Program Development Peer-Reviewei HazMat eraenc es K ^ Decontamination & Victim Chain of Survival By Scott Gunderson, Cameron Helikson & Michael Heffner C onsider the following hypothetical scenarios of workplace emergency decontamination incidents involving hazardous materials: A pressurized hose recirculating potassium goid BRIEF cyanide into a clean room HazMat emergencies represent a sigeiectroplating bath breaks nificant response challenge, especially ioose from the ciamps holdwhen employees are exposed and the ing it against the bath wall. response involves a victim. The hose whips around A growing body of literature and I and sprays the corrosive standards guides emergency medical - iiquid onto a nearby emservices (EMS) and hospital profespioyee. She hits the emersionals in HazMat victim response and gency "off" button, and as treatment. But, the SH&E professional the chaos quiets, she and her coworkers realize she is must navigate separate standards: standing in a puddie of platHazWOPER for HazMat emergencies ing solution, with the liquid and standard first aid for HazMat victim dripping from her cleanresponse. room clothing. Her first imWhat strengths each standard may pulse is to go change her have in isolation are lacking when [ clothes in the locker room, coupled with each other or as explicit ' but her supervisor orders preparation for the more advanced reher to an enclosed emersponse that follows when EMS arrives. gency shower stail with a The authors review these standards drain. She walks from the and integrate several key concepts for puddle to the shower, traileffective response to HazMat victim ing a path of wet footprints. emergencies in the workplace to make the most of the critical time hetween At another company, an employee exposure and EMS arrival. employee ioses his hold of a heavy product and I Scott Gunderson, CSP, CHMM, is a safet}' compliance officer at Oregon OSHA, with prior workplace emergency response experience in various industries including semiconductor manufacturing and chemical processing. He has published articles in Professional Safety, Systems Engineering and Journal of System Safety. Gunderson holds a B.A. from Western Oregon University and an M.A. and an M.Eng. from Portland State University. He is an Oregon emergency medical technician (EMT), an American Heart Association Basic Life Support instructor and a professional member of ASSE's Columbia-Willamette Chapter. 40 ProfessionalSafety MARCH 2014 drops it into an acid etching tank. The fuiifront apron, gloves, face shield and goggles protect him from the splashing acid. But, his coworker who has his back turned feeis the acid spiash on his back, buttocks and legs at the gaps between his apron ties. He pulls the handle of the emergency shower, an open unit against the wall, and removes his clothing as acid and rinse water cascade across the floor. Workplace HazMat emergency response is well-defined in standards and regulations such as HazWOPER, and workplace medical emergency response is equally well-defined in practices such as first aid. However, combining the two is complicated because the urgency of first-aid response tends to collide with the systematic and planned sequences of HazWOPER. This article addresses issues around HazMat emergencies with employee exposure, and focuses on safe and effecfive emergency decontamination of HazMat victims in occupational settings such as manufacturing, warehousing and laboratories (see "Maximizing HazMat Victim Care"). The authors have excluded transportation emergencies, nonoccupational exposures, and criminal, combat or terrorism events due to the broad nature of these subjects and their integration with issues such as traffic control, security and tactical operations. Transportation involves potential exposure to the nonoccupational general public, and in the case of highway incidents, the absence of readily available emergency decontamination facili- eron Helikson is the environment, health and safety (EHS) manager at Tosoh Quartz Inc. in Portland, OR. He has been in EHS for 14 years and has specialized in developing emergency response teams and in using technology in EHS. Helikson is an Oregon-licensed EMT-Intermediate and has been a volunteer with the Newberg Fire Department for 19 years. He is an American Heart Association BLS instructor and is a certified in HazMat technician (40-hour), advanced cardiac life support, advanced medical life support and prehospital trauma life support. He holds a B.S. in Business from Portland State Universit)', and has www.asse.org been published in Professional Safety. Helikson is a professional member of ASSE's Columbia-Willamette Chapter. Michael Heffner, B.S., EMT-P, is