilities using hazardous materials in transportation routes Establish emergency procedures Designate a community and a facility coordinator to implement the plan Establish mechanisms for emergency notification Establish procedures for determining a release in estimating the affected area Describe community and facility equipment and identify responsible personnel Establish evacuation plans Schedule training programmes for emergency personnel

3 R. J. McCunney: Emergency response to environmental toxic incidents 399 Table 2. Community Awareness Emergency Response Community Emergency Plan: Implementation steps* 1. Identify participants and define their roles 2. Identify risks and hazards that may lead to emergencies 3. Encourage participants to review their own plan 4. Identify response tasks that are not covered by existing plans 5. Match these tasks to resources that are available 6. Make the changes to improve existing plans 7. Write an integrated community plan and obtain local government approval 8. Educate participants about the plan and trained emergency responders 9. Establish procedures for periodic testing review and updating of the plan 10. Educate the general community about the integrated plan * Developed by the Chemical Manufacturers Association, Washington, DC. important questions, the American Industrial Hygiene Association developed Emergency Response Planning Guidelines, that provide estimates of concentration ranges where adverse affects may occur. 10 The results are based on a committee review of short-term animal inhalation studies; concentrations listed are assumed to be safe for approximately one hour without protection. A Level 1 concentration is defined as capable of causing mild, transient and reversible effects; Level 2 concentrations may cause irreversible effects; Level 3 concentrations are considered life threatening. Approximately 35 substances have been evaluated by the Committee as of the writing of this report, (see Table 3 for phosphorous pentoxide, and Table 4 for a current listing of materials that have been evaluated). The American College of Occupational and Environmental Medicine has developed continuing education courses in environmental medicine, for its members and those of other specialties, a component of which pertains to emergency response procedures. The American College of Emergency Physicians has also sponsored similar educational efforts to enable its members to become more familiar with the evaluation and treatment of exposure to hazardous materials."' 12 Poison Control Centers, with the assistance of the Chemical Manufacturers Association, have a programme entitled MEDTREC, that facilitates access to current information on the toxicology of hazardous substances. Previous reports have estimated that about 10-20% of phone calls to poison control centers are related to occupational or environmental exposures. EMERGENCY RESPONSE: MEETING THE CHALLENGE Table 3. Current AIHA ERPGs t Chemical (CAS Number) Acetaldehyde ( ) Acrolein ( ) Acrylic Acid (79-1-7) Acrylonitrile ( ) Ally! Chloride ( ) Ammonia ( ) Benzene ( ) Benzyl Chloride ( ) Bromine ( ) 1,3-Butadiene ( ) n-butyl Acrylate ( ) n-butyl Isocyanate ( ) Carbon Disulfide ( ) Carbon Tetrachloride (5-23-5) Chlorine ( ) Chlorine Trifluoride ( ) Chloraacetyl Chloride ( ) Chloropicrin ( ) Chlorosulfonic Acid ( ) Chlorotrifluoroethylene ( ) Crotonaldehyde ( ) Diborane ( ) Diketene ( ) Dimethylamine ( ) Dimethyldichlorosilane ( ) Dimethyl Disulfide ( ) Dimethyl Sulfide ( ) Epichlorohydrin ( ) Ethylene Oxide ( ) Formaldehyde ( ) Hexachlorobutadiene ( ) Hexafluoroacetone Hexafluoropropylene ( ) Hydrogen Chloride ( ) Hydrogen Cyanide ( ) Hydrogen Fluoride ( ) Hydrogen Sulfide ( ) Isobutyronitrile ( ) 2-lsocyanatoethyl Methacrylate ( ) Uthium Hydride ( ) Methanol ( ) Methyl Chloride ( ) Methyl Iodide ( ) ERPG mg/m ppm ug/m 3 Methyl Isocyanate ( ) 0.0 Methyl Mercaptan ( ) 0.00 Methylene Chloride ( ) Methyltrichlorosilane ( ) 0. Monomethylamine ( ) Oleum ( ), Sulfur Trioxide ( ), and Sulfuric Acid ( ) 2 mg/m 3 Perfluoroisobutylene ( ) Phenol ( ) Phosgene ( ) Phosphorus Pentoxide ( ) Propylene Oxide ( ) Sulfur Dioxide ( ) Styrene ( ) Tetrafluoroethylene ( ) Titanium Tetrachloride ( ) Toluene ( ) Trimethylamine ( ) Uranium Hexafluoride ( ) Vinyl Acetate ( ) ERPG ppm mg/m 3 30 ppm ug/m ppm mg/m mg/m ERPG ppm 250ppm ppm 30 ppm 500 ig/m ppm ppm mg/m ,000 ppm 100 mg/m 3 Physicians responsible for emergency response have a number of options to enhance their preparation, including medical texts, computerized information, access to poison control centers, and a 24-hour on-line * The ER PG-i for this chemical has been lowered from. " NA = not appropriate t Reproduced with permission from The 1996 Emergency Response Planning Guidelines and Workplace Exposure Level Guides Handbook. AIHA, 1996.

