Managing Hazardous Materials Incidents Volume II, Hospital Emergency Departments

U.S. Department of Human Services, Public Health Service, Agency for Toxic Substance and Disease Registry

Publication date: 01/01/1992

Table of Contents

Introduction

Emergency Department Response to Hazardous Materials Incidents
Hazard Recognition
Principles of toxicology for emergency department personnel
Personnel Protection and Safety Principles
Respiratory Protection
Emergency Department Personnel Decontamination
Communications
Selected Bibliography

Patient Management
Emergency Department Preparation
Patient Arrival
Decontamination of Patient
Considerations for Patient Treatment
Critique
Patient Management Under Mass Casualty Conditions Involving Hazardous
Selected Bibliography

Systems Approach To Planning
The Role of the Hospital in a Systems Approach to Planning
The Spectrum of Hazardous Materials Incidents
Joint Commission on Accreditation of Healthcare Organizations (JCAHO
SARA Title 111
The State Emergency Medical Services (EMS) Agency
Federal Emergency Response Activities
Hazard Analysis
Selected Bibliography

Appendix A; Hazardous Materials Classification Systems
System Notes; HEALTH (BLUE)
Flammability (RED)
Reactivity (STABILITY) (YELLOW)
U.S. Department of Transportation Research and Special Programs Administration Hazardous Materials Marking, Labeling & Placarding
Material Safety Data Sheets

Appendix B; Types of Respiratory Protection

Appendix C; Levels of Protection

Additional Information

POINT OF CONTACT FOR THIS DOCUMENT:

Tables
Telephone Information And Technical Support References
Local Telephone Information And Technical Support Resource Worksheet
Computerized Data Sources Of Information And Technical Support
Examples Of Adverse Health Effects From Exposure To Toxic Chemicals
Classification Of factors Influencing Toxicity
Dose-Response Relationship For Humans Inhaling Tetrachlorthylene
Acute LD (50) Values For Representative Chemicals When Administered
Occupational Exposure Limits
Types Of Respiratory Protection
Levels Of Protection

Figures
Levels Of Protection
Levels Of Protection (Continued)
A Chemical Cartridge Air-Purifying Respirator
A Self-Contained Breathing Apparatus/Supplied-Air Respirator
Nine-Step Personnel Decontamination Plan
Eight-Step Dry Decontamination Plan For Personnel
Material Safety Data Sheet
Material Safety Data Sheet (Continued)

Introduction

Hospital emergency departments must protect their personnel and other people within the hospital, while providing the best care for the chemically contaminated patient. This guide is intended to help hospital emergency departments plan for incidents that involve hazardous materials and improve their ability to respond to these incidents appropriately.

To ensure appropriate and timely patient care, as well as optimal worker protection, emergency personnel must have an understanding of decontamination procedures and personal protective equipment that they do not generally receive in the course of their routine professional training. They should also be aware of community resources that could be called upon to assist in emergency response.

Current training curricula for emergency physicians, nurses, and emergency medical technicians (EMTs) often do not adequately prepare these professionals to either manage the contaminated individual or decontaminate patients exposed to toxic substances. High-quality, specific, and concise guidance is needed to describe appropriate procedures to be followed by emergency medical personnel to safely care for a patient, as well as to protect equipment, hospital personnel, and others from risk of exposure. In response to this need, the Agency for Toxic Substances and Disease Registry (ATSDR) has contracted for the production of two documents: (I) Emergency Medical Services: A Planning Guide for the Management of Contaminated Patients and (II) Hospital Emergency Departments: A Planning Guide for Management of Contaminated Patients. The first document is designed for use by emergency medical technicians and other prehospital care providers to minimize their risks of exposure during the prehospital treatment and to provide for the safe and effective treatment of chemically contaminated patients.

This guide for emergency department personnel is designed to familiarize readers with the concepts, terminology, and key considerations that affect the management of incidents of chemical contamination. It has been developed not only to present uniform guidance for emergency care of chemically contaminated patients, but also to provide basic information critical to advance planning and implementation of emergency medical services' (EMS) strategies. It is intended to illustrate the characteristics of hazardous materials incidents that mandate modifications to traditional emergency response and the preparatory actions that should be taken to respond effectively to hazardous materials incidents.

All hospital and community emergency response systems may not be prepared to respond to a hazardous chemical incident to the same degree. This document may be used to assess capabilities with respect to potential community hazards and to develop response plans using national and community specific resources. Worker safety and training are also key factors in effective management of medical emergencies. This document is intended to provide source material for developing local training and safety protocols.

Emergency Department Response to Hazardous Materials Incidents, outlines general principles for hazard recognition, chemical exposure, and personal protective equipment. In addition, the hazard recognition section presents generalized guidance for determining whether a given situation constitutes a hazardous materials incident and details various hazardous materials classification systems. Basic toxicological and chemical terminology that emergency personnel need to understand to effectively conduct patient assessments is presented, as well as an outline of personal protective equipment such as respiratory devices and protective clothing.

Patient Management, includes guidelines for emergency department preparation and response to a potential hazardous materials incident. In addition, this chapter discusses patient assessment and decontamination guidelines.

Systems Approach to Planning, details the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) guidelinesfor emergency preparedness and hazardous materials and waste programs. Government and private planning activities are also outlined, such as those established under the Superfund Amendments and Reauthorization Act (SARA) Title III, the National Response Team, the Community Awareness Emergency Response (CAER) program, and the Chemical Emergency Preparedness Program (CEPP). This chapter discusses the need for hazard identification and risk analysis pertaining to hazardous materials located in the community or transported through the community.

Although this guidance document has been developed to provide for the safety of responders, as well as the needs of patients, it is not all- encompassing. Supplemental material that is vital to successful response to hazardous materials contamination is cited within the document. These supplementary materials should be reviewed before preparing any strategic plans or before conducting training exercises on this topic. This document cannot be regarded as a substitute for comprehensive instruction and training for hazardous materials incidents.

Emergency Department Response to Hazardous Materials Incidents

Hazard Recognition

• Occupancy and Location. Community preplanning should identify the specific sites that contain hazardous materials. In addition, emergency personnel should be alert to the obvious locations in their communities that use hazardous materials -- for example laboratories, factories, farm and paint supply outlets, and construction sites.
• Container Shape. Department of Transportation (DOT) regulations specify container specifications for transport of hazardous materials. There are three categories of packaging: stationary bulk storage containers at fixed facilities that come in a variety of sizes and shapes; bulk transport vehicles, such as rail and truck tank cars, that can vary in shape depending upon the cargo; and smaller quantities of hazardous materials that may be packaged in fiberboard boxes, drums, or cylinders with labeling. Often the shape and configuration of the container can be a useful clue to the presence of hazardous materials.
• Markings/Colors. Transportation vehicles must use DOT markings, including identification (]D) numbers. Identification numbers, located on both ends and both sides, are required on all cargo tanks, portable tanks, rail tank cars, and other packages that carry hazardous materials. A marking system designed by the National Fire Protection Association (NFPA) identifies hazardous materials at terminals and industrial sites but does not provide product-specific information. This system uses a diamond divided into four quadrants. Each quadrant represents a different consideration: the left, blue section refers to health; the top, red quarter pertains to flammability; the right, yellow area is for reactivity; and the bottom, white quadrant highlights special information. In addition, a number from zero through four indicates the relative risk of the hazard with zero being the minimum risk.
• Placards/Labels. These convey information by use of colors, symbols, Hazard Communication Standard, American National Standard Institute (ANSI) Standards for Precautionary Labeling of Hazardous Industrial Chemicals, United Nations Hazard class numbers, and either hazard class wording or four-digit identification numbers. Placards are used when hazardous materials are in bulk, such as in cargo tanks; labels designate hazardous materials on small packages.
• Shipping Papers. These can clarify what is labeled "dangerous" on placards. They should provide the shipping name, hazard class, ID number, and quantity and may indicate "waste" or "poison". (Shipping papers must accompany all hazardous material shipments.)
• Senses. Odor, vapor clouds, dead animals or dead fish, fire, and irritation to skin or eyes can signal the presence of hazardous materials. Generally, if one detects the odor of hazardous materials, one should assume that exposure has occurred. Some chemicals, however, can impair an individual's sense of smell (i.e., hydrogen sulfide), and others have no odor at all (i.e., carbon monoxide).

Many printed resources are available to provide information concerning response and planning for hazardous materials incidents. A selected bibliography is included at the end of each section; however, this is not a complete list of the materials available. Printed reference materials provide several advantages: they are readily available, can be transported in the response vehicle, are not dependent on a power source or subject to malfunction, and are relatively inexpensive. Disadvantages include the difficulty in determining a correct identity for an unknown chemical, materials are often out of date and cannot be easily updated, and no single volume is capable of providing all the information that may be needed

There is also a vast array of telephone and computer-based information sources concerning hazardous materials. They can help you by describing the toxic effects of the chemical, its relative potency, and the potential for secondary contamination and by recommending decontamination procedures. They may also provide advice on the adequacy of specific types of protective gear. (Table 1) is a partial listing of the many information resources available by telephone. (Table 2) is a list of suggested telephone numbers that should be filled in for your community.

Planning is an essential part of every response, and these resources will also provide guidance that can be used in forming an effective response plan. (Table 3) provides a partial listing of the available computerized and on-line information sources. It should be noted that not all on-line databases are peer reviewed. Therefore, some medical management information may be based only on DOT or MSDS data. Care and planning should be used when selecting information sources.

Computerized information sources are basically two types: (a) call-up systems that are addressed via telephone lines and (b) database systems that are housed on a local computer disc. Each system contains large amounts of information on many hazardous materials and can be searched to help identify the material involved. They are updated frequently at no extra cost to the subscriber and are extremely portable with today's computer systems. Computer databases can be expensive, as can the initial cost of the equipment. Most systems will require the operator to have some knowledge of computer terms and search protocols. Also, mechanical equipment may fall and should not be counted on asa sole source of information.

Principles of toxicology for emergency department personnel

Toxicology is the study of the nature, effects, and detection of poisons in living organisms. Some examples of these adverse effects, sometimes called toxic end points, include carcinogenicity (development of cancer), hepatotoxicity (liver damage), neurotoxicity (nervous system damage), and nephrotoxicity (kidney damage). This is by no means a complete list of toxic end points, but rather a selection of effects that might be encountered (Table 4).

Toxic chemicals often produce injuries at the site at which they come into contact with the body. A chemical injury at the site of contact with the body, typically the skin and the mucous membranes of the eyes, nose, mouth, or respiratory tract, is termed a local toxic effect. For example, irritant gases, such as chlorine and ammonia, can produce a localized toxic effect in the respiratory tract; corrosive acids and bases can produce a local damage to the skin. In addition, a toxic chemical may be absorbed into the blood stream and distributed to other parts of the body. These compounds may then produce systemic effects. For example, many pesticides are absorbed by the skin, distributed to other sites in the body, and produce adverse effects such as seizures or other neurological problems. It is important for medical providers to recognize that exposure to chemical compounds can result not only in the development of a single systemic effect but also in the development of multiple systemic effects or a combination of systemic and local effects.

Routes and Extent of Exposure--

There are three main routes of chemical exposure: inhalation, skin contact, and ingestion. Inhalation results in the introduction of toxic compounds into the respiratory system. Most of the compounds that are commonly inhaled are gases or vapors of volatile liquids; however, solids and liquids can be inhaled as dusts or aerosols. Inhalation of toxic agents generally results in a rapid and effective absorption of the compound into the blood stream because of the large surface area of the lung tissue and number of blood vessels in the lungs. Skin contact exposure does not typically result in as rapid systemic dosage as inhalation, although some chemicals are readily absorbed through the skin. Many organic compounds are lipid (fat) soluble and can therefore be rapidly absorbed through the skin. Some materials that come in contact with the eyes can also be absorbed. Ingestion is a less common route of exposure for emergency response personnel at hazardous materials incidents. However, incidental hand-to-mouth contact, smoking, and swallowing of saliva and mucus containing trapped airborne contaminants can cause exposure by this route. In addition, emergency medical personnel in both hospital or prehospital settings will see chemical exposures in patients who have ingested toxic substances as a result of accidental poisonings or suicide attempts.

Compounds can also be introduced into the body by injection; however, injection exposure is an unlikely scenario involving spills or discharges of hazardous materials.

The route by which personnel are exposed to a compound plays a role in determining the total amount of the compound taken up by the body because a compound may be absorbed following exposure by one route more readily than by another. In addition to the route of exposure, the amount of the compound absorbed by the body depends on the duration of exposure to the compound and the concentration of the compound to which one is exposed. Therefore, a complex relationship exists between the total amount of the compound absorbed by the body (dose) and the concentration of that compound in the environment. This relationship is important for emergency medical personnel to understand because the adverse effects produced by a toxic compound are often related to the dose of that compound received by a patient.

However, because we usually only monitor the concentration of the toxic substance in the environment (e.g., parts per million (ppm) of a compound in air), the actual dose of the compound received by the patient is seldom known. Factors specific to the exposed patient, such as size of the skin surface area exposed, presence of open wounds or breaks in the skin, and rate and depth of respiration, are important in estimating the dose of the compound received by the patient.

Dose-Response Relationship--

The effect produced by a toxic compound is a function of the dose of the compound received by the organism. This principle, termed the dose- response relationship, is a key concept in toxicology. Many factors affect the normal dose-response relationship and should be considered when attempting to extrapolate toxicity data to a specific situation (Table 5).

Typically, as the dose increases, the severity of the toxic response increases. For example, humans exposed to 100 ppm of tetrachloroethylene, a solvent that is commonly used for dry-cleaning fabrics, may experience relatively mild symptoms, such as headache and drowsiness. However, exposure to 200 ppm tetrachloroethylene can result in a loss of motor coordination in some individuals. Exposure to 1,500 ppm tetrachloroethylene for 30 minutes may result in a loss of consciousness (Table 6). As shown in Table 6, the severity of the toxic effect is also dependent on the duration of exposure, a factor that influences the dose of the compound in the body.