a captain with the Cit)- of Salem Fire Department where he is assigned to one of Oregon's 13 regional HazMat response teams. He is an Oregon-licensed paramedic and a certified HazMat technician. Heffner teaches emergency medical care, HazMat response and hospital first receiver classes throughout Oregon. He holds a B.S. from Portland State University and Eastern Oregon University. fies such as emergency showers. Addifionally, law enforcement, military or other potential mass casualty emergencies, such as terrorist attacks with chemical weapons, involve even more issues, such as significant public exposure, potentially long periods wifh unidenfified contaminants and ongoing tactical threats (e.g., acfive shoofer and secondary explosives timed for arrival of emergency responders). Magnitude of Problem Agency for Toxic Substances and Disease Regisfry (ATSDR, 2009) surveyed data from 13 sfafes in the firsf half of 2009, cataloging 3,458 HazMat emergencies. These emergencies involved 1,050 victims, of whom 44 died. Of these emergencies, 68% were in fixed facilities, with manufacturing representing the highest number (27%). Of the victims, 91% were in fixed facilities, with employees representing the highest number of victims (44%). In the second half of 2009, six states reported 1,352 HazMat emergencies wdth 319 victims and 8 fatalities. Like the first half of the year, fixed facilities and manufacturing represenfed the highest (99% and 27%, respectively). These fixed facilities again reported the highest number of victims (83%), with employees representing 10% (ATSDR, 2009). HazMat Victim Decontamination Decontamination practices have evolved since the NFPA 472 standard was created and replaced NFPA 471, which spent much of its decontaminafion section on standardized procedures for controlled entry and exit through an established corridor linking the operational areas of the hot zone (e.g., exclusion or contamination area), warm zone (e.g., transition or contamination reducfion area) and cold zone (e.g., support or clean area). Although this separation of operational areas is ideal in principal, NFPA 472 acknowledges the more realistic pofenfial for chaos as emergency responders arrive, with five categories of decontaminafion. 1) Emergency decontamination. "The physical process of im- r mediately reducing contamination of individuals in potentially life-threafening situafions with or without the formal establishment of a decontamination corridor" (NFPA, 2008b). This is what workplace emergency responders perform when they assist an employee in an emergency shower until emergency medical service (EMS) personnel arrive, and it is the primary focus of this article. 2) Gross decontamination. This may be an initial part of emergency decontamination of victims, or the first step in technical deconfaminafion of responders exifing the hot zone through a supervised decontamination corridor. In both cases, as high a percentage as feasible of contaminafion is rinsed off prior fo further deconfaminafion. 3) Mass decontamination. "The physical process of reducing or removing surface contaminants from large numbers of vicfims in pofentially lifethreatening situations in the fastest time possible" (NFPA, 2008b). This may be an emergency decontamination or a gross decontamination, and simply describes the fact that more than one person undergoes decontamination. Although typically performed by FMS personnel, the authors are aware of two separate workplace incidents with two exposed employees each, forcing fhem to each walk to separate emergency showers; in one incident. Maximizing HazMat Victim Care Transitioning From Workplace Emergency Responders to Emergency Medical Services SH&E professionals can do much to establish safe and effective HazMat victim response and strong links in the response chain between workplace responders and emergency medical services (EMS). Prevention remains the best sfrafegy, and design for safety and training for safe operafion is paramount, but a solid emergency response program should at a minimum include the following: Hardware. Functioning and appropriately located emergency eyewash and shower systems, PPE for employees and workplace responders, first-aid supplies and response supplies such as absorbents on reserve and dedicated for emergency-only use. All hardware must be inspected regularly, maintained and tested periodically. Information. Safet)' data sheets and a sitespecific emergency response plan at a minimum, ideally including HazMat-specific procedures for highly hazardous maferials such as hydrofiuoric acid fhat require rapid response. Internal communications. HazMaf victims must be able fo summon assistance and workplace