Protective Equipment/Medical Monitoring & First Receiver Limitations

Objectives• Explain the need for, types, selection criteria

and limits of protective equipment commonly used in Haz Mat incidents.

• How to select, don, and doff the proper personal protective equipment.

• Understanding the hazards and limitations of personal protective equipment

The Haz Mat Response Process

-Operations Level-Command - Identification- Action Plans

-Protective Equipment - Containment / Control -Decon

- Protective Actions -Disposal -

Documentation

SIN

CIA

PCP

DDD

Hazard Control or the“Hierarchy of Controls”

• Engineering Controls

• Administrative Controls

• Personal Protective Equipment

PPE is the last and least desirable for of protection - Why?

“Let’s talk PPE”

• PPE is the last and least desirable Hazard Control option after:– Engineering Controls– Administrative Controls

• But, in “uncontrolled releases” or for managing contaminated patients it is often the only alternative.

IDHA & Protective Equipment• Need for protective equipment

• After Identification and Hazard Assessment (IDHA)– Determine safety of field personnel via

protective equipment levels and needs.

Protective Equipment

• Protective Clothing– (Proper level)

• Respiratory Protection– SAR/APR

• Monitoring Devices

Incomplete IDHA?• Use highest level of PPE available• Level C is lowest recommended for

hospital-based patient decontamination• In healthcare-based spills…?

Note: Refer to

“OSHA Guidance for Hospital-Based First Receivers of Victimsfrom Mass Casualty

Incidents Involving the Release of Hazardous

Materials”January 2005

OSHA Requirements

• Require SCBA/SAR for inhalation hazards• FROs are FROs because of level of training and

PPE

Bottom Line

• PPE helps to keep you safe (if the right PPE is used in the proper circumstances)

Need for PPE

• Responders may be exposed– Inhalation– Ingestion– Absorption– Injection

Selection Criteria

• Physical form of chemical• Degree of hazard• Other– Oxygen level– Chemical Protective Clothing

(CPC) compatibility– Degree of unknowns

“Let’s go through the litany”

• Four levels of Chemical Protective Ensemble• Each has advantages and disadvantages• NO ONE ENSEMBLE IS APPROPRIATE IN ALL

CIRCUMSTANCES! • THESE ENSEMBLES DO NOT PROTECT AGAINST FIRE

OR EXPLOSION!• These were not developed with healthcare in mind

(more on that later).

Level ASkin Respiratory Comments

Vapor Protective (also known as gas tight or fully encapsulating)

Atmosphere Supplying Respirator (Self Contained Breathing Apparatus [SCBA] or Supplied Air Respirator [SAR])

Highest level of skin and respiratory protection. Bulky, heavy, and greater potential of heat stress and Slip, Trip and Fall (STF) injuries

               

Level BSkin Respiratory Comments

Liquid Splash Protection

Atmosphere Supplying Respirator (Self contained breathing apparatus [SCBA] or Supplied Air Respirator [SAR]

Lower level of skin protection with highest level of respiratory protection

               Note air supply is external to suitMinimum level of protection to enter release (hot) zone with agent unknownMay be on air hose with escape bottle (SAR) SCBA limited to approximately20 or 40 min

Level CSkin Respiratory Comments

Liquid Splash Protection

Air Purifying

Respirator [APR] Lower level of skin and respiratory protection

               

Filters air, does not supply air.Powered models provide higher levels of protection vs. mask type.Generally NOT sufficient for ‘hot’ zone if unknown substance. Cannot be used in Oxygen deficient atmospheres or Immediately Dangerous to Life and Health concentrations

Level D

Skin Respiratory

Comments

No chemical

protection No respiratory protection

Examples include: work uniforms, street clothes, scrubs, and Standard Precautions (provides minor chemical protection)

“Let’s talk respiratory protection” (Two basic types)

• Atmosphere-supplying respirator means a respirator that supplies the respirator user with breathing air from a source independent of the ambient atmosphere, and includes supplied-air respirators (SAR) and self-contained breathing apparatus (SCBA) units.