Toxicity information is often expressed as the dose of the compound that causes an effect in a percentage of the exposed subjects, which are mostly experimental animals. These dose-response terms are often found in Material Safety Data Sheets (MSDS) and other sources of health information. One dose-response term that is commonly used is the lethal dose 50 (LD50), the dose which is lethal to 50% of an animal population from exposure by any route other than inhalation when given all in one dose. Another similar term is the lethal concentration 50 (LC50), which is the concentration of a material in air that on the basis of respiratory exposure in laboratory tests is expected to kill 50% of a group of test animals when administered as a single exposure (usually 1 hour). (Table 7) lists a number of chemicals that may be encountered in dealing with hazardous materials incidents, and the reported acute LD50 values of these compounds when they are administered orally to rats.

From (Table 7), it can be seen that a dose of 3,000-3,800 mg/kg tetrachloroethylene is lethal to 50% of rats that received the compound orally; however, only 6.4 to 10 mg/kg of sodium cyanide is required to produce the same effect. Therefore, compounds with low LD50 values are more acutely toxic than substances with larger LD50 values.

The LD50 values that appear in an MSDS or in the literature must be used with caution by emergency medical personnel. These values are an index of only one type of response and give no indication of the ability of the compound to cause nonlethal, adverse or chronic effects. Furthermore, LD50 values typically come from experimental animal studies. Because of the anatomical and physiological differences between animals and humans, it is difficult to compare the effects seen in experimental animal studies to the effects expected in humans exposed to hazardous materials in the field. Therefore, emergency medical personnel should remember that the LD50 and LC50 values are only useful for comparing the relative toxicity of compounds and should only be used to determine if one chemical is more toxic than another.

Responses to toxic chemicals may differ among individuals because of the physiological variability that is present in the human population. For example, an individual may be more likely to experience an adverse health effect after exposure to a toxic chemical because of a reduced ability to metabolize that compound. The presence of preexisting medical conditions can also increase one's susceptibility to toxic chemicals. Respiratory distress in patients orworkers with asthma may be triggered by exposure to toxic chemicals at lower concentrations than might be expected to produce the same effect in individuals without respiratory disease. Factors such as age, personal habits (i.e., smoking, diet), previous exposure to toxic chemicals, and medications may also increase one's sensitivity to toxic chemicals. Therefore, exposure to concentrations of toxic compounds that would not be expected to result in the development of a toxic response in most individuals may cause an effect in susceptible individuals. Not all chemicals, however, have a threshold level. Some chemicals that produce cancer (carcinogens) may produce a response (tumors) at any dose level. Any exposure to these compounds may be associated with some risk of developing cancer. Thus, literature values for levels which are not likely to produce an effect do not guarantee that an effect will not occur.

Exposure Limits--

The various occupational exposure limits found in the literature or in an MSDS are based primarily on time-weighted average limits, ceiling values, or ceiling concentration limits to which the worker can be exposed to without adverse effects. Examples of these are listed in (Table 8).

The values listed in (Table 8) were established to provide worker protection in occupational settings. Because the settings in which these values are appropriate are quite different than an uncontrolled spill site, it is difficult to interpret how these values should be used by emergency medical personnel dealing with a hazardous materials incident. At best, TLV, PEL, IDLH, and REL values can be used as a benchmark for determining relative toxicity, and perhaps assist in selecting appropriate levels of Personal Protective Equipment (PPE). Furthermore, these occupational exposure limits are only useful if the appropriate instrumentation is available for measuring the levels of toxic chemicals in the air at the chemical spill site. Of the above occupational exposure limit values, only the OSHA values are regulatory limits. The ACGIH values are for guidance only and are not regulatory limits. In addition, the ACGIH limits have certain caveats that may or may not affect the usefulness of the values. Some of these conditions are individual susceptibility or aggravation of a preexisting condition. Nevertheless, all emergency medical personnel responsible for the management of chemically contaminated patients should be familiar with these concepts because they will be encountered in various documents dealing with patient care or the selection of PPE.

This brief discussion highlights some fundamental concepts of toxicology. Emergency medical personnel responsible for managing chemically contaminated patients are encouraged to obtain further training in recognizing and treating health effects related to chemical exposures. Also, a list of general references in toxicology is provided at the end of this section that will allow emergency medical personnel to undertake a more in-depth examination of the principles of toxicology.

Personnel Protection and Safety Principles

Federal Regulations Pertaining to Use of Personal Protective Equipment (PPE)-- The term Personal Protective Equipment (PPE) is used in this document to refer to both personal protective clothing and equipment. The purpose of PPE is to shield or isolate individuals from the chemical, physical, and biological hazards that may be encountered at a hazardous materials incident.

Recent new OSHA standards mandate specific training requirements (8 hours of initial training or sufficient experience to demonstrate competency) for employees engaged in emergency response to hazardous substances incidents at the first responder operations level. Additionally, each employer must develop a safety and health program and provide for emergency response. These standards also are intended to provide additional protection for those who respond to hazardous materials incidents, such as firefighters, police officers, and EMS personnel. OSHA's March 6, 1989, 29 CFR (1910.120) final rule as it applies to emergency medical personnel states that: "Training shall be based on the duties and functions to be performed by each responder of an emergency response organization" (p. 9329).

Training Is Essential Before Any Individual Attempts To Use PPE.

No single combination of protective equipment and clothing is capable of protecting against all hazards. Thus, PPE should be used in conjunction with other protective methods. The use of PPE can itself create significant worker hazards, such as heat stress, physical and psychological stress, and impaired vision, mobility, and communication. In general, the greater the level of PPE protection, the greater are the associated risks. For any given situation, equipment and clothing should be selected that provide an adequate level of protection. Over-protection can be as hazardous as under-protection and should be avoided. Personnel should not be expected to use PPE without adequate training. The two basic objectives of any PPE program should be to protect the wearer from safety and health hazard and to prevent injury to the wearer from incorrect use and/or malfunction of the PPE. To accomplish these goals, a comprehensive PPE program should include: hazard identification; medical monitoring; environmental surveillance; selection, use, maintenance, and decontamination of PPE; and training.

Levels of Protection--

The Environmental Protection Agency (EPA) has assigned four levels of protection to assist in determining which combinations of respiratory protection and protective clothing should be employed:

• Level A protection should be worn when the highest level of respiratory, skin, eye, and mucous membrane protection is needed. It consists of a fully-encapsulating chemical-resistant suit and self-contained breathing apparatus (SCBA).
• Level B protection should be selected when the highest level of respiratory protection is needed but a lesser level of skin and eye protection is sufficient. It differs from Level A only in that it provides splash protection by use of chemical-resistant clothing (overalls, long sleeves, jacket, and SCBA).
• Level C protection should be selected when the type of airborne substances is known, concentration is measured, criteria for using air- purifying respirators are met, and skin and eye exposures are unlikely.

• Level D is primarily a work uniform. It should not be worn on any site where respiratory or skin hazards exist. It provides no respiratory protection and minimal skin protection.

Factors to be considered in selecting the proper level of protection include the routes of entry for the chemical, degree of contact, and the specific task assigned to the user. Activities can also be used to determine which level of protection should be chosen. The EPA and NIOSH recommend that initial entry into unknown environments and into a confined space that has not been chemically characterized be conducted in at least "Level B" protection.

Routes of Entry--

PPE is designed to provide emergency medical personnel with protection from hazardous materials that can affect the body by one of three primary routes of entry: inhalation, ingestion, and direct contact. Inhalation occurs when emergency personnel breathe in chemical fumes or vapors. Respirators are designed to protect the wearer from contamination by inhalation and must wear properly and be fit tested frequently to ensure continued protection. Ingestion usually is the result of a health care provider transferring hazardous materials from his hand or clothing to his mouth. This can occur unwittingly when an individual wipes his mouth with his hand or sleeve. Direct contact refers to chemical contact with the skin or eye. Skin is protected by garments, and full-face respirators protect against ingestion and direct contact. Mucous membranes in the mouth, nose, throat, inner ear, and respiratory system are affected by one or more of the three primary routes of entry. Many hazardous materials adhere to and assimilate with the moist environment provided by these membranes, become trapped or lodged in the mucus, and, subsequently, absorbed or ingested.

Chemical Protective Clothing (CPC)--

Protective clothing is designed to prevent direct contact of a chemical contaminant with the skin or body of the user. However, there is not one single material that will afford protection against all substances. Thus, multilayered garments are often employed, which may reduce dexterity and agility. CPC is designed to afford the wearer a known degree of protection from a known type, a known concentration, and a known length of exposure to a hazardous material, but only if it is properly fitted and worn correctly. Improperly worn equipment can expose and endanger the wearer. One factor to keep in mind during the selection process is that most protective clothing is designed to be impermeable to moisture, thus limiting the transfer of heat from the body through natural evaporation. This is a particularly important factor in hot environments or for strenuous tasks since such garments can increase the likelihood of heat injury.

The effectiveness of protective clothing can be reduced by three actions: degradation, permeation, and penetration. Chemical degradation occurs when the characteristics of the material in use are altered through contact with chemical substances. Examples of degradation include cracking and brittleness, and other changes in the structural characteristics of the garment. Degradation can also result in an increased permeation rate through the garment, that is, the molecular absorption by or passage through the protective material of a chemical substance.

Permeation is the process in which chemical compounds cross the protective barrier of CPC because of passive diffusion. The rate at which a compound permeates CPC is dependent on factors such as the chemical properties of the compound, the nature of the protective barrier in the CPC, and the concentration of the chemical on the surface of the CPC. Most manufacturers of CPC provide charts on the breakthrough time, or the time it takes for the chemical to permeate the material of a protective suit, for a wide range of chemical compounds.

Penetration occurs when there is an opening or a puncture in the protective material. These openings can include unsealed seams, button holes, and zippers. Often such openings are the result of faulty manufacture or problems with the inherent design of the suit. Protective clothing is available in a wide assortment of forms, ranging from fully-encapsulating body suits to gloves, hard hats, earplugs, and boot covers. CPC comes in a variety of materials, offering a range of protection against a number of chemicals. Emergency medical personnel must evaluate the properties of the chemical versus the properties of the material. Selection of which kinds of CPC to use will depend on the specific chemical, and on the specific tasks to be performed.

Respiratory Protection

Air-Purifying Respirators (APRs)--

An air-purifying respirator depends on ambient air purified through a filtering element before inhalation. Three basic types of APRs are used by emergency personnel: chemical caxtfidges or canisters, disposables, and powered-air. The major advantage of the APR system is the increased mobility it affords the wearer. However, the respirator can only be used where there is sufficient oxygen (19.5%) since it depends on ambient air to function. In addition, the APR should not be used when substances with poor warning properties are known to be involved.

The most commonly used APR depends on cartridges (Figure 3) or canisters to purify the air by chemical reaction, filtration, adsorption, or absorption. Cartridges and canisters are designed for specific materials at specific concentrations. To aid the user, manufacturers have color-coded the cartridges/canisters to indicate the chemical or class of chemicals the device is effective against. NIOSH recommends that use of a carmdge not exceed one work shift. However, if "breakthrough" of the contaminant occurs first, then the cartridge or canister must be immediately replaced. After use, cartridges and canisters should be considered contaminated and disposed of accordingly.

Disposable APRs are usually designed for use with particulates, such as asbestos. However, some are approved for use with other contaminants. These respirators are customarily half-masks that cover the face from nose to chin, but do not provide eye protection. Once used, the entire respirator is usually discarded. This type of APR depends on a filter to trap particulates. Filters may also be used in combination with cartridges and canisters to provide an individual with increased protection from particulates. The use of half-mask APRs is not generally recommended by emergency response organizations.

Atmosphere-Supplying Respirators--

Atmosphere-supplying respirators consist of two basic types: the self- contained breathing apparatus (SCBA), which contains its own air supply, and the supplied-air respirator (SAR), which depends on an air supply provided through a line linked to a distant air source. (Figure 4) illustrates an example of each.

Self-Contained Breathing Apparatus (SCBA)--

A self-contained breathing apparatus respirator is composed of a facepiece connected by a hose to a compressed air source. There are three varieties of SCBAs: closed-circuit, open-circuit, and escape. Open-circuit SCBAs, most often used in emergency response, provide clean air from a cylinder to the wearer, who exhales into the atmosphere. Closed-circuit SCBAs, also known as "rebreathers," recycle exhaled gases and contain a small cylinder of oxygen to supplement the exhaled air of the wearer. Escape SCBAs provide air for a limited amount of time and should only be used for emergency escapes from a dangerous situation.

The most common SCBA is the open-circuit, positive-pressure type. In this type, air is supplied to the wearer from a cylinder and supplied to the facepiece under positive pressure. In contrast to the negative-pressure units, a higher airpressure is maintained inside the facepiece than outside. This affords the SCBA wearer the highest level of protection against airborne contaminants since any leakage may force the contaminant out. There is a potential danger, when wearing a negative-pressure-type apparatus, that contaminants may enter the facemask if it is not properly sealed. The use of a negative-pressure SCBA is prohibited by OSHA under 29 CFR 1910.120(q)(iv) in incidents where personnel are exposed to hazardous materials. However, one disadvantage of SCBAs is that they are bulky and heavy, and can be used for only the period of time allowed by air in the tank.

Personnel must be fit-tested for use of all respirators.

A tiny space between the respirator and you could permit exposure to a hazard by allowing contaminated air in. Anyone attempting to wear any type of respirator should be trained and drilled in its proper use. Furthermore, equipment must be inspected and checked for serviceability on a routine basis.

Supplied-Air Respirators (SARs)--

Supplied-airrespirators differ from SCBAs in that the air is supplied through a line that is connected to a source away from the contaminated area. SARs are available in both positive- and negative-pressure models. However, only positive-pressure SARs are recommended for use at hazardous materials incidents. One major advantage the SAR has over the SCBA device is that the SAR allows an individual to work for a longer period. In addition, the SAR is less bulky than the SCBA. However, by necessity, a worker must retrace his steps to stay connected to the SAR, and therefore cannot leave the contaminated work area by a different exit.