responders musf be able fo gather feam members. Depending on operafion size and complexity, internal communications can be as simple as verbally shouting across the room, using handheld radios or public address systems, or emergency shower fiow alarms con- nected to central alarm systems with security personnel on staff able fo monitor and notify workplace responders. External communications. Typically 9-1-1 in fhe U.S. If sife telephones require dialing a special number for an outside line, then this musf be included in employee training. Caller identification may or may nof be present at the 9-1-1 call center, and the physical address must be either known by employees or posted in visible locations in the workplace so thaf it can be communicated fo the dispatcher. Coordinating with EMS upon arrival. Work- place emergency responders must greet EMS upon arrival, direct fhem to the specific locafion of fhe emergency and rapidly provide accurate informafion about the emergency. Emergency locations may be far removed from typical entry points such as front gates, front doors or shipping bays. Addifionally, fire and ambulance services may arrive separately, and fhe greef-direcf-communicafe sequence may need fo be repeafed. Training. Workplace emergency responders musf know fhese procedures, fhe proper use of their resources and effective communication to EMS during an emergency. Workplace emergency responders must also understand the role of EMS and how workplace responders and EMS can best work together on site. www.asse.org MARCH 2014 ProfessionalSafety 4 1 r Table 1 such as soaps and detergents, and, depending on the protocols of the responding agency, irrigation and/or suction of nasal and oral cavities as needed. Personnel Role Expected levels of contamination The transition from emergency Workplace emergency Initial response; notify EMS; High, both scene and victim(s) decontamination of HazMat responders emergency decontamination victims by workplace emerEmergency medical Arrive at scene; assume control of High, transitioning to as IOV as gency responders to techniservices (EMS) response; emergency, mass, gross possible for victim(s) cal decontamination by EMS personnel and/or technical decontamination; personnel is discussed in more emergency medical treatment; detail. transport victim(s) 5) Definitive decontamiHospital personnel Receive victim(s); definitive Low, with exception of selfnation. This is performed in decontamination and treatment transported "walking wounded"; the hospital as part of treatemergency and technical ment, and it is outside the decontamination capabilities but scope of this article, as well as preference for receipt of outside the scope of NFPA 472 decontaminated victim(s) and NFPA 473. Table 1 summarizes typical roles, responsibilities and exthe spill size in the facility was doubled with drops pectations for each level of decontamination from and wet footprints from the emergency scene to workplace emergency responders to EMS personnel and, finally, to hospital personnel. the two showers. 4) Technical decontamination. This may describe either the controlled decontamination of HazMat Victim Care The following sections describe HazMat vicresponders leaving through the decontamination corridor (NFPA, 2008a), ot thorough decontami- tim care in reverse chronological order to provide nation of HazMat victims for emergency medical context for the final section on emergency decontreatment on site and/or prior to releasing for frans- tamination by workplace emergency responders. portation and further treatment (NFPA, 2008b). The authors believe that workplace emergency Technical decontamination of HazMat victims responders perform better if they understand the typically involves significantly more surface rins- expectations and actions of the higher-level reing than occurs in a workplace emergency shower, sponders with whom they will interact. and may involve use of brushes, cleaning agents HazMat Emergency & Victim Decontamination Responsibilities r Hospital Table 2 Summary of NFPA 473 Patient Priority Levels' Contamination level Heavy contamination; highly toxic substance Heavy contamination; low-toxicity substance Low contamination; highly toxic substance Low contamination; low-toxicity substance Medically critical Combined priorities Medically unstable Decontaminate first Medically stable Decontaminate first Combined priorities Combined priorities Combined priorities Decontaminate first Decontaminate first Medical care first Medical care first Combined priorities ^dical care first JVofe. "Summary of NFPA 473 patient priority levels for immediate decontamination, immediate medical care or combined priorities. Medically