Medical Surveillance Medical Monitoring
Fred Haas, NREMTP Paramedic District Supervisor, Sussex County EMS Domestic Preparedness Coordinator, OEMS Captain/EMT, Selbyville VFC medic738@yahoo.com
Guidelines and Requirements Haz Mat Rehab Medical Monitoring Medical Surveillance Haz Mat RIT
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
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
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
Two more fires over the next 14 hours 4 more FFs found to have toxic CN levels one suffered a heart attack
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
NFPA 471 29 CFR 1910.120 NIOSH/OSHA/USCG/EPA Occupational Safety and Health Guidance Manual for Hazardous Waste Site Activities
Safety and health program Site specific plans Safety and health training program Medical surveillance program Employer SOPs
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
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
Stressors of emergency operations Weather Fatigue Sub-optimal work conditions Nature of the workload
Get you home alive
85 reported 55 volunteer (64.7%) 28 career (32.9%) Causes 52 stress/overexertion (61.1%) Nature of Illness 48 heart attacks (56.4%)
23.5% were under age 40 We often focus on the older members Younger members Don t recognize stressors Enthusiastic Invincible Peer-pressure
960 firefighter deaths 480 stress/overexertion as contributing factors 437 listed heart attacks as causative
Relief from climatic conditions Rest and recovery Active and/or passive cooling or warming Hydration Caloric and electrolyte replacement Medical Evaluation Accountability
Ongoing Systematic Risk Evaluation Heat/cold exposure Stress Haz Mat exposure Goal is early recognition and prevention
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
Identify exclusion criteria Baseline (pre-exposure) Provide early recognition and treatment
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)
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 (?)
Pulse Oximetry Pulse Co-oximtery Non-smokers 0-5% Smokers 5-10%
Rashes Sun burn Open sores Open wounds Acne (?)
Altered mental status Slurred speech Weakness Confusion Staggered gait
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
Evaluate those wearing CPC for return to baseline Monitor for display of agent related symptoms Transport those with signs of exposure
Chest pain Dizzy Difficulty breathing Weakness Nausea Headache
Vital signs back to 10% of baseline Evaluate for signs of exposure
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
IV hydration to HR < 100 bpm and SBP > 110 mm Hg Oxygen Treat specific symptoms of exposure
Responders can easily lose 32 oz. of fluid in less than 20 minutes of strenuous activity
Pre-hydration 16 oz. within 2 hours prior to the event In Rehab Self-rehab 2 8 oz During formal rehab Satisfy thirst 12-32 oz. Water at first rehab visit Sports drink on subsequent visits Post-incident
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 64-96 oz. of water consumed
Incidents > 3 hours Working > 1 hour Hand washing before eating
Carbonated, high-fructose content, high sugar High fat and/or high protein Alcohol Tobacco Ephedrine
Rest time equal to suit time If HR not within 10% of baseline within 10 minutes, perform orthostatics
Heat Cold
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
H High heat conditions E Exertional level of work or training A Acclimation T Time
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%
Dehydration and salt depletion Lack of heat acclimation Poor physical fitness/excessive body weight Skin problems Minor illness Medications Antihistamines, TCAs, Stimulants, Diuretics, Betablockers
Chronic disease Diabetes, cardiovascular, CHF Recent alcohol use Prior heat injury Age > 40 years Highly motivated people Genetics
Heat Cramps Strenuous activity Electrolyte loss (Sodium) Voluntary muscles of extremities Rest and replace electrolytes Early warning sign
Heat Exhaustion Fluid volume depletion Hypoperfusion Symptoms Fainting Profuse sweating Headache Tingling in extremities Pale Dyspnea Nausea/vomiting
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
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
Forearm immersion Misting fans
Humidity less of an effect colder air less able to hold water Wind chill is a major factor
> 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
Entry time Vital signs Assessment Interventions Repeat vital signs Exit time Limitations or concerns
For hot incidents Shade Air conditioning Cold incidents Dry area Heated Out of the wind
Nearby structure garage Large trees Tent School bus Ambulance
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
Tents / shelter Fans Blankets Portable heating Lighting Generator Misting fans
Chairs Hand washing Coolers Accountability supplies log, tags Trash collection Medical supplies - monitoring
Fitness for duty Detect any changes in health status Physical Chemical
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
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
Medical history Baseline exposure level Potential risk exposure Meet work standards Wear respirator
Prior chemical exposure Previous illness Chronic illness Allergies / sensitivities Family history Social history alcohol, drugs, tobacco
Height and weight Vital signs HR, RR, BP, and temp Sight Hearing Cardiac (ECG) Respiratory Skeletal and spine Abdomen hernia, rectal Skin CNS
Blood and urine Liver Kidneys Chest X-ray Pulmonary function test ECG
Symptom onset may be delayed Medical evaluation Briefing Potential for exposure Signs and symptoms Directions for follow-up Exposure log
Exposures exceeding permissible levels Measured concentrations Potential sources of harm Eyes Skin Respiratory Directions for medical follow-up
Identified substances Exposure levels Times Exposures Work times (in PPE) Rest periods Metering / methods Post-incident debriefing and follow-up
Health screenings / exams Exposure log Injury reports Confidentiality Available to employee Maintained for 30 years post employment
Rapid intervention team to support fallen responders Modeled after fire service experience Dedicated rescue team separate from back-up team
SKEDs Back-up air supply Appropriate hand tools (irons) Site map
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!
OSHA Technical Manual www.osha.gov NIOSH Firefighter Fatality Investigation and Prevention www.cdc.gov/niosh/fire USFA Emergency Incident Rehabilitation www.usfa.fema.gov Go to order publications and search for rehab
National Fire Protection Association NFPA 471 www.nfpa.org Select codes and standards and search for 471 NIOSH/OSHA/USCG/EPA Occupational Safety and Health Guidance Manual for Hazardous Waste Site Activities
Fred Haas, NREMTP medic738@yahoo.com fhaas@sussexcountyde.gov