Emergency Department Personnel Decontamination

• Protects all hospital personnel by sharply limiting the transfer of hazardous materials from the contaminated area into clean zones;
• Protects the community by preventing transportation of hazardous materials from the hospital to other sites in the community by secondary contamination; and
• Protects workers by reducing the contamination and resultant permeation of, or degradation to, their protective clothing and equipment.

Avoiding contact is the easiest method of decontamination -- that is, not to get the material on the worker or his protective equipment in the first place. However, if contamination is unavoidable, then proper decontamination or disposal of the worker's outer gear is recommended. Segregation and proper disposal of the outer gear in a polyethylene bag or steel drum is recommended. With extremely hazardous materials, it may be necessary to dispose of equipment as well.

Physical decontamination of protective clothing and equipment can be achieved in some cases by several different means. These all include the systematic removal of contaminants by washing, usually with soap and water, and then rinsing. In rare cases, the use of solvents may be necessary. There is a trend toward dry decontamination, which involves using disposable clothing (e.g., suits, boots, and gloves) and systematically removing these garments in a manner that precludes contact with the contaminant. The appropriate procedure will depend on the contaminant and its physical properties. A thorough work-up of the chemical involved and its properties or expert consultation is necessary to make these kinds of decisions.

Care must be taken to ensure that decontamination methods, because of their physical properties, do not introduce fresh hazards into the situation. Additionally, the residues of the decontamination process must be treated as hazardous wastes. The decontamination stations and process should be confined to the Contamination Reduction Zone. Steps for dry decontamination (not using water) are outlined in (Figure 6).

• Decontamination of Personnel
  ---Personnel should remove protective clothing in the following sequence.

1. Remove tape securing gloves to suit.
2. Remove outer gloves turning them inside out as they are removed.
3. Remove suit turning it inside out and avoid shaking.
4. Remove plastic shoe cover from one foot and step over "clean line." Remove other shoe cover and put that foot over the line.
5. Remove mask. The last staff member removing his/her mask may want to wash all masks with soapy water before removing suit and gloves. Place masks in plastic bag and hand over the clean line, and place in second bag held by another member of the staff. Send for decontamination.
6. Remove inner gloves and discard in drum inside dirty area.
7. Close off dirty area until level of contamination is established and the area is properly cleaned.
8. Personnel should then move to a shower area, remove scrub suit and place it in a plastic bag.
9. Shower and redress in normal working attire.

Communications

Selected Bibliography

Arena, J.M. Poisoning: Toxicology, Symptoms, Treatments. Fifth Edition. Charles C. Thomas, Springfield, Illinois, 1986.

Browning, E. Toxicity and Metabolism of Industrial Solvents. Elsevier, Amsterdam, 1965.

Klaassen, C.D., Amdur, M.O., Doull, J., eds. Casarett and Doull's Toxicology: The Basic Science of Poisons. Third Edition. Macmillan Publishing Company, New York, 1986.

Clayton, G.D., Clayton, F.E. Patty's Industrial Hygiene and Toxicology. Revised Edition. John Wiley and Sons, New York, 1985.

Chemical Manufacturers Association (CMA), and the Association of American Railroads. Terms for Personal Protective Equipment. CMA, Washington, DC, October 1987.

Dreisbach, R.H., Robertson, W.O. Handbook of Poisoning: Prevention, Diagnosis, and Treatment. Twelfth Edition. Lange Medical, Los Altos, California, 1986.

Ellenhorn, M.J., B arceloux, D .G. Medical Toxicology: Diagnosis and Treatment of Human Poisoning. Elsevier, New York, 1988.

EPA Region VII. Chemical Response Planning and Operations. EPA Region VII, EPA, Washington, DC, January 1989.

Goldfrank, L.R. Goldfrank's Toxicological Emergencies, A Comprehensive Handbook in Problem Solving. Third Edition. Appleton Century Crofts, New York, 1986.

Gosselin, R.E., Smith, R.P., Hodge, H.C. Clinical Toxicology of Commercial Products. Fifth Edition. Williams and Wilkins Publishers, Baltimore, Maryland, 1984.

Hayes, A.W., ed. Principles and Methods of Toxicology. Raven, New York, 1989.

Hodgson, E., Levi, P.E. A Textbook of Modern Toxicology. Elsevier, New York, 1987.

Levine, S .P., Martin, W.F. Protecting Personnel at Hazardous Waste Sites. Butterworth Publishers, Boston, Massachusetts, 1985.

Lu, F.C. Basic Toxicology: Fundamentals, Target Organs, and Risk Assessment. Hemisphere, Washington, DC, 1985.

National Fire Academy/National Emergency Training Center. Recognizing and Identifying Hazardous Materials. National Audio-Visual Center, Capitol Heights, Maryland, 1985.

Sax, N.I. Dangerous Properties of Industrial Materials. Seventh Edition. Van Nostrand Reinhold Publishing Corp., New York, New York, 1988.

Schwope, A.D., Costas, P.P., Jackson, J.O., Weitzman, D.J. Guidelines for the Selection of Chemical Protective Clothing. Third Edition. American Conference of Governmental Industrial Hygienists, Cincinnati, Ohio, 1987.

Windholz, M., ed. The Merck Index. Tenth Edition. Merck and Co., Rahway, New Jersey, 1983.

Patient Management

When a hospital receives a call that a patient exposed to hazardous materials is to be received, a planned course of action should be implemented. Steps in a protocol must be practiced before a hazardous materials emergency occurs. All staff members of an emergency department should know their responsibilities and how to perform them. All required equipment should be immediately available or readily accessed.

Individuals receiving a potential hazardous materials call should obtain as much information as possible. A checklist should be developed and made available for all telephone or radio communication centers. Information that will aid in initiating appropriate actions includes:

• Type and nature of incident
• Caller's telephone number
• Number of patients
• Signs/symptoms being experienced by the patients
• Nature of injuries
• Name of chemical(s) involved
• Extent of patient decontamination in the field
• Estimated time of arrival

If incident notification comes from other than usual emergency communication channels, the call should be verified before a hazardous materials response plan is initiated. Ambulance personnel should be notified of any special approach or entrance to the emergency department and also advised not to bring the patient into the emergency department until the patient has been assessed and accepted by the emergency department.

Often patients contaminated by hazardous materials may be brought into the emergency department unannounced or not through regular EMS channels. This could be an ambulatory patient or a patient transported by private vehicle. The ideal response to this is to call a fire department which is properly trained and equipped or a hazmat team to come to the hospital and set up a decontamination area outside the ambulance entrance. In any event, these patients should be isolated from other patients and assessed and decontaminated as soon as possible.

Emergency Department Preparation

Emergency Department Mobilization--

The person receiving a call of incoming victims should notify the Nursing Supervisor who will in turn notify appropriate personnel according to the hospital's response plan. The hospital operator should be instructed to notify security and maintenance, and the nurse on duty should contact the predesignated resource center.

Decontamination Area Preparation--

Any victim of a hazardous materials incident must be considered to be contaminated until demonstrated otherwise. Therefore, the route from the emergency entrance to the decontamination area may also become contaminated and all persons along that route should be removed by security personnel. Ideally, this area should be protected with plastic or paper sheeting. This barrier should be taped securely to the floor, and care should be taken while walking on it because plastic can be very slippery when wet.

Security personnel should be stationed at the main entrance of the emergency department close to the decontamination area to prevent unauthorized entry, to control the entrance of the contaminated patient into the department, and to direct the vehicle transporting the patient to the appropriate area. A reception area should be set up just outside the emergency department entrance, where arriving contaminated patients can be screened for adequate decontamination before entering the department.

A decontamination area should be large enough to facilitate decontamination of more than one patient and accommodate the many personnel involved in patient treatment and contamination reduction. The ventilation system should either be separate from the rest of the hospital or turned off in order to prevent spread of airborne contaminants throughout the facility. If the ventilation system is shut off during the handling of a contaminated victim in an enclosed area, the emergency department medical team could be endangered. Therefore, OSHA regulations (i.e., 29 CFR 1910.120(q)(3)(iv) on monitoring the atmosphere should be adhered to, especially if APRs are used. The best place (weather permitting) to evaluate and initially treat contaminated patients is outside where ambient ventilation will keep cross- exposure low. Some hospitals have radiation decontamination facilities that can be used with minor changes. An outside or portable decontamination system is a viable substitute and would aid in preventing contamination of the emergency department and other patients. A practical alternative for facilities with limited resources is to have a warm shower nozzle, soap, a wading pool, and plastic garbage bags in a predesignated area outside the emergency department back door. The patient may be able to remove his or her own contaminated clothing, place it in a double bag, and do his or her own soap and water decontamination. A partial tent or curtain can provide privacy for the patients. In most circumstances, ordinary hospital gowns, plastic goggles, and plain latex gloves will adequately protect hospital staff in case they have to assist the patient in removing soaked clothing, wash exposed skin and hair, or perform eye irrigation. With large amounts of concentrated corrosives or very oily materials, such as pesticides, disposable CPC and unmilled nitrile gloves will offer additional protection. If it is anticipated that your facility is likely to receive heavily contaminated patients who have not received prior decontamination, then it may be appropriate to purchase appropriate protective gear and to fit and train emergency department staff in its use. However, no person should wear and use specialized PPE, especially respiratory protective gear, without prior training.

To prevent unnecessary contamination, all nonessential and nondisposable equipment should be removed from the decontamination area. All door knobs, cabinet handles, light switches, and other areas that have contact with hands should be taped, and the floors should be covered with plastic or paper sheeting to prevent contamination. The floor coverings should be securely taped to prevent slippage, and the entrance to the room marked with a wide strip of colored tape to indicate a contaminated area. Personnel should not enter the area unless properly protected, and no personnel or equipment should leave the area until properly decontaminated. A "clean" member of the staff should stand on the clean side of the entrance to hand in supplies and receive medical specimens. The essential requirements for any decontamination task are:

• A safe area to place a patient while undergoing decontamination
• A method for washing contaminants off a patient
• A means of containing the rinsate
• Adequate protection for personnel handling the patient
• Disposable or cleanable medical equipment to treat the patient

A decontamination team should be predesignated and trained in appropriate personal protection equipment and procedures. The team should consist of:

• Emergency physician
• Emergency department nurses and aides
• Support personnel
  1. Nursing Supervisor
  2. Occupational Health and Safety Officer
  3. Security
  4. Maintenance
  5. Recorder The decontamination team should be equipped with personal protective clothing (as discussed in Section I) for whatever level described as appropriate for the substance(s) involved. This may be determined by consulting reference guidebooks, database networks, or telephone hotlines.

     Appropriate dress for the decontamination team should include:
     

     • A scrub suit
     • Plastic shoe covers
     • Disposable CPC with hood and booties built in; tape hood at neck
     • Poly Vinyl Chloride (PVC) gloves taped to sleeves
     • Respiratory protection as appropriate
     • Multiple layers of surgical gloves, neoprene or disposable nitrile gloves; change whenever torn; tape bottom layer
     • Protective eyewear
     A 2-inch-wide piece of masking tape with the team member's name placed on the back of the protective suits will often assist employee in communicating.

     Patient Arrival

     The emergency physician-in-charge or an emergency department nurse should meet the ambulance upon arrival and assess the condition of the patients as well as the degree of contamination. Personnel should keep in mind that the actual contamination may be (or become) a life-threatening condition. Triage procedures should also be initiated at this point, if necessary. During initial patient survey and stabilization, contamination reduction should simultaneously be performed. This consists of cutting away or otherwise removing all suspected contaminated clothing, including jewelry and watches, and brushing or wiping off any contamination. Care should be taken to protect any open wounds from contamination. Emergency department personnel should make every effort to avoid contact with any potentially hazardous substance.

     Ideally, decontamination should be performed before patient transport; however, field decontamination facilities are limited and emergency department personnel should consider that all hazardous materials patients need decontamination. If a patient's clothing was not removed at the incident site, it should be removed outside the ambulance but before entry into the emergency department. This will reduce further exposure to the patient and lessen the extent of contamination introduced to the emergency department. Contaminated clothing should be double bagged in plastic bags, sealed, and labeled. The decontamination team should bring the prepared stretcher to the ambulance, transfer the patient, and take him or her directly to the decontamination area along the predesignated route.

     Priority should be given to the ABC (Airway, Breathing, and Circulation) and simultaneous contamination reduction. Once life-threatening matters have been addressed, emergency department personnel can then direct attention to thorough decontamination and secondary patient assessment. Identification of hazardous materials involved can be simultaneously performed by other personnel. It is important to remember that appropriate personal protective clothing must be worn until personnel are no longer in danger. Therefore, the sooner the patient becomes decontaminated the sooner personnel may reduce protective measures.

     Effective decontamination consists of making the patient As Clean As Possible (ACAP). This means that the contamination has been reduced to a level that is no longer a threat to the patient or the responder. The recorder notes on a diagram of the body the areas found by the physician to be contaminated.

     Decontamination of Patient

     The basic purpose of decontamination is to reduce external contamination, contain the contamination present, and prevent the further spread of potentially dangerous substances. In other words, remove what you can and contain what you can't. With a few exceptions, intact skin is more resistant to hazardous materials than injured flesh, mucous membranes, or eyes. Therefore, decontamination should begin at the head of the patient and proceed downward with initial attention to contaminated eyes and open wounds. Once wounds have been cleaned, care should be exercised so that the wounds are not recontaminated. This can be aided by covering the wounds with a waterproof dressing. For some chemicals, such as strong alkali, it may be necessary to flush exposed skin and eyes with water or normal saline for an extended period of time.

     External decontamination should be performed using the least aggressive layer methods. Mechanical or chemical irritation to the skin should be limited to prevent damage to the epidermal layer, which would result in increased permeability. Contaminated areas should be gently washed under a spray of water, with a sponge and a mild soap. Warm, never hot, tap water should be used. Care should be taken so that contaminants are not introduced into open wounds. All run-off from decontamination procedures should be collected for proper disposal.