critical is defined as compromised airway, serious shock, cardiac arrest and/or lifethreatening trauma or bums. Medically unstable is defined as shortness of breath, unstable vital signs, altered levels of consciousness and/or significant trauma or burns. Medically stable /s defined as stable vital signs, no altered level of consciousness and/or no significant trauma or burns. Adapted f-om Table A.5.4.2, NFPA 473, Standard for Competencies for EMS Personnel Responding to Hazardous Materials/Weapons of Mass Destruction Incidents, by NFPA, 2008, Quincy, MA: NFPA. 4 2 ProfessionalSafety MARCH 2014 www.asse.org Definitive treatment varies with the severity of exposure, the hazard of fhe substance, positive idenfificaon of the substance and the treating physician's diagnosis. Whether simple observation and evaluation, or more advanced decontamination and treatment, it wiU most likely occur in the hospital (Currance, Clements & Bronstien, 2007). EMS operating under written prestanding orders and medical direction typically include f Table 3 Transition Issues Between Workplace Emergency Responders & EMS Barriers Competency of workplace emergency responders Understanding by workplace emergency responders of EMS procedures EMS familiarity of site and trust in workplace emergency responder competency physician review of victims as a standard conclusion in their protocols for HazMat exposures. It is rare for a HazMat victim emergency to end with EMS personnel not transporting the victim for further evaluation and care. Delayed or incomplete scene size-up by One critical issue for the EMS upon arrival hospital is secondary conDelayed or incomplete first impression tamination, which occurs by EMS of HAZMAT victim upon arrival when hospital personnel, other patients and property are exposed to hazardous materials due to improper decontamination of victims transported to the facility. Where EMS personnel are designated as first responders with high levels of HazMat response training, hospital personnel are typically designated as first receivers, potentially with less training in emergency decontamination, due to the assumption that EMS personnel will perform proper decontamination prior to transportation (OSHA, 2005; 2008b). Strong communication between EMS and hospital personnel, as well as good technical decontamination practices in the field, can prevent secondary contamination (Horton, Berkowitz & Kaye, 2003). NFPA 473 strongly emphasizes HazMat victim decontamination as soon as possible and certainly prior to transportation: "It is unwise to accept a contaminated patient into a transport unit or to be unsure of the level of decontamination performed. A poor decision in the field can have significant ramifications at the door of the hospital" (Trebisacci, 2008, p. 485). Solutions Effective training Effective training, emergency preplanning meetings with EMS, joint exercises with EMS Site tours, emergency preplanning with site representatives, joint exercises with workplace emergency responders, workplace emergency responders provide site emergency response procedures and other information (e.g., floor plans, SDS, etc.) to EMS upon arrival Workplace emergency responders mark safe vs. hazardous areas prior to EMS arrival Workplace emergency responders have critical information ready for transfer to EMS prior to EMS arrival (e.g., incident summary, SDS, time HazMat victim in emergency shower, etc.) Photo 1 : Mass decontamination. EMS responders have erected an inflatable mass decontamination tent to process victims through tv\\/o separate corridors, one for male and one for female victims, who will place their clothing and personal belongings in plastic bags for tracking and further testing. Emergency Medical Services Horrific case studies of ambulance contamination following a fatal exposure to hydrofluoric acid and an emergency department shutdown following the arrival of a pesticide-contaminated patient illustrate the reasons why healthcare professionals emphasize early and thorough victim decontamination (Vogt & Sorensen, 2002). Contamination to personnel and hardware is a real threat to everyone in the emergency response chain; this threat is key to EMS personnel balancing responder safety and victim care. NFPA 472 and 473, as well as other sources, give priority to EMS personnel safety (NAEMT & American College of Surgeons Committee on Trauma, 2007; OSHA, 2009). EMS personnel perform an initial scene size-up on arrival for their own safety and to prevent increasing the magnitude of the emergency by having responders become additional victims. The actions and communications of workplace emergency responders before and during EMS arrival can either facilitate