• Air-purifying respirator means a respirator with an air-purifying filter, cartridge, or canister that removes specific air contaminants by passing ambient air through the air-purifying element.

SCBAType/Description Advantages Disadvantages

Self Contained Breathing ApparatusA compressed air tank (less common is a rebreather system) containing 30 or 60 minutes (usually effective for less than the rated time) of breathable air. It is mounted on a harness worn on the back with a tight fitting face piece. Weight ~ 25-40 lbs

An Atmosphere-supplying respirator. Greater mobility. Can be used for unknowns, in oxygen deficient atmospheres, and atmospheres above the Immediately Dangerous to Life and Health level.

Heavy and bulky (increased overexertion injury hazard). Limited air supply. Users must be fit tested. No facial hair allowed that interferes with mask. High level of training required. High cost.

SARType/Description Advantages Disadvantages

Supplied Air Respirators (In line system)A hose attaches the user to a hip mounted regulator that is connected by another hose to either a compressed gas tank, compressor, or piped system. The mask can be either a tight fitting mask or loose fitting hood.

Reduced potential of overexertion injuries. Can be configured for extended use. Loose fitting hoods do not require fit testing and can be used by persons with beards. Can place multiple responders on one system through use of a manifold system with a variety of air sources. (Thanks Howard)

Greater slip, trip and fall hazard from hoses. Limited range.

APR/PAPR

Type/Description Advantages Disadvantages

Air purifying respirators (APR)A specialized filter attached to either a tight fitting or loose fitting afterpiece. Can be of a demand valve or powered type (PAPR).

A filtered air source. High mobility PAPRs are generally more comfortable than APR. Often less expensive than atmosphere supplying respirators.

Cannot be used for unknown substances, atmospheres below 19.5% oxygen, materials with poor warning properties, or materials present above the Immediately Dangerous to Life and Health level. Same tight fitting face piece issues as SCBA. Loose fitting hood can only be used with PAPR. Filters must be specific to type of contaminant present.

TABLE 3 Practical Personal Protective Equipment (PPE)

Recommended

•A PPE ensemble that includes a PAPR with a protection factor of 1000 equipped with a HEPA Organic Vapor/Acid Gas cartridge, chemically resistant protective clothing for body and head, •Chemically Resistant Boots •Double gloves; butyl over nitrile•This recommended equipment to be worn by everyone whose role or function would cause them to work inside the Decontamination Zone

FROM: Best Practices for Hospital-Based First

Receivers of Victims from Mass Casualty

Incidents Involving the Release of Hazardous

Substances

Note: For Decon - not necessarily for spill response

TABLE 3 SCOPE AND LIMITATIONS

1.The hospital is not the release site.G

2.Prerequisite conditions of hospital eligibility are already met (Tables 1and 2). 3.The identity of the hazardous substance is unknown.H

Note: This table is part of, and intended to be used with, the document entitled OSHA Best Practices for Hospital-based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances.

• Powered air-purifying respirator (PAPR) that provides a protection factor of 1,000.J The respirator must be NIOSH-approved.K

• Combination 99.97% high-efficiency particulate air (HEPA)/organic vapor/acid gas respirator cartridges (also NIOSH-approved). • Double layer protective gloves.L

• Chemical resistant suit. • Head covering and eye/face protection (if not part of the respirator). • Chemical-protective boots. • Suit openings sealed with tape.

Hospital Decontamination Zone

All employees in this zone (Includes, but not limited to, any of the following employees: decontamination team members, clinicians, set-up crew, cleanup crew, security staff, and patient tracking clerks.)

All employees in this zone

Hospital Post-decontamination ZoneM Normal work clothes and PPE, as necessary, for infection control purposes (e.g., gloves, gown, appropriate respirator).