     The first priority in the process of decontamination should be contaminated open wounds. These areas allow for rapid absorption of hazardous materials. Wounds should be irrigated with copious amounts of normal saline, and deep debridement and excision should be performed only when particles or pieces of material have been embedded in the tissues. Decontamination of eyes should also have high priority. Gentle irrigation of the eyes should be performed with the stream of normal saline diverted away from the medial canthus so that it does not force material into the lacrimal duct. Contaminated nares and ear canals should also be gently irrigated with frequent suction to prevent any material being forced deeper into those cavities. Washing with soap and tepid water is usually all that is needed to remove contamination. Hot water, stiff brushes, or vigorous scrubbing should never be used because they cause vasodilation and abrasion. This increases the chances for absorption of hazardous materials through the skin.

     Considerations for Patient Treatment

     Primary goals for emergency department personnel in handling a contaminated patient include termination of exposure to the patient, patient stabilization, and patient treatment -- while not jeopardizing the safety of emergency department personnel. Termination of exposure can best be accomplished by removing the patient from the area of exposure and by removing contaminants from the patient. Basically, a contaminated patient is like any other and may be treated as such except that staff must protect themselves and others from dangers due to contamination.

     Personnel must first address life-threatening issues and then decontamination and supportive measures. Priority should be given to the ABC with simultaneous contamination reduction. Once life-threatening matters have been addressed, emergency department personnel can then direct attention to thorough decontamination, secondary patient assessment, and identification of materials involved. It is important to remember that appropriate personal protective clothing must be worn until personnel are no longer in danger. Therefore, the sooner the patient becomes decontaminated the sooner personnel may reduce protective measures or downgrade the level of protection. Primary and secondary surveys should be completed as conditions allow. In treating patients, personnel should consider the chemical-specific information received from the hazardous materials response resources. In multiple patient situations, proper triage procedures should be implemented. Presenting signs and symptoms should be treated as appropriate and when conditions allow. The sooner a patient has been decontaminated the sooner he or she can be treated like a "normal" patient. Orders of the designated poison control center and attending physician should be administered. Invasive procedures, such as IVs or intubation, should be performed only for life-threatening conditions, until decontamination is performed. These procedures may create a direct route for introducing the hazardous material into the patient. The patient should be frequently re-assessed because many hazardous materials have latent physiological effects.

     Information on Materials Involved--

     Identification of materials involved should also be determined early in a hazardous material incident. Using resources outlined in this section, and in Section I under Hazard Recognition, personnel should identify and obtain detailed information involving treatment, decontamination procedures, and possible adverse health effects of the specific chemical(s) involved. Information that may be needed will include:

      

     • Chemical name of substance involved
     • Form of material (solid, liquid, gas)
     • Length of exposure
     • Routes of exposure
     • Possible adverse health effects
     • Treatment/antidote therapy
     • PPE required
     • Decontamination procedures
     The importance of finding out as much as possible, as soon as possible, about an unknown substance cannot be emphasized enough; however, based on experience, NIOSH and EPA recommend that "Level B" protection is the minimum level to be worn when entering an area containing unknown substances. However, if the substance in question is suspected to involve the skin as a route of exposure or is otherwise noted to be dangerous by absorption, corrosion, and the like, "Level A" protection should be worn because it provides additional skin protection.

     Removal of Patient from Decontamination Room--

     After the patient has been decontaminated, he or she should be discharged home or admitted to the hospital, depending on the patient's clinical condition. Place a clean piece of plastic on the floor for the patient and staff to use when exiting the clean area. If the patient is not ambulatory a clean stretcher or wheelchair should be brought to the doorway by an individual who has not been exposed. After the patient is transferred to the clean area, the physician can perform the physical examination and initiate routine patient management.

     Note: The attending staff must remember that since exposure to some substances can result in serious delayed effects, sustained observation and monitoring are required.

     Critique

     As soon as possible after each incident, all participating units should send knowledgeable representatives to review the measures that were taken by each unit or agency. The purpose of this review is to examine which activities succeeded and which did not, and to evaluate the overall coordination effort.

     Patient Management Under Mass Casualty Conditions Involving Hazardou

     Chemicals

     Basic medical procedures in a large-scale hazardous materials incident are not substantially different from life-saving measures in other mass casualty disasters. Primary attention to the ABC continues to have first priority with decontamination performed at the same time. A chemical disaster may overwhelm any one hospital, particularly if it occurs along with another disaster such as an earthquake. Hospitals need to preplan what they will do if they are overwhelmed with hazmat patients.

     There are, however, several important differences in disasters involving hazardous materials. Such differences include the need for the effective decontamination of exposed patients and response personnel, and the need for effective safety measures to protect response personnel. Training in the appropriate procedures to be followed is essential for potential responders to a hazardous materials incident involving mass casualties. Standard principles of tnage apply in chemical disasters, except in exposures to very toxic substances. The patient, injured or not, must be decontaminated before being transported to the emergency department to protect EMS and emergency department staff.

     Selected Bibliography

     Cashman, J.R. Hazardous Materials Emergencies, Response and Control. Revised, second edition. Technomic Publishing Co., Lancaster, Pennsylvania, 1988.

     Currance, P.L., Bronstein, A.C. Emergency Care for Hazardous Materials Exposure. C.V. Mosby, St. Louis, Missouri, 1988.

     Department of Transportation (DOT). Emergency Response Guidebook. Washington, DC, 1987; DOTP-5800.5

     Federal Emergency Management Agency (FEMA). Disaster Planning Guidelines for Fire Chiefs. Prepared by International Association of Fire Chiefs, Inc: February 1981. FEMA, Washington, DC. Federal Emergency Management Agency (FEMA). Guidance for Developing State and Local Radiological Emergency Response Plans and Preparedness for Transportation-Accidents. FEMA, Washington, DC, 1985.

     Federal Emergency Management Agency (FEMA). Hazardous Materials Management System. A Guide for Local Emergency Managers. Prepared by the Multnomah County Office of Emergency Management: July 1981. FEMA, Washington, DC.

     Federal Emergency Management Agency (FEMA). Hospital Emergency Department Management of Radiation Accidents. FEMA, Washington, DC, 1984.

     Goldfrank, L.R. Goldfrank's Toxicological Emergencies, A Comprehensive Handbook in Problem Solving. Appleton Century Crofts, New York, New York, 1986.

     Haddad, L.M., Winchester, J.F. Clinical Management of Poisoning and Overdose. WB Saunders Co., Philadelphia, Pennsylvania, 1983.

     Leonard, R.B., Ricks, R. Emergency Department Radiation Accident Protocol, Annals of Emergency Medicine, September, 1980.

     Noji, E.K., Kelen, G.D. Manual of Toxicologic Emergencies. Year Book Medical Publishers, Chicago, Illinois, 1989.

     Noll, G., Hildebrand, M.S., Yvorra, J.G. Hazardous Materials, Managing the Incident. Fire Protection Publications, Oklahoma State University, Stillwater, Oklahoma, 1988.

     Ricks, R.C. Hospital Emergency Department Management of Radiation Accidents. Oak Ridge Associated Universities, Oak Ridge, Tennessee, 1984.

     Stutz, D.R., Ricks, R., Olsen, M. Hazardous Materials Injuries, a Handbook of Prehospital Care. Bradford Communications Corporation, Greenbelt, Maryland, 1982.

      

     ---

     Systems Approach To Planning

     The Role of the Hospital in a Systems Approach to Planning

     The potential for hazardous materials incidents exists almost everywhere. While occurring infrequently, chemical incidents are capable of endangering the health of individuals and the emergency personnel directed to assist them. People who have been seriously injured by a hazardous material have a greater chance of recovery without complications when appropriate emergency treatment is provided by trained prehospital EMS personnel at the scene, and the patient is transported to a facility having the most appropriate personnel and technical resources to manage his or her care. This requires an integrated emergency medical response. However, many local governments, private businesses, and hospitals do not have a tested integrated hazardous materials response plan in place that involves all of the responders. This has resulted in several problems including:

      

     • On-site incidents have been poorly managed by first responders.
     • Communication channels between the private sector and the public sector or among public responders have not been clearly identified and formalized.
     • The medical community has not been firmly integrated into many response systems and may not be prepared to treat multiple casualties resulting from a serious hazardous materials incident.
     Hospitals are a crucial link in the community response system for emergency preparedness planning. Not only are hospitals asked to treat patients who have been chemically contaminated at remote sites, but as repositories of hazardous materials themselves, are potential sites of hazardous materials incidents. Coordination and communication between hospitals and other elements of an Emergency Medical Services plan can best be achieved by hospital staff and physicians fully participating at local meetings for hazmat planning and protocol review.

     Hospitals must acknowledge their role as a component of the community-wide emergency response system. Hospital administrators must familiarize themselves with the contingency planning of other components, such as fire, police, and health departments, and understand what services are expected from hospitals. Optimally, hospital staff should be represented on planning committees that develop and periodically review these contingency plans.

     A common characteristic of the successful management of chemical incidents is adequate contingency planning. Planning requires the involvement of an array of community institutions -- fire and police departments and community hospitals. Not every hospital in an area needs to have an emergency department capable of handling hazardous materials patients. In fact many communities have centralized such services into one major area hospital or shock trauma center. However, all hospitals should be capable of performing decontamination and basic care since some patients may come in on their own -- not through the Emergency Medical Services (EMS) Systems. In addition, emergency department personnel must be knowledgeable about where to send patients for further specialized care.

     The Spectrum of Hazardous Materials Incidents

     Local and state EMS agencies should be able to participate in the response to a range of hazmat incidents from the individual level, to the multi-casualty, to the disaster level. The hospital and emergency medical responders are key components of the local response system. Planning should integrate hospital personnel, equipment, and supply needs into the state and local hazmat plans. In turn, the hospital must be familiar with these plans and know how to use them if it is involved in a incident that overwhelms its capabilities.

      

     • Individual patient -- a single individual is contaminated and must be transported to an emergency department:
     • Can be an occupational or accidental exposure.
     • May pose a problem in rural areas with small hospitals, or where there are low levels of hazmat skills and experience for EMTs.
     • Multi-casualty -- this situation is usually limited to a single location:
     • Involves normal systems of transportation.
     • Patients are usually treated at the same level facility as a single emergency response, but the demand on all systems is much greater.
     • Disaster -- disrupts a large segment of the community:
     • Involves several locations.
     • Involves additional units to the normal responders; such units are not part of the local EMS system, and these units may not know how it works.
     • Involves long-range mutual aid; normal systems of transportation (ambulances) are inadequate or disrupted.
     • Patients may be treated locally at different facilities providing various levels of care, or even outside of the area altogether.
     While transportation incidents attract larger media attention, statistics show that almost 75% of all acute hazardous materials events, excluding fuel spills, occur in the fixed locations where they are used or stored. In addition, events resulting in death and injury occur almost 1.5 times as often in plants as in transit.

     Hazardous material incidents range from small releases at a factory site to rapidly expanding events that endanger a community. Regardless of its size, an incident's successful management depends on preplanning. This preplanning often requires coordination between local, state, and federal agencies, and industries, as well as those in the community who use and maintain stocks of potentially hazardous materials. Contributions to hazardous materials planning come from a variety of sources: regulations from the Joint Commission on Accreditation of Healthcare Organizations, state and local planning committees established by SARA Title III, state EMS agencies, and federal agencies.

     Joint Commission on Accreditation of Healthcare Organizations (JCAHO

     In drawing up contingency plans, administrators of hospitals have significant guidance available from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The JCAHO establishes standards that must be met before a hospital can receive accreditation. A comprehensive accreditation survey occurs once every three years with intermittent evaluation if a specific area of weakness is identified at the time of full review.

     The Key Indicator Probe (KIP) system in the Plant Technology and Safety Management Standards is a valuable addition to the accreditation process. Before the JCAHO survey is conducted, KIPs define what the accreditation survey expects a hospital to have completed in order to comply with a specific standard. For example, JCAHO standard PL.1.11.1 describes the hospital's role in community-wide emergency preparedness plans. The description of the hospital's role in community-wide emergency preparedness plans is the key indicator. The probe for this key indicator presents the question "Is the role of this facility and other health care organizations and community civil services addressed in the program?"

     Additionally, JCAHO standard PL.1.11.2 discusses procedures in response to environmental or man-made events. For the key indicator item "information about how the hospital plans to implement specific procedures in response to environmental or man-made events," there are five probes. These include:

     1. Has the organization identified alternate sources of essential utilities?
     2. Is there an emergency communication system?
     3. Is there a procedure for identifying an alternate care site?
     4. Are facilities available for radioactive or chemical isolation and decontamination?
     5. Is there a workable plan for total facility evacuation?

         

     JCAHO Accreditation Standards for Hospitals outlines the JCAHO standards and indicator probes that there relevant for treating chemically contaminated patients.

     JCAHO Accreditation Standards for Hospitals, 1989

     ER.5.2 Current toxicologic reference materials and antidote information are readily available in the emergency department/service, along with the telephone number of the regional poison control information center.

     ER.5.3 A list of referral and consultation services is prominently displayed and includes, as appropriate, the regional coordinating office for radiologic emergency assistance, antivenin service, county coroner or medical examiner, police department, state and local health departments, ambulance transport and rescue services, tissue donation centers, and special care services not provided by the hospital.

     ER.6.8.3 Standard drugs, antivenin (in geographic areas as indicated), common poison antidotes, syringes and needles, parenteral fluids and infusion sets, plasma substitutes and blood administration sets, and surgical supplies are available for immediate use.

     PL.I.10 There is a hazardous materials and wastes program, designed and operated in accordance with applicable law and regulation, to identify and control hazardous materials and wastes; the program includes:

     PL.1.10.1 policies and procedures for identifying, handling, storing, using, and disposing of hazardous materials from receipt through use and hazardous wastes from generation to final disposal;

     PL.1.10.2 training for and, as appropriate, monitoring of personnel who manage and/or regularly come into contact with hazardous materials and/or wastes;

     PL.1.10.3 monitoring of compliance with the program's requirements; and

     PL.1.10.4 evaluation of the effectiveness of the program, with reports to the safety committee and to those responsible for other appropriate monitoring activities.

