Medical Surveillance Medical Monitoring

Transcription

1 Medical Surveillance Medical Monitoring

2 Fred Haas, NREMTP Paramedic District Supervisor, Sussex County EMS Domestic Preparedness Coordinator, OEMS Captain/EMT, Selbyville VFC

3 Guidelines and Requirements Haz Mat Rehab Medical Monitoring Medical Surveillance Haz Mat RIT

4 Providence Rhode Island Structure fire at a fast food restaurant FF became sick Headache, weakness, SOB and cough Back at the station after the call Began talking incoherently

5 FF reluctant to be transported Eventually went to ED Worked up as smoke inhalation A very observant MD happened to walk by and noticed the FF s condition He recommended a test for CN poisoning Found to have toxic levels in blood

6 Believed to be an isolated case Precaution all other FFs operating that call were brought in for testing 3 out of 16 also had toxic levels First thought was that the restaurant fire had something special about it causing CN poisoning

7 Two more fires over the next 14 hours 4 more FFs found to have toxic CN levels one suffered a heart attack

8 Produced by combustion of nitrogen and carbon containing substances Plastic and polymers Wool, silk, cotton, paper 35 times more toxic than CO Enters through all routes Incapacitates quickly

9 NFPA CFR NIOSH/OSHA/USCG/EPA Occupational Safety and Health Guidance Manual for Hazardous Waste Site Activities

10 Safety and health program Site specific plans Safety and health training program Medical surveillance program Employer SOPs

11 Interventions designed to mitigate against the physical, physiological and emotional stress of emergency operations Goal is to sustain energy, improve performance and decrease likelihood of on-scene injury or death

12 NFPA 1500 Standard on Fire Department Occupational Safety and Health Programs Develop policies and procedures for emergency incident rehabilitation Includes incident scenes and training exercises NFPA 1584 Recommended Practice on the Rehabilitation of Members Operating at Incident Scene Operations and Training Exercises NFPA 471

13 Stressors of emergency operations Weather Fatigue Sub-optimal work conditions Nature of the workload

14 Get you home alive

15 85 reported 55 volunteer (64.7%) 28 career (32.9%) Causes 52 stress/overexertion (61.1%) Nature of Illness 48 heart attacks (56.4%)

16 23.5% were under age 40 We often focus on the older members Younger members Don t recognize stressors Enthusiastic Invincible Peer-pressure

17 960 firefighter deaths 480 stress/overexertion as contributing factors 437 listed heart attacks as causative

18 Relief from climatic conditions Rest and recovery Active and/or passive cooling or warming Hydration Caloric and electrolyte replacement Medical Evaluation Accountability

19 Ongoing Systematic Risk Evaluation Heat/cold exposure Stress Haz Mat exposure Goal is early recognition and prevention

20 EMS has authority delegated from the IC to keep members in rehab or to transport them for further evaluation and treatment Keep IC informed and advised Notify IC of any member removed from service and/or transported BLS

21 Identify exclusion criteria Baseline (pre-exposure) Provide early recognition and treatment

22 Complete on all those wearing CPC As soon as possible upon arrival of Haz Med team members Within one hour prior to entry Pre-entry hydration ( 16 oz)

23 Blood pressure DBP > 105 mm Hg Pulse 70% of maximum target heart rate (220- age) Respiratory rate > 24 bpm Temperature > 37.5 C (oral) / 38 C (core) < 36 C (oral) / 37 C (core) EKG rhythm - dysrhythmias Weight (?)

24 Pulse Oximetry Pulse Co-oximtery Non-smokers 0-5% Smokers 5-10%

25 Rashes Sun burn Open sores Open wounds Acne (?)

26 Altered mental status Slurred speech Weakness Confusion Staggered gait

27 New meds (including OTC) taken within the past 72 hours Alcohol consumption within the past 24 hours New medical procedures or illnesses within the past two weeks Symptoms within the past 72 hours Fever Nausea / Vomiting Diarrhea Cough / URI

28 Evaluate those wearing CPC for return to baseline Monitor for display of agent related symptoms Transport those with signs of exposure

29 Chest pain Dizzy Difficulty breathing Weakness Nausea Headache

30 Vital signs back to 10% of baseline Evaluate for signs of exposure

31 Body weight loss > 3% Positive orthostatic changes HR increase by 20 bpm BP decrese by 20 mm Hg HR > 85% of maximum target heart rate Temp > 38 C (oral) / 39 C (core) N/V, diarrhea, AMS, respiratory, cardiac or skin problems

32 IV hydration to HR < 100 bpm and SBP > 110 mm Hg Oxygen Treat specific symptoms of exposure

33 Responders can easily lose 32 oz. of fluid in less than 20 minutes of strenuous activity

34 Pre-hydration 16 oz. within 2 hours prior to the event In Rehab Self-rehab 2 8 oz During formal rehab Satisfy thirst oz. Water at first rehab visit Sports drink on subsequent visits Post-incident

35 Overhydration Too much fluid too quickly may overwhelm the stomach s ability to handle fluid Results in nausea and vomiting Hyponatremia (water intoxication) Drink 1 sports drink for every oz. of water consumed