a smooth transition or cause delays as EMS personnel review the scene for their own protection. Photo 2: Technical decontamination of EMS responder. EMS responders render their PPE safe by systematically rinsing, washing and re-rinsing with soap and water in the warm zone of a decontamination corridor. www.asse.org MARCH 2014 ProfessionalSaiety 4 3 f Table 4 Standards Related to HazMat Emergencies & HazMat Victim Response Standard Hazard Communication OSHA 1910.1200 Target audience All workplace employees Emergency Action Plan OSHA 1910.38 Medical and First Aid OSHA 1910.151 All workplace employees Hazardous Waste Operations and Emergency Response OSHA 1910.120 Contingency Plan and Emergency Procedures EPA 265 Subpart D Workplace emergency responders NFPA471 NFPA472 Workplace emergency responders Workplace emergency responders Workplace and public emergency responders Emergency medical service (EMS) personnel NFPA 473 Photo 3: Technical decontamination of victim (training exercise with manikin). EiVIS responders have removed and contained the victim's clothing and jewelry to significantly reduce external contamination. Next, EMS responders will systematically rinse, wash and re-rinse both the front and back side of a victim before preparing him/her for ambulance transport to the appropriate receiving hospital. Workplace Emergency Response The HazWOPER standard is the cornerstone of most workplace HazMat emergency response plans (OSHA, 2008a). The advanced planning and education of employees required by this standard contributes to emergency prevention and response, and it is the knowledge of facility employees who work with hazardous materials that can help prevent secondary contamination in the EMS and hospital systems (Berkowitz, Horton & Kaye, 2004). Wliile the HazWOPER standard thoroughly covers HazMat scene safety and directs attenfion to issues such as spill response and recovery, its coverage of emergency decontamination and HazMat victim care is limited, even though the standard contains provisions that require planning for medical monitoring andfirstaid. Where HazWOPER lacks specifics on emergency decontamination and HazMat victim care, standard first aid and other emergency decontamination references provide few details on these subjects and typically exclude reference to site control and the wider response. First-aid training courses Photo 4: Definitive decontamination of victim (training exercise with manikin). Hospital first receivers in Level C PPE provide definitive decontamination of a HazMat victim before admission into the facility to avoid secondary contamination of hospital personnel, other patients and equipment. 44 ProfessionalSafety MARCH 2014 The authors have witnessed EMS personnel refuse to enSummary ter HazMat emergenq? scenes Basic training requirements on safe use as because they were not conwell as emergency response to hazardous fident about the accuracy of materials in the workplace information from workplace Basic emergency requirements (e.g., emergency responders, resultnotification, evacuation) ing in delayed medical care to Requirements for first-aid supplies, first-aid training and emergency eyewash/showers HazMat victims. (see also ASTM 2009 and ANSI 2009) Once confident that they Detailed requirements for HazMat can safely respond, EMS peremergency response, including long-term sonnel will assume control cleanup of contaminated sites of the scene for entry and reDetailed requirements specific to hazardous sponse, including victim care. waste, including documentation of plans and For HazMat victim emergenadvanced communications with local cies. Table 2 (p. 42) summarizauthorities (e.g., fire, EMS) es the priorities for immediate Withdrawn (see NFPA 472 and NFPA 473) decontamination, immediCompetencies for HazMat emergency responders ate medical care or combined Competencies for EMS personnel responding priorities. to HazMat incidents, with emphasis on Workplace emergency reHazMat victim care at emergency site and sponders can either facilitate during transportation to hospital or delay EMS response. The authors believe that early attention to proper emergency decontamination and accurate information will permit EMS personnel to more quickly begin medical care for victims. Additionally, preplanning, including tours and training drills, between site and EMS representatives can improve EMS knowledge of the site, its hazards and the capabilities of the workplace responders. This builds working relationships, and improves communications and efficiency during the critical transition between workplace responder and EMS control of emergency operations (Table 3, p. 43). www.asse.org emphasize emergency decontaminafion