     PL.1.11 There is an emergency preparedness program designed to manage the consequences of natural disasters or other emergencies that disrupt the hospital's ability to provide care and treatment; the program includes:

     PL.1.11.1 a description of the hospital's role in community wide emergency preparedness plans;

     PL.1.11.2 information about how the hospital plans to implement specific procedures in response to environmental or man-made events;

     PL.1.11.3 provisions for the management of space, supplies, communications, and security;

     PL.1.11.4 provisions for the management of staff, including distribution and assignment of responsibilities and functions;

     PL.1.11.5 provisions for the management of patients, including scheduling of services, control of patient information, and admission, transfer, and discharge;

     PL.1.11.6 staff training in their roles during emergencies;

     PL.1.11.7 semiannual implementations of the plan, either in response to an emergency or in a planned drill.

     PL.I.11.7.1 The hospital's performance during implementation of the plan is evaluated, documented, and reported to the safety committee through the hospital-wide information collection and evaluation system.

     Key Items

     PL.1.10.3 monitoring of compliance with the program's requirements; and Probes

     a. Are reports of hazardous materials and waste monitoring programs presented to the safety committee?

     b. Are all hazardous materials and waste incident reports reviewed by the safety committee?

     PL.1.10.4 evaluation of the effectiveness of the program, with reports to the safety committee and to those responsible for other appropriate monitoring activities.

     a. Does the safety officer or other responsible individual(s) compare the results of the program with standards established by law, regulation, or the organization to evaluate the effectiveness of the program?

     b. Is the analysis reported to the safety committee and others as appropriate?

     PL.1.11 There is an emergency preparedness program designed to manage the consequences of natural disasters or other emergency situations that disrupt the hospital's ability to provide care and treatment; the program includes:

     Is there a current written program at the facility that addresses the responsibilities of the medical staff, the nursing staff, and support services during a variety of applicable emergencies, both within the organization and in the surrounding community?

     PL.1.11.1 a description of the hospital's role in community-wide emergency preparedness plans;

     Is the role of this facility and other health care organizations and community civil services addressed in the program?

     PL.1.11.2 information about how the hospital plans to implement specific procedures in response to environmental or man-made events; a. Has the organization identified alternate sources of essential utilities?

     b. Is there an emergency communication system?

     c. Is there a procedure for identifying an alternate care site?

     d. Are facilities available for radioactive or chemical isolation and decontamination?

     e. Is there a workable plan for total facility evacuation?

     PL.1.11.3 provisions for the management of space, supplies, communications, and security;Does the facility's plan address the use of space, replenishment of supplies, and the loss of communication, security, and utilities?

     PL.1.11.4 provisions for the management of staff, including distribution and assignment of responsibilities and functions;

     a. Does the program list staff roles and responsibilities during emergencies?

     b. Is there a reliable method for notifying staff of an emergency?

     c. Is there a procedure for assigning available staff that reflects staffing changes on various shifts and days?

     d. Was the plan tested during drills or actual implementation?

     e. Are staff lists current?

     PL.1.11.5 provisions for the management of patients, including scheduling of services, control of patient information, and admission, transfer, and discharge;

     Does the plan include procedures for:

     a. modification or discontinuation of less than essential services?

     b. moving of patients within the facility?

     c. relocating patients outside the facility in the event of an emergency?

     d. provision of appropriate medical staff services and physical facilities to implement the plan?

     PL.1.11.6 staff training in their roles during emergencies; and

     a. Is there documentation of the training and education of all personnel who have an assigned role in the emergency preparedness program?

     b. Can a random sample of staff adequately describe training they have received in the emergency preparedness program and in the fire plan?

     PL.I.11.7 semiannual implementation of the plan, either in response to an actual emergency or in a planned drill.

     Is there evidence of semiannual implementation, either in response to an emergency, or in a planned drill?

     NOTE: Drills separated by at least four months are acceptable.

     NOTE: Organizations that offer emergency services and/or are designated as disaster receiving stations must have at least one implementation per year that includes an influx of patients.

     PL.1.11.7.1 The hospital's performance during implementation of the plan is evaluated, documented, and reported to the safety committee through the hospital-wide information collection and evaluation system.

     Is there evidence:

     a. of evaluation of the emergency preparedness plan gathered from previous drills, changes in the mission or capability of hospitals, and changes in the community?

     b. in the community of a review of the effectiveness of the program, and changes made where appropriate?

     c. of critiques of each implementation addressing elements of hospital preparedness, staff preparedness, and patient management?

     d. for each critique, evidence of identification of problems, corrective actions taken, and recommendations for modification of the program?

     e. of a random sample of staff being asked about the drill?

     NOTE: Some organizations may not participate in a community-wide emergency plan. In these cases, item (b) is not applicable, and compliance with PL.1.11.7.1 will be scored:

      

     1. a,c,d,e

         

     2. 3 of 4

         

     3. 2 of 4

         

     4. 1 of 4

         

     5. none in place

         

     The emergency department standards include: 1) current toxicologic reference materials and antidote information (ER.5.2), 2) a list of referral and consultation services (ER.5.3), and 3) equipment for chemical incidents (ER.6.8.3). In addition, JCAHO standards and key indicator probes for a hazardous materials and wastes program (PL.1.10) and an emergency preparedness program (PL.1.11 ) are provided. A hospital can more readily comply with some JCAHO standards by using community response and public information systems mandated by SARA Title III.

     SARA Title 111

     Title III of the Superfund Amendments and Reauthorization Act (SARA), passed by Congress in 1986, provides for an infrastructure in states and local communities to plan for effective response to hazardous material emergencies. In addition, the legislation also provides for public access to information on the presence and releases of specified hazardous chemicals in communities.

     Title III, "The Emergency Planning and Community Right-to-Know Act of 1986," required that each state establish a State Emergency Response Commission (SERC), which consists of members with technical expertise in emergency response, environmental and natural resources, public health, occupational safety, media, and transportation. The SERC is responsible for establishing local emergency planning districts (usually on a county level), appointing and overseeing local emergency planning committees (LEPC), establishing procedures for handling public requests for information, and reviewing LEPC emergency plans.

     SARA Title III requires that the local committees must include, at a minimum, representatives from the following groups: State and local officials, law enforcement, civil defense, firefighting, environmental, hospital, media, first aid, health, transportation, and facility owners or operators subject to the emergency planning requirements. The LEPC was primarily responsible for preparing a comprehensive emergency response plan for its district by October 1988, and for making information on hazardous chemicals, which is submitted under Title III, available to the public. Using information about the presence of potentially hazardous chemicals reported by businesses and other facilities under Title III, the LEPC was to have developed its plan.

     As part of the planning process, the LEPC must evaluate available resources for developing, implementing, and exercising the plan. The plan must include the following:

      

     • identification of facilities subject to planning provisions under Title III
     • identification of transportation routes for extremely hazardous substances
     • identification of risk-related facilities
     • methods and procedures for response
     • designated community and facility coordinators
     • procedures for public notification
     • methods for determining release occurrence and area affected
     • description of emergency equipment and facilities and those responsible
     • evacuation plans and training programs
     Under Title III's planning provisions, EPA was mandated by Congress to establish a list of chemicals to help focus local emergency planning activities. In April 1987, EPA listed 406 Extremely Hazardous Substances (EHS) and established a Threshold Planning Quantity (TPQ) for each. If any business or facility contains one of these EHS, in an amount equal to or greater than its respective TPQ, the facility owner or operator is required to notify the SERC and LEPC. These facilities must name a facility coordinator to work with the LEPC for specific inclusion of that facility in the local plan.

     Representative facilities covered under the planning provisions include not only major chemical manufacturing facilities, but also a wide variety of chemical users, such as farmers, dry cleaners, and other service-related businesses. Exemptions under this provision apply only to vessels (ship/boat), federal facilities, and transportation. Storage incidental to transportation is exempt provided that the EHS are still moving under active shipping papers and have not reached the final consignee.

     Accidental releases of EHSs and other hazardous substances identified in the Comprehensive Environmental Response, Compensation, and Liability Act of 1980 (CERCLA) must be reported to the LEPC and SERC. This requirement ensures immediate notification to local response personnel. Other provisions of Title III provide further information on the presence, storage, and emissions of hazardous and toxic chemicals. These data further assist the LEPC in obtaining a fuller picture of chemical risk in the local district.

     Hospitals can be better prepared for response to incidents that involve contaminated patients by actively participating in the LEPC planning process. Title III provides for the submission of information on hazardous and toxic chemicals as presented above. In addition, Title III contains a specific provision for the disclosure of chemical identity by facility owners or operators on chemicals for which facilities have made trade secret claims. Access to chemical identity assists health professionals, physicians, and nurses in obtaining further information for diagnostic purposes during emergencies and for prevention and treatment measures during nonemergencies.

     The State Emergency Medical Services (EMS) Agency

     Planning for hazardous materials incidents should include the appropriate linkage to the state EMS agency. The state agencies are responsible for overseeing a network of local EMS units, and thus are an essential part of the planning process. Often this body is part of the SERC.

     Duties of the agencies vary from state to state. However, EMS agencies usually are responsible for medical management and medical control of first responders. EMS agencies develop medical mutual aid agreements between counties, and establish procedures for distribution of casualties between hospitals. In addition, these agencies maintain an inventory of disaster medical supplies. Further, EMS agencies develop and maintain communications protocols for on-site activities: between receiving hospitals and the base hospital, between base hospitals and ambulances, and between all hospitals and the Regional Poison Control Center. The EMS agencies also work with counties in designating field casualty decontamination and collection points for a major disaster.

     Suggested planning activities may include:

     Medical Direction -- the local EMS agency should be contacted for information on how medical control is provided for the EMS system.

     Patient Destination -- hospital emergency departments are able to provide supportive care. However, in some cases it may be more appropriate to take the patient to a hospital that has expertise in handling certain kinds of poison exposures. The plan should include directions for obtaining this information. One option is to go through the Regional Poison Control Center via the base hospital. The poison center will often know which hospitals are best prepared for which substances.

     Decontamination and Medical Management Protocols -- the literature on the clinical management of hazardous materials exposures is sometimes inconsistent in its recommendations. Provision should be made in the plan for obtaining field and hospital medical management information from experienced physicians. For example, the Regional Poison Control Center can provide decontamination and medical management protocols via facsimile transmission or telephone to all receiving hospitals, and through the base hospital or via cellular telephone to EMTs in the field. They also have rapid access to experts.

     Coordination with Burn Centers, Hyperbaric Chamber Facilities, and Other Specialty Centers -- provision should be made to alert and coordinate patient destination with various specialty care centers.

     Federal Emergency Response Activities

     Contingency planning is essential to the successful implementation of any system designed to manage chemically contaminated patients and to promptly contain the hazard itself. Contingency plans require a coordinated community response that may also involve state and federal agencies. Pre-planning and coordination of services are equally critical at the national level. A National Contingency Plan (NCP) has been established by the federal govemment to promote coordination of resources and services of federal and state response systems. To oversee this plan, a National Response Team (NRT) and National Response Center, a network of Regional Response Teams (RRTs), and a group of On-Scene Coordinators (OSCs) have been established.

     The Hazardous Materials Emergency Planning Guide, referred to as NRT-1, provides guidance to help local communities prepare for potential hazardous materials incidents. The NRT-1 can be used by local communities developing their own plan, as well as by LEPCs formed in accordance with the "Emergency Planning and Community Right-to-Know Act" (SARA Title III) of 1986.

     The objectives of the Hazardous Materials Emergency Planning Guide are to:

      

     • Focus communities on emergency preparedness and response.
     • Provide communities with information that can be used to organize the emergency planning task.
     • Furnish criteria for risk and hazard assessments, and assist communities in determining whether a hazardous materials incidents plan is needed, in addition to the district-wide plan developed by the LEPC.
     • Help LEPCs and individual communities prepare a plan that is appropriate for their needs and consistent with their capabilities.
     • Provide a method for revising, testing, and maintaining community emergency plans.
     The NRT-1 is published by the National Response Team, and was developed cooperatively by its 14 federal member agencies, including the Department of Defense, Department of the Interior, Department of Transportation (Research and Special Programs Administration and U.S. Coast Guard), Environmental Protection Agency (EPA), Department of Commerce (National Oceanic and Atmospheric Administration [NOAA]), Federal Emergency Management Agency (FEMA), Department of State, Department of Agriculture, Department of Health and Human Services (Agency for Toxic Substances and Disease Registry), Department of Justice, Department of Labor (Occupational Safety and Health Administration), Nuclear Regulatory Commission, and the Department of Energy. The NRT-1 represents a concerted effort by federal agencies to consolidate their general hazardous material planning guidance into an integrated federal document.

     NRT-1 states that an emergency plan must include response procedures of facilities and local emergency and medical personnel, as well as a description of emergency equipment and facilities in the community. It also recommends that hospital, emergency medical service, and health department personnel be included as members of an emergency planning team. As previously mentioned, SARA Title III requires medical, hospital, and first aid personnel to be members of the local emergency planning committee. The NRT-1 describes relevant publications that provide specific operational guidance to emergency responders, such as the DOT's Emergency Response Guidebook for first responders, which provides guidance for firefighters, police, and other emergency services personnel to help them protect themselves and the public during the initial minutes immediately following a hazardous materials incident.

     In addition, the document provides information on the Chemical Manufacturers Association's (CMA) Community Awareness Emergency Response (CAER) and Chemical Transportation Emergency Center (CHEMTREC) programs. The CAER program encourages local facilities to inform local residents, public officials, and emergency response organizations about industry operations and to integrate their on-site emergency response plans with the planning efforts of the local community. In some areas of the country, the chemical industry has established physician networks. The purpose of the networks is to develop a better dialogue between company physicians and local health authorities. CAER has outlined that the following specific steps be taken: review the plant emergency plan, improve employee awareness and training, prepare a community relations plan, inventory the status of local emergency planning, develop a briefing paper, prepare a list of initial contacts, meet with initial contacts and identify key officials, establish a coordinating group, and begin implementation steps. On the federal level, EPA and FEMA provide technical assistance and guidance to local and state planners through the SARA Title III program.