MINIMUM PPEZONE

FROM: Best Practices for Hospital-Based First

Receivers of Victims from Mass Casualty

Incidents Involving the Release of Hazardous

Substances

Components of SCBAs

• Face Piece• Regulator• Cylinder• Harness

Components of SARs

Supplied Air Respirators• Face Piece or Loose Fitting Hood• Escape bottle• Air hoses• Air Source (Med Air, Air Pumps, Air

Compressor)

Components of APRs

• Face Piece• Canister• Blower pack (PAPR)

Respiratory Protection

• Respiratory– Appropriate Use and Limitations – If respiratory protection is being used, all

participants must be enrolled in a Respiratory protections program that meets the OSHA Respiratory Standard

– For example:• Maintenance and care• Fit testing (not required if using loose fitting face piece.)• Medical Clearance

Problems with PPE

• Heat Stress

• Slips / Trips / Falls

• Overexertion (strains and sprains)

PPE Risks and Limits

• Penetration• Degradation• Permeation

Chemical Protective Clothing

• Body– Chemical Protective Clothing• Compatibility (Use charts)• Permeation, Penetration,

Degradation

Inspection Procedures

Before Wearing Any Chemical Protective Clothing & Equipment (CPC&E) It Should Be Properly Inspected

• Create a Checklist for Visual Inspections• Suit Should Be Inspected Immediately

Before Use• Monthly When Not in Use

From FEMA Noble Training Center HERT MCI WMD

Inspection Procedures

Spread suit out on a flat surface• Examine the outside for the following:

– Fabric for abrasions, cuts, holes, or tears– Fabric has retained the original flexibility and

durability– Seams for separation or holes– Zippers, buttons, storm flaps, and other

connecting devices for proper sealing and operation

Inspection Procedures (cont'd)

Inside a dark room: Use flashlight inside of the suit – Look for pinpoints of light from outside

the suit• Refer to manufacturer’s

recommendations for:– Routine, and/or – Special inspection procedures

Inspect Respirator Equipment

• Components– Face-piece– Breathing tube– Hood

• Cartridges• Belt and snaps• Cleanliness• Batteries

– Flow check (4-6 cfm)

Pre-Donning• Hydrate• Urinate• Remove anything you want to see again or that may

restrict movement:– Jewelry (earrings, big rings, watches, bracelets, necklaces)– Pocket contents (wallet, keys)

• If you can change into an inner suit such as a set of scrubs or bunny suit, all the better

• Take vital signs (pulse at a minimum)

Pg II A 29

Suit Fully Donned

“The Law of Unintended Consequences”

• The primary hazards of wearing PPE:

– Heat Stress– Slips / Trips / Falls– Overexertion (strains and sprains)

Personnel Monitoring and Medical Surveillance

• Base Line - pulse, temperature, (BP, weight)• Exit• Medical Surveillance (Employee Health

Services)

Heat EmergenciesHeat emergencies result from one of two primary causes: environmental (exogenous heat load when the temperature exceeds 32º C or 90º F) or excessive exercise in moderate to extreme environmental conditions (endogenous heat load). Regardless of the cause, hyperthermic conditions can lead to the following conditions: Heat Cramps, Heat Exhaustion, or Heat Stroke.

Heat Cramps most commonly occur in the patient who exercises and sweats profusely, and subsequently consumes water without adequate salt. Heat cramps most commonly involve the most heavily exercised muscles. These patients may present with normal temperature but hot sweaty skin with mild tachycardia and normal blood pressure.

Heat Exhaustion presents with minor mental status changes, dizziness, nausea, headache, tachycardia and mild hypotension. Temperatures is less than 103º F. Rapid recovery generally follows saline administration.

Heat EmergenciesHeat Stroke occurs when the patient's thermoregulatory mechanisms break down completely. Body temperature is elevated to extreme levels resulting in multi-system tissue damage, including altered mental status and physiological collapse. Heat stroke usually affects the elderly patient with underlying medical disorders.

Patients with heat stroke usually have dry skin; however, up to 50% of patient's with exertional heat stroke may exhibit persistent sweating. Therefore, the presence of sweating does not preclude the diagnosis. This is a true medical emergency.