as the primary action for HazMaf exposure: remove fhe contaminants from fhe vicfim as soon as possible (Markenson, Eerguson, Chameides, et al., 2010; Koenig, 2003). Many SH&E professionals are familiar with boilerplate language in the typical safefy data sheet, advising 15-minute eye and skin flushing and medical care if employees are exposed. Alfhough general in their language, fhe aufhors agree wifh the references and standards for workplace first aid and emergency eyewash and shower equipment that recommend site- and substance-specific emergency training for employees, hazard-specific procedures and hazard-specific response hardware (ANSI, 2009; ASTM, 2009; OSHA, 2006). Table 4 summarizes relationships among these various standards related to HazMat emergencies and victim response. Cardiac Chain of Survival While individually strong, numerous HazMat emergency and HazMat vicfim response sources are either silent or only provide hints about how they can work together. The cardiac chain of survival provides a comparison for cardiac emergencies; if is explicit on the connection between victim care and the wider response (Travers, Rea, Bobrow, et al, 2010). 1) early notification to EMS; 2) early CPR; 3) early defibrillation; 4) early advanced emergency medical care. Figure 1 Emergency Decontamination Performance Support Tool for Site Emergency Responders Location address: 1234 Street, City, State Location phone number: (555) 555-5555 Department/Area: Metal Finishing Primary entry/EMS arrival location: Shipping/receiving Name(s] of exposed employee(s): Name(s) of exposed chemical(s): Time employee(s) in emergency shower/eyewash: Name Time 9-1-1 notified: Site emergency responders notified: Spill scene identified/marked: SDS printed/pulled for EMS: Emergency responder(s] to primary entry for EMS: HazMat Victim Chain of Survival If the workplace emergency and victim response standards suffer in isolation, then a HazMat victim chain of survival, similar to the established cardiac chain of survival, provides a conceptual fra;mework for bridging these critical emergency response steps: 1) Early notification to EMS: Every second delayed before calling EMS (e.g., 9-1-1 in most U.S. locations) results in delayed dispatch and arrival. As with cardiac and other medical emergencies, workplace responders to HazMat victim emergencies can fall into tunnel vision performing immediate response activities. Early notification allows site responders to get EMS en route before proceeding fo more complicated tasks such as establishing hot, warm and cold operational zones. 2) Early emergency decontamination: Every delayed second starting emergency decontamination allows hazardous materials to injure exposed employees by burning, absorption or inhalation. The span between these first and second steps should be as short as possible, and preferably done simulfaneously by multiple employees and/or workplace emergency response team members. 3) Early scene control and HazMat characteriza- fion: Uncontrolled scenes can permit unauthorized entry and potential exposure to other employees. Gaps in informafion or communication lapses can delay immediately required response actions such as topical application of calcium gluconate for hydrofluoric acid exposure, topical application of polyefhylene glycol for phenol exposure, administration of hydrogen cyanide antidote or other applicable treatments. 4) Accurate communication to EMS: Gaps in informafion, if unresolved on EMS arrival, can cause furfher delays in technical decontamination, medical stabilization, ambulance transportation, definitive decontamination and treatment. Like the cardiac chain of survival, the HazMat victim chain of survival is relatively simple, facilifafing fraining and retention for workplace emergency responders. The concepts easily work their way into a performance support tool (Eigure 1), which can be added to site emergency response hardware (e.g., spill equipment storage units, firstaid kits) mounted at walls near emergency eyewash and shower equipment. www.asse.org MARCH 2014 ProfessionalSafety 45 Conclusion Koenig, K.L. (2003, Sept.). Strip and shower: The duck and cover for the 21st century. Annals of Emergency Medicine, 42(3), 391-394. A nonroutine task with inadequate energy isoMarkenson, D., Ferguson, J.D., Chameides, L., lation results in a pressurized chemical pipe et al. (2010). Part 17: First aid: 2010 American Heart spraying liquid onto an employee. He screams Association and American Red Cross guidelines for first and staggers into an emergency shower as aid. Circulation, 322(suppl 3), S934-S946. others close the valve. His colleagues refer to NAEMT & American College of Surgeons Coma checklist posted outside the shower, begin mittee on Trauma (2007). PHTLS: Prehospital trauma to page site emergency responders and call life support. Burlington, MA: Jones & Battlett Learning. 