     The NRT-I document also recommends that contingency plans include: standard operating procedures for entering and leaving sites, accountability for personnel entering and leaving sites, decontamination procedures, recommended safety and health equipment, and personal safety precautions. The document suggests that emergency plans include a list of emergency response equipment appropriate to various degrees of hazard using the EPA levels of protection (A, B, C, and D). Further, it recommends that the list include the type of respirator (e.g., self-contained breathing apparatus, supplied-air respirator, or air-purifying respirator), the type of clothing that must be worn, and the equipment needed to protect the head, eyes, face, ears, hands, arms, and feet.

     In addition, the NRT- 1 recommends that medical personnel be made aware of significant chemical hazards in the community in order to train properly and prepare for possible hazardous materials incidents. It also states that emergency medical teams and hospital personnel must be trained in the proper methods for decontaminating and treating persons exposed to hazardous chemicals.

     Hazard Ananlysis

     Hazard analysis is a necessary step in comprehensive emergency planning for a community. It is a three-step decision-making process comprised of: hazard identification, vulnerability analysis, and risk analysis. The first task in conducting analysis is to complete an inventory of the hazardous materials present in the community and describe the nature of the hazard. This is a key step because it permits planners to describe and evaluate risks and, to allocate resources accordingly. However, the task of analyzing all relevant hazards may not prove cost effective to many communities. The planning committee therefore should assign priorities to the hazards found in its community,and establish affordable limits for analysis. It should be noted that several federal agencies (e.g., DOT, FEMA, and EPA) report that frequently encountered substances often pose the most prevalent dangers. These materials include fuels and chemicals, such as chlorine, ammonia, and hydrochloric and sulfuric acids. Such materials should be given special attention by the LEPC in the planning process.

     In this context, a hazard is any situation that is capable of causing injury or impairing an individual's health. During the process of identifying hazards, facilities or transportation routes will be pinpointed that contain materials that are potentially dangerous to humans. The identification of hazards also should provide the following information:

      

     • The types, quantities, and location of hazardous materials in the community, or transported through a community
     • The nature of the hazard that would accompany incidents, such as explosions, spills, fires, and venting to the atmosphere
     Hazards should be identified at as many facilities in the community as possible. These include the obvious ones such as chemical plants, refineries, petroleum plants, and storage facilities and warehouses. In requesting information directly from facilities, remember that SARA Title III planning provisions require certain facilities to provide the LEPC with any information on the facility that the committee needs to develop and implement its plan. The LEPCs may provide assistance here, particularly if the LEPC has industry representatives on it. It is essential that these industries or businesses understand the role these data play in ensuring a sound emergency response plan. As previously stated, placing business or industrial representatives on the community-wide planning committee as required under SARA Title III may assist in gaining their cooperation. The cooperation and assistance of a facility that regularly deals with hazardous materials presents the local planning unit with a wide array of services. For example, such a facility can provide technical experts, 11spill prevention control and countermeasure (SPCC) plans, training and safe handling instructions, and cleanup capabilities.

     In addition, hospitals and educational and governmental facilities should not be overlooked since they all contain a variety of chemicals. Major transportation routes and transfer points, such as airports, vessels in port, railroad yards, and trucking terminals, should be included in the overall hazards identification plan. SARA Title III planning provisions, for example, address many of these potential risk areas by requiring the following: facility cooperation in plan preparation, a wide range of chemical handlers (manufacturers to service-related businesses), and specific risk areas to be addressed in the plan (i.e., transportation).

     Risk analysis includes the probable damage that may occur if a chemical incident occurs. Information that is necessary for a risk analysis includes:

      

     • The type of risk to humans, such as an acute, chronic, or delayed reaction
     • The groups that are at highest risk
     • The type of risk to the environment, such as permanent damage or recoverable condition
     Many documents can be of assistance in conducting a risk analysis. Risk analysis in transportation settings has been outlined in the DOT's "Community Teamwork: Working Together To Promote Hazardous Materials Safety, A Guide for Local Officials". In conjunction with FEMA and DOT, EPA published a supplement to NRT-1 in December 1987. This document, entitled Technical Guidance for Hazardous Analysis and often referred to as the "Green Book," provides technical assistance to LEPCs in assessing the lethal hazards associated with potential airborne releases of extremely hazardous substances.

     Selected Bibliography

     Department of Transportation. Community Teamwork: Working Together To Promote Hazardous Materials Safety, A Guide for Local Officials. Washington, DC, May 1983.

     Environmental Protection Agency and Federal Emergency Management Agency. Technical Guidance for Hazardous Anaysis: Emergency Planning for Extremely Hazardous Substances. Environmental Protection Agency, Washington, DC, December 1987.

     Federal Emergency Management Agency. Guide for Development of State and Local Emergency Operations Plan. Washington, DC, October 1985; CPG 1-8.

     Federal Emergency Management Agency. Planning Guide and Checklist for Hazardous Materials. U.S. Government Printing Office, Washington, DC, July 1981; FEMA-10.

     National Institute for Occupational Safety and Health/Occupational Safety and Health Administration. Pocket Guide to Chemical Hazards. U.S. Government Printing Office, Washington, DC, 1985.

     National Response Team. Hazardous Materials Emergency Planning Guide. U.S. Government Printing Office, Washington, DC, 1987; NRT 2100.

     SARA Title 111 Compliance Guidebook, Government Institutes, Inc., 1988; ISBN: 0-86587-749-1.

      

     ---

     Appendix A; Hazardous Materials Classification Systems

     • National Fire Protection Association, 704M System
     • Department of Transportation DOT Chart 9
     • Example of Department of Labor Material Safety Data Sheet NFPA 704M

     System Notes; HEALTH (BLUE)

     In general, health hazard in firefighting is that of a single exposure which may vary from a few seconds up to an hour. The physical exertion demanded in firefighting or other emergency conditions may be expected to intensify the effects of any exposure. Only hazards arising out of an inherent property of the material are considered. The following explanation is based upon protective equipment normally used by firefighters.

     4 Materials too dangerous to health to expose firefighters. A few whiffs of the vapor could cause death or the vapor or liquid could be fatal on penetrating the firefighter's normal full protective clothing. The normal full protective clothing and breathing apparatus available to the average fire department will not provide adequate protection against inhalation or skin contact with these materials.
     3 Materials extremely hazardous to health but areas may be entered with extreme care. Full protective clothing -- including self- contained breathing apparatus, coat, pants, gloves, boots, and bands around legs, arms, and waist -- should be provided. No skin surface should be exposed.
     2 Material hazardous to health, but areas may be entered freely with full-faced mask self-contained breathing apparatus which provides eye protection.
     1 Materials only slightly hazardous to health. It may be desirable to wear self-contained breathing apparatus.
     0 Materials which on exposure under fire conditions would offer no hazard beyond that of ordinary combustible material.

     Flammability (RED)

     Susceptibility to burning is the basis for assigning degrees within this category. The method of attacking the fire is influenced by this susceptibility factor.

     4 Very flammable gases or very volatile flammable liquids. Shut off flow and keep cooling water streams on exposed tanks or containers.
     3 Materials which can be ignited under almost all normal temperature conditions. Water may be ineffective because of the low flash point.
     2 Materials which must be moderately heated before ignition will occur. Water spray may be used to extinguish the fire because the material can be cooled below its flash point.
     1 Material that must be preheated before ignition will occur. Water may cause frothing if it gets below the surface of the liquid and turns to steam. However, water fog gently applied to the surface will cause a frothing which will extinguish the fire.
     0 Materials that will not burn.

     Reactivity (STABILITY) (YELLOW)

     The assignment of degrees in the reactivity category is based upon the susceptibility of materials to release energy either by themselves or in combination with water. Fire exposure was one of the factors considered along with conditions of shock and pressure.

     4 Materials which (in themselves) are readily capable of detonation or of explosive decomposition or explosive reaction at normal temperatures and pressures. Includes materials which are sensitive to mechanical or localized thermal shock. If a chemical with this hazard rating is in an advanced or massive fire, the area should be evacuated.
     3 Materials which (in themselves) are capable of detonation or of explosive decomposition or of explosive reaction which require a strong initiating source which must be heated under confinement before initiation. Includes materials which are sensitive to thermal or mechanical shock at elevated temperatures andpressures or which react explosively with water without requiting heat or confinement. Fire fighting should be done from an explosive- resistant location.
     2 Materials which (in themselves) are normally unstable and readily undergo violent chemical change but do not detonate. Includes materials which can undergo chemical change with rapid release of energy at normal temperatures and pressures or which can undergo violent chemical change at elevated temperatures and pressures. Also includes those materials which may react violently with water or which may form potentially explosive mixtures with water. In advanced or massive fires, firefighting should be done from a safe distance or from a protected location.
     1 Materials which (in themselves) are normally stable but which may become unstable at elevated temperatures and pressures or which may react with water with some release of energy but not violently. Caution must be used in approaching the fire and applying water.
     0 Materials which (in themselves) are normally stable even under fire exposure conditions and which are not reactive with water. Normal firefighting procedures may be used.
     

     U.S. Department of Transportation Research and Special ProgramsAdministration Hazardous Materials Marking, Labeling & Placarding

     June 15, 19931 Guide

     This Marking, Labeling and Placarding Guide will assist shippers, carriers, fire departments, police, emergency response personnel, and others in complying with, and enforcing the regulations governing the safe transport of hazardous materials by highway, rail, water and air.

     The information and illustrations presented in this Guide are intended to serve as an introduction to regulations governing hazardous materials transportation. The Guide should be read in conjunction with the Hazardous Materials Regulations (HMR; 49 CFR 100-199). Published annually, and amended periodically, the HMR are the key to compliance and contain the information needed to comply with the requirements for the safe transport of hazardous materials.

     ** The DOT Chart 9 and the Guidelines for Hazardous Materials Warning Labels can be ordered from the Publication Warehouse 404-639-6360.

     Material Safety Data Sheets

     The Material Safety Data Sheet (MSDS) has become a major source of chemical information. It is the key document used to provide hazard information to employees and can become an invaluable tool for emergency personnel when used in a chemical emergency.

     Occupational Safety and Health (OSHA) Hazard Communication Standard (29 CFR 1910.1200) requires all manufacturers of pure chemicals and/or mixtures to evaluate their products and relate, via MSDS, any hazards that may be encountered while handling these materials. This standard is intended for all workplaces, manufacturing and non-manufacturing alike. The Environmental Protection Agency's (EPA) Emergency Response and Community Right-to-Know Act of 1986 ensures the availability of MSDS to emergency response personnel such as fire departments, first aid crews, and hospital emergency room staff.

     MSDS contain a wealth of information which may be understood with a minimum of training. It is the purpose of this document to briefly explain the format and information found in properly prepared MSDS.

     SECTION 1--Figure 7

     This section identifies the material by product or trade name and chemical name. It is the product or trade name that is usually found on the container labels although the chemical name is also required by some states. Section I will also contain the manufacturer's name, address, and telephone number.

     SECTION 2--Figure 7

     This section lists the chemical ingredients of the material if they are known or suspected to be hazardous. Hazardous materials which are not carcinogens must be reported if they represent 1 percent or more of the product. Carcinogens must be reported and identified as such if their levels are O.1 percent or higher. Also included in this section are Threshold Limit Values (TLV) and OSHA Permissible Exposure Limit (PEL).

     SECTION 3--Figure 7

     Section 3 provides physical data about the product that can be utilized for proper identification. Included are specifics such as color, odor, specific gravity (weight), vapor pressure, and boiling point.

     SECTION 4--Figure 7

     Section 4 includes fire and explosion hazard data. This information is especially useful when devising both in-house and community contingency plans. Plant first responders, local fire deparunents, and HAZMAT teams need unlimited access to this information.

     SECTION 5--Figure 8

     This section contains information on the reactivity of the product. It will list other chemicals which, when mixed with the product, will result in a chemical reaction. If a product is water reactive it will be noted in this section.

     Also, hazardous decomposition products such as carbon monoxide and other hazardous gases formed and emitted during chemical reactions or during fires are listed. It is imperative that this section be carefully noted by firefighters, both in-house and local.

     SECTION 6--Figure 8

     Section 6 contains health hazard data. It will describe any acute (short- term exposure) and/or chronic (long-term exposure) effects on the body. These will include routes (inhalation, skin, ingestion) of overexposure and the bodily organs affected as well as the signs and symptoms of overexposure. First aid procedures will also be found in this section.

     SECTION 7--Figure 8

     Section 7 lists the procedures that should be used if the product spills or leaks, including waste disposal methods.

     SECTION 8--Figure 8

     Section 8 contains information regarding the proper personal protective equipment (PPE) necessary to handle the product in a manner which will minimize exposure. Ventilation practices are also listed in this section.

     Summary --

     A Material Safety Data Sheet can aid in making the right decisions on health and safety issues in a plant or in a community. Yet, it must be noted that it is but one of many references that should be used to make final determinations. MSDS are offered by manufacturers for identification and verification and are not the last word on safety and health practices.

      

     ---

     Appendix B; Types of Respiratory Protection

     (Table 9)

      

     ---

     Appendix C; Levels of Protection

     (Table 10)

      

     ---

     Additional Information

     The Agency for Toxic Substances and Disease Registry would greatly appreciate your comments and suggestions for improving future editions of this guidance material. They may be addressed to:

     ATSDR
     Attention: Scott V. Wright
     Hazardous Materials Response Committee
     Emergency Response and Consultation Branch (MS E57)
     1600 Clifton Road, N.E.
     Atlanta, GA 30333

     Acknowledgements

     To facilitate the usefulness of this guidance document, the Agency for Toxic Substances and Disease Registry (ATSDR) convened a panel of experts to guide the project in identifying and ranking the important actions and requirements involved in the safe management of chemically contaminated patients. The panel members brought to the project their different emergency medical perspectives, as well as their life experiences, to ensure that their colleagues would find this guidance document both realistic and useful.