When to discontinue work in PPE due to Heat Stress

• Sustained (several minutes) heart rate in excess of 180 bpm minus individual’s (w/normal cardiac performance) age

• Body core is greater than 38.5°C (101.3°F) (38 °C for non-acclimatized workers)

• Recovery heart rate after one minute peak work effort is greater than 110 bpm

• Symptoms of sudden and severe fatigue, nausea, dizziness, or lightheadedness.

• Source: ACGIH

Hand Signals

•Hand gripping throat - Out of air, can't breathe•Grip partner's wrist (or both hands around waist) - Leave area immediately•Hands over head waving in circles - Need assistance•Thumbs up - OK, I am all right, I understand•Thumbs down - No, negative

http://www.osha.gov/Publications/complinks/OSHG-HazWaste/Append.pdf

Donning• Begin with the team member standing:

– Assist with donning an inner suit, inner gloves and outer gloves

• Have the team member sit:– Pull the outer suit up to the knees with boots over feet – do not tape at this

point– Wear additional disposable boot coverings or protectors, if necessary.

• Have the team member stand:– Pull the outer suit up and over the shoulders, – Tape gloves to suit sleeve and boots to suit leg, then – Affix the PAPR power unit belt to waist

• Have the team member sit and await a briefing.

Waiting For Briefing

Donning• When directed have the team member stand:

– Turn the PAPR motor on and place the hood over the head tucking inner cowling into suit collar

– Zipper suit tight and ensure tape/Velcro seals the zipper flap– Place team member’s name and position on tape affixed to the PPE

suit, not the PAPR, usually on the arm or upper leg

• Place the belt buckle in the center of the waist and ensure the wearer can easily access that buckle for emergency purposes.

• Helper should observe wearer for a short period of time to be assured that the wearer is comfortable and the equipment is functioning properly.

Doffing• Doffing team members

– Suited in Standard Precautions PPE - include face shield if possible

• Begin with the Decon Team Member standing.– Advise team member that they do not need to assist you – Use provided towels to remove as much water as practical from suit – Remove PAPR hood – turn off PAPR motor– Unbuckle PAPR blower unit belt and remove – Remove tape from boots and gloves– Remove outer gloves – remove with suit in next step if possible– Remove suit with outer gloves from shoulders down to knees – leave inner gloves on

• Have team member sit:– Remove boots - remove with suit in the next step if possible– Remove suit from legs - ONE LEG AT A TIME– Have team member place feet in a safe location preferably directly into provided foot ware

• Have team member stand:– Have team member remove inner gloves and hand them to you – Have team member move away from your location

PPE Donning/Doffing

Activity

•We show you first.•Then you do it.

• Head • Shoulders• Knees and • Toes and

• Eyes and

• Ears and

• Mouth and

• Nose and

• Hands

Head, Shoulders, Knees and Toes

Post Doffing

• Don appropriate footwear as necessary.• Ensure your vital signs are taken.• Report to your Unit Leader.• Hydrate• Urinate• Rehabilitate including medical monitoring.• Debrief

Suit ConstructionBefore Buying Things to look for:

•Hoods•Cuffs•Elastic

The interface and inter-wrist and inter-feet. •Seams•Zippers•Sizes

Things to consider:•Respiratory

protection•Gloves•Boots •Kneepads

Extremities• Most likely to come in contact with the chemicals– Hands

• Compatibility (Nitrile and butyl appropriate for most chemicals encountered in healthcare)

• Double gloving

– Feet• Compatibility• Steel toed/Steel Shanked if crushing or penetration hazard exists.• Boots, overboots, booties

– To tape or not to tape?

Head, Eye and Ear Protection

• Head - If the incident presents a potential of falling objects, head protection (e.g.; hard hat) that meets the ANSI standards is indicated.

• Eyes and Ears– Use eye protection that meets the ANSI 1987

standard if a hazard exists– Use appropriate ear protection if noise level meets

Action Level

Suit Log Times

Pg II A 35

Review

• Summary of Chapter

• Questions