9-1-1. The supervisor directs one employee to NFPA. (2002). Recommended practice for responding print the safety data sheef, another employee to to hazardous materials incidents (NFPA 471). Quincy, mark the floor contamination with traffic cones MA: Author. and caution tape, and another employee to NFPA. (2008a). Standard for competence of responders to hazardous materials/weapons of mass destruction go to the primary entrance to direct EMS perincidents (NFPA 472). Quincy, MA: Author. sonnel to the emergency scene. The superviNFPA. (2008b). Standard for competencies for EMS sor and other employees tell the victim to stay personnel responding to hazardous materials/weapons in the shower and that EMS is on the way. of mass destruction incidents (NFPA 473). Quincy, MA: When EMS personnel arrive, they drive to the Author. employee waving at the primary entrance. InOSHA. (2005). Best practices for hospital-based first side, the supervisor briefs EMS personnel on receivers of victims from mass casualty incidents involvthe emergency and the hazardous material ining the release of hazardous materials (QSHA 3249-98N). volved, points out the marked spill zone and Retrieved from www.osha.gov/Publications/osha3249 hands them the safety data sheet. Aware of the .pdf hazards, the hazardous area and the amount OSHA. (2006). Best practices guide: Fundamentals of a of time the victim has been in the shower, EMS workplace first-aid program (QSHA 3317-06N). Retrieved personnel begin their response in an environfrom www.osha.gov/Publications/OSHA3317first ment of rapid emergency decontamination and -aid.pdf clearly communicated information promotOSHA. (2008a). Hazardous waste operations and emering responder safety and prompt victim care. gency response (QSHA 3114-07R). Retrieved from www Workplace emergency responders who complete .osha.gov/Publications/OSHA3114/OSHA-3114-haz such a performance support tool, have all the ele- woper.pdf OSHA. (2008b). Hospitals and community emerments in place for rapid notification to internal and gency response: What you need to know (QSHA 3152external responders, rapid emergency decontami- 3R). Retrieved from www.osha.gov/Publications/ nation of HazMat victims and accurate information OSHA3152/3152-hospitals.pdf to arriving EMS personnel who can proceed to vicOSHA. (2009). Best practices for protecting EMS tim care with fewer delays for self-protective scene responders during treatment and transport of victims of evaluation. PS hazardous substance releases (OSHA 3370-11). Retrieved from www.osha.gov/Publications/OSHA3370-pro tecting-EMS-respondersSM.pdf References Travers, A.H., Rea, T.D., Bobrow, B.J., et al. (2010). Part 4: CPR overview: 2010 American Heart AssociaAgency for Toxic Substances and Disease Registry (ATSDR). (2009). Hazardous substances emergency tion guidelines for cardiopulmonary resuscitation and events surveillance: Annual report 2009. Retrieved from emergency cardiovascular care. Circulation, n2(suppl 3), S676-S684. www.atsdr.cdc.gov/HS/HSEES/HSEES%202009%20 Trebisacci, D. (Ed.). (2008). Hazardous materials/ report%20final%2008%2017%2011_9.pdf weapons of mass destruction response handbook. Quincy, ANSI/ISEA. (2009). American national standard for MA: NFPA. emergency eyewash and shower equipment (ANSI/ Vogt, B.M. & Sorensen, J.H. (2002). How clean is ISEA Z358.1-2009). Arlington, VA: Author. safe? Improving the effectiveness of decontamination of ASTM International. (2009). Standard guide for destructures and people following chemical and biological fining the performance of first-aid providers in occupaincidents (Report No. ORNL/TM-2002/178). Retrieved tional settings (ASTM F2171-02). West Conshohocken, from http://emc.ornl.gov/publications/PDF/How PA: Author. _Clean_is_Safe.pdf Berkowitz, Z., Horton, D.K. & Kaye, W.E. (2004). Hazardous substances releases causing fatalities and/ or people transported to hospitals: Rural/agricultural vs. other areas. Prehospital and Disaster Medicine, 19 QulySept. 2004). Disclaimer Currance, P.L., Clements, B. & Bronstein, A.C. The opinions in this article are those of the (2007). Emergency care for hazardous materials exposure. authors and do not represent official positions St. Louis, MO: Mosby Elsevier. of Oregon OSHA or any affiliated agency. Horton, D.K., Berkowitz, Z. & Kaye, W.E. (2003). Secondary contamination of ED personnel from hazardous materials events, 1995-2001. The American Journal of Emergency Medicine, 21(3), 199-204. 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