     ATSDR thanks the panel members for their contributions:

     • Phillip L. Currance, EMT-P
       Emedia, Inc.
       3300 East First Avenue Suite 330
       Denver, Colorado 80206
       (303) 377-9100
     • Ralph B. "Monty" Leonard, Ph.D., M.D., F.A.C.E.P.
       Department of Emergency Medicine
       Bowman Gray School of Medicine
       Medical Center Boulevard
       Winston-Salem, North Carolina
       (919) 748-4625
     • Chief Mary Beth Michos, R.N.
     • Training Officer, Montgomery County,
       Maryland Department of Fire-Rescue Services
     • EMS Specialist, Montgomery County,
       Maryland Hazardous Incidents Response Team
       Department of Fire and Rescue Services
       101 Monroe Street, 12th Floor
       Rockville, Maryland 20850
       (301) 217-2099
     • Eric K. Noji, M.D., M.P.H, F.A.C.E.P.
       Assistant to the Branch Chief for Emergency Response
       Health Studies Branch (Mail Stop F28)
       Division of Environmental Hazards and Health Effects
       National Center for Environmental Health and Injury Control
       Centers for Disease Control
       Atlanta, Georgia 30333
       (404) 639-4682
     • Martin J. O'Neill, Industrial Hygienist
       Roy F. Weston, Inc.
       Raritan Plaza One
       4th Floor Raritan Center
       Edison, New Jersey 08837
       (908) 225-3990
     • Paul R. Seidlitz, R.N.
       Seidlitz and Associates
       457 Altgeld
       Glendale Heights, Illinois 60139
       (708) 469-9552

     The project was directed by Scott V. Wright, Environmental Health Scientist, Program Operations Section, Emergency Response and Consultation Branch (ERCB), Division of Health Assessment and Consultation (DHAC), ATSDR. Contributors were Frank Mitchell, D.O. Chief Medical Officer, ATSDR; Michael Straight, M.D., Division of Health Studies, ATSDR; and Edwin Kent Gray, Chief, Emergency Response Coordination Group, National Center for Environmental Health and Injury Control, CDC. Consultants to the project were Rosalind Brannigan, Gary Turner, Shelli Rossman, Ron Brown, Eugenia Davis, and B.J. Boyd of Technical Resources, Inc.

     This document is the result of an intensive process of comment and review by the panel members, the aforementioned project directors and consultants, and other appropriate federal, state, and private agencies. These include:

      

     • Ben Blankeshire, NREMT-A, NAEMT, Secretary,
       Board of Directors, Board of Governors
       Emergency Management Committee
       National Association of Emergency Medical Technicians
       9140 Ward Parkway
       Kansas City, Missouri 64114
       (816) 444-3500
     • Kenneth Bouvier, NREMT-I, Chairman
       Emergency Management Committee
       National Association of Emergency Medical Technicians
       9140 Ward Parkway
       Kansas City, Missouri 64114
       (816) 444-3500
     • MacNeil Cross,
       NREMT-P, Co-Chairman,
       Mass Casualty Incidents
       Emergency Management Committee
       National Association of Emergency Medical Technicians
       9140 Ward Parkway
       Kansas City, Missouri 64114
       (816) 444-3500
     • Robert Daughdril,
       NREMT-P, NAEMT Board of Governors
       Emergency Management Committee
       National Association of Emergency Medical Technicians
       9140 Ward Parkway
       Kansas City, Missouri 64114
       (816) 444-3500
     • Craig Deatley,
       EMT-P, PA-C, Advisory Committee Member
       Emergency Management Committee
       National Association of Emergency Medical Technicians
       9140 Ward Parkway
       Kansas City, Missouri 64114
       (816) 444-3500
       
     • Eileen Fanes,
       NREMT-P, Advisory Corrktnittee Member
       Emergency Management Committee
       National Association of Emergency Medical Technicians
       9140 Ward Parkway
       Kansas City, Missouri 64114
       (816) 444-3500
     • Steve Finefrock,
       Education Specialist Technological Programs
       Division Emergency Management Institute
       Federal Emergency Management Agency
       Building "N" NETC Campus
       Emmitsburg, Maryland 21727
       (301) 447-1282
     • John Friery,
       NREMT-A Emergency Management Committee
       National Association of Emergency Medical Technicians
       9140 Ward Parkway
       Kansas City, Missouri 64114
       (816) 444-3500
     • Niel Holtz, NREMT-P
       Emergency Management Committee
       National Association of Emergency Medical Technicians
       9140 Ward Parkway Kansas City, Missouri 64114
       (816) 444-3500
     • Winston E. Jones, R.N.
       NREMT-P, NAEMT Board of Directors
       Emergency Management Committee
       National Association of Emergency Medical Technicians
       9140 Ward Parkway Kansas City, Missouri 64114
       (816) 444-3500
     • William J. Keffer,
       Senior Engineering Advisor
       Environmental Services Division
       U.S. Environmental Protection Agency, Region VII
       25 Funston Road
       Kansas City, Kansas 66115
       (913) 551-5009
     • Gus A. Koehler, Ph.D.
       Disaster Medical Response Planner
       California Emergency Medical Services Authority
       1930 9th Street, Suite 100
       Sacramento, California 95814
       (916) 322-2300
     • Kenneth Kuntz
       Fire Data Specialist
       Office of Fire Data and Analysis
       U.S. Fire Administration
       16825 South Seton Avenue
       Emmitsburg, Maryland 21727
       (301) 447-1272
     • Paul Manascalo,
       NREMT-P, NAEMT Vice President
       Emergency Management Committee
       National Association of Emergency Medical Technicians
       9140 Ward Parkway
       Kansas City, Missouri 64114
       (816) 444-3500
     • Kent R. Olson, M.D., F.A.C.E.P.,
       Medical Director
       San Francisco Area Regional Poison Control Center
       San Francisco General Hospital
       1001 Potrero Avenue
       San Francisco, California 94110
       (415) 821-5526
     • Chappell D. Pierce, Director
       Office of Fire Protection Engineering and Systems Safety Standards
       U.S. Department of Labor
       Occupational Safety and Health Administration
       200 Constitution, N.W.- Room North 3609
       Washington, D.C. 20210
       (202) 523-7216
     • Alonzo Smith, NREMT-P
       Emergency Management Committee
       National Association of Emergency Medical Technicians
       9140 Ward Parkway
       Kansas City, Missouri 64114
       (816) 444-3500
     • Clark Staten, NREMT-P,
       Co-Chairman Hazardous Materials Emergency Management Committee National Association of Emergency Medical Technicians
       9140 Ward Parkway
       Kansas City, Missouri 64114
       (816) 444-3500
     • Dave Tauber, NREMT-P
       Emergency Management Committee
       National Association of Emergency Medical Technicians
       9140 Ward Parkway
       Kansas City, Missouri 64114
       (816) 444-3500
     • Joe E. Taylor, R.N., Ph.D.
       Emergency Nurses Association
       16 Chickasaw Drive
       Laurel, Mississippi 39440
       (601) 425-6809 (pager)
       (601) 426-4720 (office)
     • Sandra L. Tirey, Associate Director
       Health, Safety, and Chemical Regulations
       Chemical Manufacturers Association
       2501 M Street, N.W.
       Washington, D.C. 20037
       (202) 887-1274
     • Wallace Weaver
       Emergency Management Specialist
       U.S. Department of Energy
       EM-50. I
       12800 Middlebrook Road
       Germantown, Maryland 20585
       (301) 353-7669
     • Steve White, NREMT-P, NAEMT Board of Directors
       Emergency Management Committee
       National Association of Emergency Medical Technicians
       9140 Ward Parkway
       Kansas City, Missouri 64114
       (816) 444-3500

     U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service
     Agency for Toxic Substances and Disease Registry

     The Agency for Toxic Substances and Disease Registry (ATSDR) has produced a three-volume series entitled Managing Hazardous Materials Incidents. The series is designed to assist emergency response and health care professionals plan for and respond to hazardous material emergencies.

     Volume I Emergency Medical Systems: A planning Guide for the Management of Contaminated Patients.

     Volume II Hospital Emergency Departments: A Planning Guide for the Management of Contaminated patients.

     Volume III Medical Management Guidelines for Acute Chemical Exposures.

     Volumes I and II are planning guides to assist first responders and hospital emergency department personnel in planning for incidents that involve hazardous materials.

     Volume III is a guide for health care professionals who treat persons who have been exposed to hazardous materials.

     Agency for Toxic Substances and Disease Registry
     William L. Roper, M.D., Administrator
     Barry L. Johnson, Ph.D., Assistant Administrator

     Division of Health Assessment and Consultation
     Robert C. Williams, P.E., Director
     Juan J- Reyes, Acting Deputy Director

     Emergency Response and Consultation Branch
     C. Harold Emmett, P.E., Chief

     Additional copies of this report are available from:

     Emergency Response and Consultation Branch (E57), Division of Health Assessment and Consultation, Agency for Toxic Substances and Disease Registry, 1600 Clifton Road, N.E., Atlanta, Georgia 30333, (404) 639-6360

     Use of trade names is for identification only and does not constitute endorsement by the Public Health Service or the U.S. Department of Health and Human Services.

     ---

     POINT OF CONTACT FOR THIS DOCUMENT:

     To request a copy of this document or for questions concerning this document, please contact the person or office listed below. If
     requesting a document, please specify the complete name of the

     document as well as the address to which you would like it mailed. Note that if a name is listed with the address below, you may wish to contact this person via CDC WONDER/PC e-mail.
     SCOTT V WRIGHT
     AGENCY FOR TOXIC SUBSTANCES AND DISEASE REGISTRY
     Centers for Disease Control
     1600 Clifton Rd, NE MS(E-57)
     Atlanta, GA 30333
     

     ---

     Table 1

     Table 1 Telephone Information and Technical Support References
     ========================================================================================================================================================================================
     Resource                                     Contact                                                 Services Provided
     ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     CHEMTRAC                                   1-800-424-9300                                     24-hour emergency number. Connection with manufacturers and/or shippers who will provide
     (Chemical Transportation Emergency                                                            advice on handling rescue gear needed, decontamination considerations, etc.  Also provides
     Center)                                                                                       access to Chlorine Emergency Response Plan (CHLOREP)
     
     ATSDR                                      1-404-639-0615                                     24-hour emergency number for health-related support in hazard materials emergencies,
     (Agency for Toxic Substances                                                                  including on-site assistance, if necessary.
     and Disease Registry)
     
     Bureau of Explosives                       1-202-639-2222                                     24-hour emergency number for hazardous materials incidents involving railroads.
     
     Emergency Planning and Community Right-    1-800-535-0202                                     8:30 am-7:30 pm (EST) Provides information on SARA Title III.  Provides list of extremely
     to-Know Information Hotline                                                                   hazardous substances and planning guidelines.
     
     EPA (Environmental Protection Agency)                                                         Environmental response team available.
     Regional Offices                           Region I               -  (617)565-3698
                                                CT, ME, MA, NH, RI, VT
                                                Region II              -  (212) 264-0504
                                                NJ, NY, PR, VI
                                                Region III             -  (215) 597-0980
                                                DE, DC,MD, PA, VA, WV
                                                Region IV              -  (404) 347-3454
                                                AL, FL, GA, KY, MS, NC, SC, TN
                                                Region V               -  (312) 886-7579
                                                IL, IN, MI, MN, OH, WI
                                                Region VI              -  (214) 655-6760
                                                AR, LA, NM, OK, TX
                                                Region VII             -  (913) 236-2850
                                                IA, KS, MO, NE
                                                Region VIII            -  (303) 293-1720
                                                CO, MT, ND, SD, UT, WY
                                                Region IX              -  (415) 974-7460
                                                AM, SAMOA, AZ, CA, GU, HI, NV, Trust Territory of
                                                the Pacific Isl., Marshall Isl.,Palau, Ponape
                                                Region X               -  (206) 442-2782
                                                AK, ID, OR, WA
     
     National Animal Poison Control Center      1-217-333-3611                                    24-hour consultation concerning animal poisonings or chemical contamination.  Provides an
                                                                                                  emergency response team to investigate incidents and perform laboratory analysis.
     
     National Response Center                   1-800-424-8802                                    For reporting transportation incidents where hazardous materials are responsible for death,
                                                                                                  serious injury, property damage in excess of $50,000, or continuing danger to life and
                                                                                                  property.
     
     ========================================================================================================================================================================================
     

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     Table 2

     Table 2 Local Telephone Information and Technical Support Resource Worksheet
     =============================================================================================================================
     Resource                                           Contact                             Services Provided
                                               (fill in future reference)                 (fill in for future reference)
     -----------------------------------------------------------------------------------------------------------------------------
     EPA Regional Office
     
     -----------------------------------------------------------------------------------------------------------------------------
     Regional Poison Control Center
     
     -----------------------------------------------------------------------------------------------------------------------------
     State Emergency Response Commission
     
     -----------------------------------------------------------------------------------------------------------------------------
     State Health Department
     
     -----------------------------------------------------------------------------------------------------------------------------
     Community Fire Department
     
     -----------------------------------------------------------------------------------------------------------------------------
     Community Police Department
     
     -----------------------------------------------------------------------------------------------------------------------------
     Local Emergency Planning Committee
     
     -----------------------------------------------------------------------------------------------------------------------------
     Local Health Department
     
     -----------------------------------------------------------------------------------------------------------------------------
     State Department of Natural Resources
     
     -----------------------------------------------------------------------------------------------------------------------------
     =============================================================================================================================
     
     

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     Table 3

     Table 3 Computerized Data Sources of Information and Technical Support
     ===============================================================================================================================================================================
     Data Systems                         Contact                                      Description
     -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     ANSWER                               ANSWER                                   National Library of Medicine's Workstation of Emergency Response (ANSWER) - to advise
                                          Specialized Information Svcs.            emergency response health professionals on potential hazardous chemical emergencies.
                                          National Library of Medicine
                                          Building 38A
                                          8600 Rockville Pike
                                          Bethesda, Maryland  20894
                                          (301) 496-6531
     
     CAMEO                                CAMEO Database Manager                   Computer-Aided Management of Emergency Operations available to on-scene responder
                                          National Oceanic and                     Chemical identification database assists in: identifying substance involved, predicting
                                          Atmospheric Administration               downwind concentrations, providing response recommendations, and identifying potential
                                          (NOAA) Hazardous Materials               hazards.
                                          Response Branch, N/OMA-34
                                          7600 Sand Point Way, NE
                                          Seattle, Washington  98115
                                          (206) 526-6317
     
