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Focus on Hazmat
It Ain't Over Till It's Over

When the "bean counters" start assessing the expense of mitigating even a small HazMat incident the monetary costs rapidly approach astronomical levels. Expendable items, fuel, wages and overtime, consumables, equipment damaged or destroyed, product lost, all are listed and all must be paid for by someone. However, with the application of enough cash all of these items can be replaced or rebuilt. The only thing that money cannot replace is human life; yet we sometimes fail to adequately protect this one valuable component of the emergency response effort.

Equipment deteriorates in use and at some point will, in spite of periodic maintenance, become unusable or at least uneconomical for continued utilization. When this happens we discard the item and purchase a replacement. This is an accepted business practice known as "depreciation". It works well when one is talking about cast iron but it looses is attractiveness when one begins to talk about human beings. During the lifespan of inanimate equipment the wise owner makes frequent inspections to determine the status of the mechanism. Are the bearings showing wear or do the tires need replacing? If so, we set about tending to these items to forestall a breakdown at a critical time and to extend the useful life of the equipment as much as possible.

Humans like to have a long useful lifespan and obsolescence is not a popular concept with them. Yet all too often we fail to carry out the "inspections" necessary to ensure that there will be no premature failure or unexpected breakdown.

One of the main reasons for this failure is the fact that humans are such prolific generalists; they may be exposed to a different hazard every day and each one can, if not detected, contribute to the deterioration of the individual. Additionally, synergistic reactions do occur; for instance: exposure to product "A" may do no discernable harm and neither does a brief exposure to product "B". However, when the patient who has been exposed to product "A" is later exposed to product "B" he manifests severe symptoms and there is evidence of residual organic damage. "The whole is greater than the sum of the parts"

It is standard practice to assess the physical condition of responders working at the scene of an incident but what about follow-up? Sam Spade, a volunteer responder, may have been exposed to benzene during the last hazmat incident. We checked him out at the end of the run, to be sure, and we could find no evidence of injury; but did we examine a blood smear six months later to check for anomalies such as basophilic stippling?

OSHA requires that workers who are subject to chronic exposure to dangerous chemicals be tested periodically to ensure that they are not being adversely affected by contamination of their workplace environment. This is, of course, a prudent precaution and one that is also taken for emergency response personnel, such as members of a plant's emergency response team who respond to incidents involving the same materials time after time. But, what about the firefighter who faces a different hazard on every run? Do we check him for every hazard that he has, or may have, encountered? From a practical point of view could we check for clinical symptoms relating to every possible hazard? Obviously not; yet we must ensure the safety of these individuals insofar as it is humanly possible to do so.

It is often very difficult if not impossible to really define the hazards present at a hazmat incident. To be sure we have or can find out the identities of those materials that were known or expected to be present when the incident occurred; but chemicals do combine and the end products of an explosion or conflagration are usually very different from the materials that were present initially. Thus a shipment of a metallic sulfide (usually an innocuous solid) could, in the event of a derailment or other untoward happening, come in contact with a mineral acid (a liquid) and give rise to hydrogen sulfide (H2S), a poisonous gas not present prior to the incident and therefore not mentioned in any documentation.

Only two possible protocols can be used to ensure that emergency response personnel can be kept safe and both of them must be implemented at every incident. One is to have in place an impeccable operating policy pertaining to the use of protective equipment; one that is strictly and consistently enforced at all times. "Protective equipment" is not, in this case, restricted to specialized clothing; it should include breathing air supplies, instrumentation for monitoring and early detection of hazards so that the proper precautions may be taken in a timely fashion. In some instances ground transportation vehicles for use inside the "hot zone" will be needed and of course, decontamination facilities appropriate to the material involved. Responders may at times feel that such protocols are "overkill" and it may well be that in some cases they are; but those who object must be "encouraged" to remember that "it is OK to look silly in those white suits today so that one can some back and look silly again tomorrow. They must accept the fact that it is always better to observe unneeded safety procedures than to omit one that is absolutely essential.