36 Incidents > 3 hours Working > 1 hour Hand washing before eating

37 Carbonated, high-fructose content, high sugar High fat and/or high protein Alcohol Tobacco Ephedrine

38 Rest time equal to suit time If HR not within 10% of baseline within 10 minutes, perform orthostatics

39 Heat Cold

40 Routes of heat transfer Thermal radiation Conduction (direct contact) Convection (moving air or water) Relative Humidity Determines rate of heat transfer by evaporation Higher humidity = less evaporation

41 H High heat conditions E Exertional level of work or training A Acclimation T Time

42

43 Linked to heat stress Each 1% of body fluid loss will raise core temperature 0.25 to 0.5 F A 4% decrease in fluid volume will decrease performance by 50%

44 Dehydration and salt depletion Lack of heat acclimation Poor physical fitness/excessive body weight Skin problems Minor illness Medications Antihistamines, TCAs, Stimulants, Diuretics, Betablockers

45 Chronic disease Diabetes, cardiovascular, CHF Recent alcohol use Prior heat injury Age > 40 years Highly motivated people Genetics

46 Heat Cramps Strenuous activity Electrolyte loss (Sodium) Voluntary muscles of extremities Rest and replace electrolytes Early warning sign

47 Heat Exhaustion Fluid volume depletion Hypoperfusion Symptoms Fainting Profuse sweating Headache Tingling in extremities Pale Dyspnea Nausea/vomiting

48 Heat Exhaustion Signs Pale, cool, moist skin Rapid thready pulse BP initially elevated, then rapidly drops Narrowed pulse pressure Shock Treatment Cool Hydrate IV Transport and evaluate at ED

49 Heat Stroke Temperature regulating and cooling mechanisms fail Signs Skin flushed, hot, dry Altered mental status Treatment Lower body temperature ASAP Wet sheet, fan, ice packs Cautious IV fluids

50 Forearm immersion Misting fans

51 Humidity less of an effect colder air less able to hold water Wind chill is a major factor

52

53 > 25 F = little danger if properly clothed 25 to -75 F increasing danger, flesh may freeze < -75 F great danger, flesh may freeze in 30 seconds

54 Entry time Vital signs Assessment Interventions Repeat vital signs Exit time Limitations or concerns

55 For hot incidents Shade Air conditioning Cold incidents Dry area Heated Out of the wind

56 Nearby structure garage Large trees Tent School bus Ambulance

57 Area should be large enough Members in PPE Drop off area for SCBA and gear removal Away from exhaust fumes of vehicles and equipment Away from spectators / media Accessible for ambulance

58 Tents / shelter Fans Blankets Portable heating Lighting Generator Misting fans

59 Chairs Hand washing Coolers Accountability supplies log, tags Trash collection Medical supplies - monitoring

60 Fitness for duty Detect any changes in health status Physical Chemical

61 Those potentially exposed to at or above permissible exposure limits Those who wear respirators for 30 days per year Those who become sick from possible exposure Members of Haz Mat teams

62 For Haz Mat team On assignment to team At least once per year MD may deem a longer interval is appropriate Not longer than biennially At termination or re-assignment If exhibiting signs and symptoms of exposure More frequently at direction of MD

63 Medical history Baseline exposure level Potential risk exposure Meet work standards Wear respirator

64 Prior chemical exposure Previous illness Chronic illness Allergies / sensitivities Family history Social history alcohol, drugs, tobacco

65 Height and weight Vital signs HR, RR, BP, and temp Sight Hearing Cardiac (ECG) Respiratory Skeletal and spine Abdomen hernia, rectal Skin CNS

66 Blood and urine Liver Kidneys Chest X-ray Pulmonary function test ECG

67 Symptom onset may be delayed Medical evaluation Briefing Potential for exposure Signs and symptoms Directions for follow-up Exposure log

68 Exposures exceeding permissible levels Measured concentrations Potential sources of harm Eyes Skin Respiratory Directions for medical follow-up

69 Identified substances Exposure levels Times Exposures Work times (in PPE) Rest periods Metering / methods Post-incident debriefing and follow-up

70 Health screenings / exams Exposure log Injury reports Confidentiality Available to employee Maintained for 30 years post employment

71 Rapid intervention team to support fallen responders Modeled after fire service experience Dedicated rescue team separate from back-up team

72 SKEDs Back-up air supply Appropriate hand tools (irons) Site map

73

74 Haz Mat response is a strenuous activity Consider rehab and medical monitoring essential safety functions for your team Review your department SOP/SOG Make your team s health and safety a top priority!

75 OSHA Technical Manual NIOSH Firefighter Fatality Investigation and Prevention USFA Emergency Incident Rehabilitation Go to order publications and search for rehab

76 National Fire Protection Association NFPA Select codes and standards and search for 471 NIOSH/OSHA/USCG/EPA Occupational Safety and Health Guidance Manual for Hazardous Waste Site Activities

77 Fred Haas, NREMTP