     CHRIS                                CIS, Inc.                                Chemical Hazard Response Information System, developed by the Coast Guard and comprised
                                          Fein Management Associates               reviews on fire hazards, fire fighting recommendations, reactivities, physicochemical
                                          7215 York Road                           properties, health hazards, use of protective clothing, and shipping information for over
                                          Baltimore, Maryland  21212               chemicals
                                          (800) 247-8737
     
     HAZARDTEXT                           Micromedex, Inc.                         Assists responders dealing with incidents involving hazardous materials such as spills, leaks,
                                          660 Bannock Street                       and fires.  Emergency medical treatment and recommendations for initial hazardous response
                                          Denver, Colorado  80203-3527             are presented.
                                          (800) 525-9083
     
     HMIS                                 David W. Donaldson                       Hazardous Material Information Systems provides name and emergency phone number of
                                          Information Sys. Specialist              manufacturer, chemical formula, NIOSH number, fire fighting, spill, and leak procedures.
                                          Dept. of Trans/RSPA/OHMT
                                          400 7th Street, S.W.
                                          Washington, D.C.  20590
                                          (202) 366-5869
     
     HSDB                                 Toxicology Data Network                  Hazardous Substances Data Bank, compiled by the National Library of Medicine, provides
                                          (TOXNET)                                 reviews on the toxicity, hazards, and regulatory status of over 4,000 frequently used chemicals.
                                          National Library of Medicine
                                          Toxicology Information Program
                                          8600 Rockville Pike
                                          Bethesda, MAryland  20894
                                          (301) 496-6531
     
     1st MEDICAL RESPONSE PROTOCOLS       Micromedex, Inc.                         For use in developing training programs and establishing protocols for first aid or initial
                                          660 Bannock Street                       workplace response to a medical emergency.
                                          Denver, Colorado  80203-3527
                                          (800) 525-9083
     
     MEDITEXT                             Micromedex, Inc.                         Provides recommendations regarding the evaluation and treatment of exposure to industrial
                                          660 Bannock Street                       chemicals.
                                          Denver, Colorado  80203-3527
                                          (800) 525-9083
     
     OHMTADS                              CIS, Inc.                                Oil and Hazardous Materials Technical Assistance Data Systems provides effects of spilled
                                          Fein Management Associates               chemical compounds and their hazardous characteristics and properties, assists in identifying
                                          7215 York Road                           unknown substances, and recommends procedures for handling and cleanup.
                                          Baltimore, Maryland  80203-3527
                                          (800) 247-8737
     
     TOMES                                Micromedex, Inc.                         The Tomes Plus Information Systems is a series of comprehensive databases on a single CD-
                                          660 Bannock Street                       ROM disc.  It provides information regarding hazardous properties of chemicals and medical
                                          Denver, Colorado  80203-3527             effects from exposure. The Tomes Plus database contains Meditext, Hazardtext, HSDB
                                          (800) 525-9083                           CHRIS, OHMTADS, and 1st Medical Response Protocols.
     
     TOXNET                               Toxicology Data Network                  Computerized system of three toxicologically oriented data banks operated by the National
                                          (TOXNET)                                 Library of Medicine-- the Hazardous Substances Data Bank, the Registry of toxic Effects of
                                          National Library of Medicine             Chemical Substances, and the Chemical Carcinogenesis Research Information System.
                                          Toxicology Information Prog.             TOXNET provides information on the health effects of exposure to industrial and environmen-
                                          (301) 496-6531                           tal substances.
     
     ===============================================================================================================================================================================
     

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     Table 4

     Table 4 Examples of Adverse Health Effects from Exposure to Toxic Chemicals
     =============================================================================================================
     Toxic End Point           Target Organ            Example of                    Health Effect
                               Systems                 Causative            Acute                Chronic
                                                       Effects
     -------------------------------------------------------------------------------------------------------------
     Carcinogenicity           Multiple Sites          Benzene              Dermatitis           Aleukemia
                                                                            Tightness in Chest   Myeloblastic
                                                                                                 leukemia
     Hepatotoxicity            Liver                   Carbon Tetra-        Vomiting             Liver Necrosis
                                                       chloride             Vesication           Fatty Liver
                                                                            Dizziness
     
     Neurotoxicity             Nervous System          Lead                 Nausea               Wrist Drop
                                                                            Vomiting             IQ Deficits
                                                                            Abdominal Pain       Encephalopathy
     
     Nephrotoxicity            Kidney                  Cadmium              Vomiting             Kidney Damage
                                                                            Diarrhea             Anemia
                                                                            Chest Pain
     =============================================================================================================
     

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     Table 5

     Table 5 Classification of Factors Influencing Toxicity
     ==================================================================================================================
     Type                                              Examples
     ------------------------------------------------------------------------------------------------------------------
     1. Factors related to the chemical.        Composition (salt, freebase, etc.);physical characteristics
                                                (size, liquid, solid, etc.); physical properties (volatility, solu-
                                                bility, etc.); presence of impurities; breakdown products; carriers
     
     2. Factors related to exposure.            Dose; concentration; route of exposure (inhalation, ingestion,
                                                etc.) duration.
     
     3. Factors related to person exposed.      Heredity; immunology;nutrition; hormones; age; sex; health
                                                status; preceding diseases.
     
     4. Factors related to environment.         Media (air, water, soil, etc.) additional chemicals present;
                                                temperature; air pressure.
     
     ==============================================================================================================
     

     ---

     Table 6

     Table 6 Dose-Response Relationship for Humans Inhaling Tetrachloroethylene Vapors
     ===================================================================================================
     Levels in Air          Duration of Exposure            Effect on
                                                            Nervous System
     ---------------------------------------------------------------------------------------------------
     50   ppm                                               Odor threshold
     100  ppm                  7 hours                      Headache, drowsiness
     200  ppm                  2  hours                     Dizziness, uncoordination
     600  ppm                 10  minutes                   Dizziness, loss of inhibitions
     1000 ppm                 1-2 minutes                   Marked dizziness
                                                            intolerable eye and
                                                            respiratory tract irritation
     1500 ppm                 30  minutes                   Coma
     

     ---

     Table 7

     Table 7 Acute LD50 Values for Representative Chemicals When Administered Orally to Rats
     =========================================================================================
     Chemical                                    Acute Oral LD50
                                                     (mg/kg)*
     -----------------------------------------------------------------------------------------
     Sodium cyanide                                  6.4 - 10
     Pentachlorophenol                               50 - 230
     Chloride                                        83 - 560
     Lindane                                         88 - 91
     Toluene                                       2,600 - 7,000
     Tetrachloroethylene                           3,000 - 3,800
     -----------------------------------------------------------------------------------------
     *Milligrams of the compound administered per kilogram body weight of the
      experimental animal.
     =========================================================================================
     
     

     ---

     Table 8

     Table 8 Occupational Exposure Limits
     ============================================================================================================================
       Value                        Abbreviation                 Definition
       Threshold Limit Value            TLV                      Refers to airborne concentrations of substances
       (3 Types)                                                 and represents conditions under which it is
       (ACGIH)                                                   believed that nearly all workers may be repeatedly exposed
                                                                 day after day without adverse effect.
     
     1)Threshold Limit Value-         TLV-TWA                    The time-weighted average concentration for a normal
       Time-Weighted Average                                     8-hour workday and a 40-hour workweek, to which
       (ACGIH)                                                   nearly all workers may be repeatedly exposed, day after
                                                                 day, without adverse effect.
     
     2)Threshold Limit Value          TLV-STEL                   The concentration to which workers can be exposed
       Short-Term Exposure Limit                                 continuously for a short period of time without suffer-
                                                                 ing from: 1) irritation, 2) chronic or irreversible tissue
                                                                 damage, or 3) narcosis of sufficient degree to increase the
                                                                 likelihood of accidental injury, impair self-rescue or mate-
                                                                 rially reduce work efficiency, and provided that the daily
                                                                 TLV-TWA is not exceeded.
     
     3)Threshold Limit Value-         TLV-C                      The concentration that should not be exceeded during
       Ceiling (ACGIH)                                           any part of the working exposure.
     
       Permissible Exposure           PEL                        Same as TLV-TWA.
       Limit (OSHA)**
     
     Immediately Dangerous            IDLH                      A maximum concentration (in air) from which one could to
     to Life and Health (OSHA)**                                escape within 30 minutes without any escape-impairing
                                                                symptoms or any irreversible health effects.
     
     Recommended Exposure              REL                      Highest allowable airborne concentration that is not
     Limit (NIOSH)***                                           expected to injure a worker, expressed as a ceiling limit or
                                                                time-weighted average for an 8- or 10- hour work day.
     ----------------------------------------------------------------------------------------------------------------------------
     *   American Conference of Governmental Industrial Hygienists
     **  Occupational Safety and Health Administration
     *** National Institute for Occupational Safety and Health
     ============================================================================================================================
     

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     Table 9

     Table 9 Appendix B Types of Respiratory Protection
     ======================================================================================================================================
     Type of Respirator                    Advantages                            Disadvantages
     
     Air Purifying                         Enhanced mobility.                    Cannot be used in IDLH or oxygen-
     Air-Purifying Respirator                                                    deficient atmospheres (less than 19.5%
     (Including powered air-purifying      Lighter in weight than an SCBA.       oxygen at sea level).
     respirators [PAPRs].)                 Generally weighs 2 pounds (1 kg)
                                           or less (except for PAPRS).           Limited duration of protection. May be
                                                                                 hard to gauge safe operating time
                                                                                 in field conditions.
     
                                                                                 Only protects against specific chemicals,
                                                                                 and up to specific concentrations.
     
                                                                                 Use requires monitoring of contaminant
                                                                                 and oxygen levels.
     
                                                                                 Can only be used: (1) against gas
                                                                                 and vapor contaminants with adequate
                                                                                 warning properties or (2) for specific gases or
                                                                                 vapors provided that the service is known
                                                                                 and a safety factor is applied, or if the unit
                                                                                 has an ESLI (end-of-service-life-indicator).
     Atmosphere-Supplying
     
     Self-Contained Breathing              Provides the highest available        Bulky, heavy (up to 35 pounds).
     Apparatus (SCBA)                      level of protection against airborne
                                           contaminants and oxygen deficiency.   Finite air supply limits work duration.
     
                                           Provides the highest available        May impair movement in confined spaces.
                                           level of protection under strenuous
                                           work conditions.
     
     Positive-Pressure Supplied-           Enables longer work periods than      Not approved for use in atmospheres
     Air Respirator (SAR)                  an SCBA.                              immediately dangerous to life or health
     (also called air line respirator)                                           (IDLH) or in oxygen-deficient atmo-
                                           Less bulky and heavy than an SCBA.    spheres unless equipped with an emer-
                                           SAR equipment weighs less than        gency egress unit, such as an escape-only
                                           5 pounds(or around 15 pounds, if      SCBA that can provide immediate
                                           escape SCBA protection is included).  emergency respiratory protection in
                                                                                 case of air line failure.
                                           Protects against most airborne
                                           contaminants                          Impairs mobility.
     
                                                                                 Mine Safety and Health Administration/
                                                                                 NIOSH certification limits hose length to
                                                                                 300 feet (90 meters).
     
                                                                                 As the length of the hose is increased, the
                                                                                 minimum approved airflow may not be delivered
                                                                                 at the faceplate.
     
                                                                                 Air line is vulnerable to damage, chemi-
                                                                                 cal contamination, and degradation.
                                                                                 Decontamination of hoses may be difficult.
     
                                                                                 Worker must retrace steps to leave work area.
     
                                                                                 Requires supervision/monitoring of the
                                                                                 air supply line.
     
     ======================================================================================================================================
     

     ---

     Table 10

     Table 10  Appendix C Levels of Protection*
     ===============================================================================================================================================================
     Level of
     Protection     Equipment                  Protection Provided                     Should Be Used When:                    Limiting Criteria
         A          Recommended:               The highest available level of res-     The chemcial substance has been         Fully-encapsulated suit material
                                               piratory, skin, and eye protection.     identifies and requires the highest     must be compatible with the
                    Pressure-demand, full                                              level of protection for skin, eyes,     substances involved.
                    Fully encapsulating,chemical-                                      and the respiratory system based
                    resistant suit.                                                    on either:
     
                    Inner chemical-resistant gloves                                    - Measured (or potential for)
                    Chemical-resistant safety boots/                                   high concentration of atmos-
                    shoes.                                                             pheric vapors, gases, or par-
                                                                                       ticulates or
                    Two-way radio communication.                                       - Site operations and work func-
                                                                                       tions involving a high poten-
                    OPTIONAL:                                                          tial for splash, immersion or
                    Cooling unit.                                                      exposure to unexpected vapors,
                                                                                       gases, or particulates of
                    Coveralls.                                                         materials that are harmful to
                                                                                       skin or capable of being ab-
                    Long cotton underwear.                                             sorbed through the intact skin.
     
                    Hard hat.                                                          Substances with a high degree of
                                                                                       hazard to the skin are known or
                    Disposable gloves and boot cov-                                    suspected to be present, and skin
                    ers.                                                               contact is possible.
     
                                                                                       Operations must be conducted in
                                                                                       confined, poorly ventilated areas
                                                                                       until the absence of conditions
                                                                                       requiring Level A protection is
                                                                                       determined.
     
     ---------------------------------------------------------------------------------------------------------------------------------------------------------------
     * Reprinted from NIOSH/OSHA/USCG/EPA
     Occupational Safety and Health Guidance Manual for Hazardous Waste Site Activities,
     Department of Health and Human Services, October 1985.
     

     ---

     Figure 1

     Levels Of Protection

     

      

     ---

     Figure 2

     Levels Of Protection (Continued)

     

      

     ---

     Figure 3

     A Chemical Cartridge Air-Purifying Respirator

     

      

     ---

     Figure 4

     A Self-Contained Breathing Apparatus/Supplied-Air Respirator

     

      

     ---

     Figure 5

     Nine-Step Personnel Decontamination Plan

     

      

     ---

     Figure 6

     Eight-Step Dry Decontamination Plan For Personnel

     

      

     ---

     Figure 7

     Material Safety Data Sheet

     

      

     ---

     Figure 8

     Material Safety Data Sheet (Continued)