4 400 Occup. Med. Vol. 46, 1996 service from the Agency of Toxic Substances and Disease Registry (Tel: [+1] ). B Computerized information Despite the proliferation of computer databases for access to current medical and toxicological information, it is preferable to learn about the hazards present in a facility well ahead of any release. In an emergency, immediate access to information related to the substance is essential. Many computer databases, including those of TOXNET and ANSWER are available. 14 One particular database, TOMES Plus, has sections on medical management, (Meditext) safe handling of hazardous materials (Hazard text), and reporting for Superfund Act Reauthorization Amendment (SARATEXT). Preparing for the response: Medical concerns The physician can play a major role in preparing for any potential emergency response, primarily with a thorough understanding of the materials that may be released, and a review of on-site healthcare resources, emergency medical technicians and ambulances. 15 Coordination of activities of an on-site facility with those located off-site is essential in an emergency. One needs to ensure that medical resources are prepared for treating symptoms due to exposure to toxic substances, especially with the administration of appropriate antidotes, such as calcium gluconate for hydrofluoric acid burns. Decontamination procedures for people injured in a release and for health care professionals as well as for the facilities must be established. 16 Medical evaluations of personnel involved in the emergency (both before and after an episode) are other responsibilities of the physician. 2 A related activity associated with examinations, is ensuring that emergency responders have proper personal protective equipment. These decisions may involve discussions with industrial hygiene and safety personnel. (Table 5 outlines the personal protective equipment grades). Physician participation in the local emergency planning committee (LEPC) can be extraordinarily valuable. The LEPC must coordinate numerous activities related to releases of hazardous materials and ensure appropriate training and drills for responders and file the necessary reports. THE RESPONSE In responding to a chemical release, it is wise not to drive or walk through spilled materials and to avoid contamination of equipment used in the rescue. Shipping papers, required for certain trucking activities should not be obtained unless adequate personal protective equipment is available. An awareness of meteorological patterns, especially in the context of a gas release, can help prevent illnesses. Table 5. Classes of personal protective equipment* A. Totally encapsulating chemical resistance suit with a self-containing breathing apparatus (SCBA) B. A splash protection with chemical resistance clothing and a positive pressure full face SCBA. C. Splash protection with chemical resistance clothing and a chemical resistant full-faced piece air purifying respirator. D. Standard work uniform. * Source: Reference 2. Fundamental medical treatment at an emergency scene includes ensuring that the airway is open, that bleeding is stopped and that consciousness is roused. Ideally, people should be treated outside of the contaminated areas in accordance with conventional triage procedures, especially for invasive procedures. Many health issues surface in responding to a chemical emergency, including selection of proper personal protective equipment and monitoring of airborne concentrations of the material released. One must also decide when and where to administer first aid and be aware of the need to neutralize the chemical with an appropriate substance. A careful review of the Material Safety Data Sheet (MSDS) will help avoid incompatibilities that can create further risk between the control measures and the hazard. Certain hazardous materials are more likely to cause secondary contamination of clothing and equipment, including acids, alkalis, cyanide salts, hydrofluoric acid solutions, mercaptans, pesticides and polychlorinated biphenyls (PCBs). 16 Immediate onsite treatment is necessary for organophosphate pesticides, hydrogen cyanide, hydrofluoric acid and hydrogen sulfide because of the acute hazard that these substances pose. THE ROLE OF THE PHYSICIAN The role of the physician in responding to the release of a hazardous material depends on background, training and interests, including the needs of the organization for which services are provided. A thorough understanding of the toxicity of the materials, including their acute and potential long-term effects, as well as biological monitoring techniques, is essential. Ideally, the physician will be a member of the LEPC and participate in training sessions along with other first responders, including emergency room physicians, police and fire personnel. Ensuring the accuracy of material safety data sheets, especially the corresponding treatment protocols will avoid confusion during an emergency. Consultative advice to other physicians, including the emergency room professionals, is often expected. Although serving as a spokesperson to the media is a potentially difficult task, it is essential that accurate information be conveyed to reduce the anxiety and uncertainty often