The other protocol required to maximize personnel safety is follow up medical evaluations. This is the area where Fire Departments, particularly the smaller volunteer organizations and plant operations most often fail. While many, if not most, of these organizations require annual physical examinations, they provide the examiner with little or no data regarding what exposures have occurred, what specific symptoms he should be looking for and what particular tests should be run. The doctor can't treat what he doesn't know exists. He'll ask questions about family and personal past chronic illnesses and surgery. But I've never had a doctor ask me what types of hazardous materials I might have been exposed to in my work. If he doesn't know about it he won't treat it and the destruction and degradation will continue until they become manifest through the appearance of clinically significant symptoms. By this time irreparable damage and/or deterioration may have been sustained.

The first step in achieving an effective evaluation protocol is to establish a set of baseline values for each responder. This can usually take form in the routine "CMP" or "Complete Metabolic Panel" routinely run by any competent hospital laboratory. This panel of tests can and should be augmented by any specialized tests appropriate to a particular chemical, such as benzene, which is likely to be encountered. The laboratory examination should be done as a part of the pre-employment physical or at least as part of a physical given when the employee is first assigned to the emergency response team. This initial examination provides a baseline or starting point and allows the evaluating physician to later detect any variation from the individual's normal values. Any such deviation should be investigated thoroughly.

The next step is to obtain as much information as possible regarding any materials to which response personnel have been, or may have been, exposed. The MSDS of any commodity in commerce is required to have a 24-hour telephone number that can be used to connect on site physicians and other health care providers to a source of valid medical information. The information obtained from this contact will tell the treating physician what to look for and how to interpret his findings. This contact should also be able to provide information regarding the reactions that may occur between the material in question and the environment or other materials involved in the incident.

Response personnel should always verify the telephone number given on shipping papers or other documents as the source for medical information as soon as possible after arrival at the incident site. This will verify that the number on the shipping paper or the MSDS is actually the correct one (telephone numbers do change and the paperwork may not have been updated) and also serve to alert the manufacturer's medical department that an incident has occurred, thus allowing them time to begin gathering the information that may be needed later. At this time they can be apprised of the location of the incident as well as the present conditions, weather, traffic, neighboring facilities etc. at the incident site. In point of fact, this may well be the first notice that the manufacturer has of the incident and it will instigate the alerting and, if necessary the deployment of the company response team. Any and all medical information regarding materials present at an incident should be forwarded to the responding organization's physician.

As soon as practicable after the incident those responders who have or may have been exposed to a particular material should be examined by competent medical authority. This examination should include laboratory tests appropriate to the material in question. The results should be compared to the responder's baseline values and any variations investigated thoroughly. This is not, however "the end of it". There is often a considerable delay between the time of exposure and the appearance of clinically significant changes in the patient's baseline values: therefore it is absolutely necessary that additional follow-up examinations be made until it is certain that no discernable permanent damage has been done or that further degradation has been halted and any damage has been treated to the greatest extent possible.

This follow-up step, while important, is the step of those most often omitted in the medical protocol. Employees leave, assignments change and transfers within the company happen. The physician performing the annual physical for emergency responder may not know about Sam's exposure to benzene and he may not be the best practitioner to handle such a case. In reality there may not even be a periodic physical for Sam. For whatever reason, in the process the fact that Sam Spade was or may have been exposed to benzene three months ago is overlooked and no follow-up is done. It is overlooked, that is, until Sam begins to complain of symptoms of cancer or other disorders related to benzene. Then we look and sure enough there is that tell-tale basophilic stippling which, if seen earlier, could have triggered the initiation of treatment that would have given Sam a much better chance of recovery.

Follow-up is just as essential as first aid. "it ain't over till it's over" and it isn't over until follow up studies have demonstrated that there has been no long term damage or that any such structural or cellular degradation has been confined and treated to the greatest extent possible. This may mean years of periodic testing and in some cases repeated courses of treatment, but when and only when the patient is stabilized, the damage confined and the most effective treatment possible has been provided, then it's over.


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