5 R. J. McCunney: Emergency response to environmental toxic incidents 401 associated with emergency releases. Rumors about the hazard or its health consequences can create confusion that may prove difficult to clear later. SUMMARY This discussion of the unexpected release of hazardous materials, with attention to the physician's role, has uncovered a number of findings. 1. The accidental liberation of hazards in the USA occurs frequently and results in preventable death, injury and evacuation. 2. The reporting and follow-up of releases need improvement The ATSDR initiative, if expanded to all 50 US states and if inclusive of newspaper accounts, will add substantial data to foster our understanding of the extent of the problem. 3. The role of the physician, especially the occupational medicine specialist, is not widely recognized either within or outside the profession. This observation, that is, of the nebulous responsibilities of the physician, has been noted in reports originating in the United Kingdom" and the European Union as well. 18 Recurring problems include the paucity of information available from previous disasters, coupled with questionable understanding of the response plan by participants, and the unique character of each release. The medical response is only one component of a multidisciplinary effort necessary in effectively dealing with these health emergencies. Repeat drills, despite their lack of appeal, can promote a familiarity with procedures, since a sense of urgency and panic is often present. One needs to act quickly, but not randomly, to prevent further illnesses and death among those with direct exposure to hazardous materials. REFERENCES 1. Mehta PS. Bhopal tragedy's health effects. JAMA 1990; 264: Hazardous Waste Operations and Emergency Response. 29CFR Health and Safety Executive. The Control of Major Industrial Accident Hazard Regulations, 1984 (CIMAH): Further Guidance on Emergency Plans. London: HMSO, Baxter PJ. Occupational and Environmental Medicine: What is it? Occup Environ Med 1994; 51: Hall HI, Dhara VR, Price-Green PA, Kaye WE. Surveillance for emergency events involving hazardous substances the United States, MMWR 1994; 43: Binder S. Deaths, injuries and evacuations from acute hazardous materials releases. AmerJ Public Health 1989; 79: Binder S, Bonzo S. Acute hazardous materials release. AmerJ Public Health 1989; 79: Thanabalasingham T, Beckett WM, Murray V. Hospital response to a chemical incident: Report on casualties of an ethyl dichloro saline spill. Brit Med J 1991; 302: US Department of Health and Human Services. Managing Hazardous Materials Incidents. Hospital Emergency Departments. A Planning Guide for the Management of Contaminated Patients. Atlanta (GA) USA: US Department HHS. Agency for Toxic Substances and Disease Registry. 10. Rusch, GM. The history and development of emergency response planning guidelines. J Haz Mat 1993; 33: Leonard, RB, Calabro.JJ, Ognogi, EK, Leviton, RH. SARA Superfund Amendments and Reauthorization Act, Title III: Implications for Emergency Physicians. Annals Emerg Med 1989; 18: Kirk MA, Cisekj, Rose SR. Emergency department response to hazardous materials incidence. Emerg Med Clin NAmer 1994; 12: Mitchell E The agency for toxic substances and disease registry. In: McCunney RJ, ed. A Practical Approach to Occupational and Environmental Medicine. Boston: Little Brown, 1994: Decker WJ. Toxicological information series IV. Information resources for chemical emergency response. FundAppl Toxicol 1990; 15: Baxter PJ, Davies PC, Murray V. Medical planning for toxic releases into the community: The example of chlorine gas. Bri J Ind Med 1989; 46: Lavoie FW, Coomes T, Cisekj E, Fulkerson L. Emergency department, external decontamination for hazardous chemical exposure. Veterin Human Toxicol 1992; 34: Baxter P. Major chemical disasters. Britain's health services are poorly prepared. Brit MedJ 1991; 302: Organization for Economic Cooperation and Development. OECD Environment Monograph Number 81 on Health Aspects of Chemical Accidents. Paris: OECD, 1994.