Driving behaviors associated with emergency service vehicle crashes in the U.S. fire service.

OBJECTIVE: Emergency service vehicle incidents are a leading cause of firefighter fatalities and are also hazardous to civilian road users. Modifiable driving behaviors may be associated with emergency service vehicle incidents. The goal of this study was to use telematics to identify driving behaviors associated with crashes in the fire service. METHODS: Forty-three emergency service vehicles in 2 fire departments were equipped with telematics devices (12 in Department A and 31 in Department B). The devices collected vehicle coordinates, speed, and g forces, which were monitored for exceptions to driving rules established by the fire departments regarding speeding, harsh braking, and hard cornering. Fire department administrative reports were used to identify vehicles involved in crashes and merged with daily telematics data. Penalized logistic regression was used to identify driving rules associated with crashes. Least absolute shrinkage and selection operator (LASSO) regression was used to generate a telematics-based risk index for emergency service vehicle incidents. RESULTS: Nearly 1.1 million km of driving data and 44 crashes were recorded among the 2 departments during the study. Harsh braking was associated with increased odds of crash in Department A (odds ratio [OR] = 2.22; 95% confidence interval [CI], 1.09-4.51) and Department B (OR = 1.55; 95% CI, 1.12-2.15). For every kilometer of nonemergency speeding, the odds of crash increased by 35% in Department A (OR = 1.35; 95% CI, 1.03-1.77) and by over 2-fold in Department B (OR = 2.09; 95% CI, 1.19-3.66). In Department B, hard cornering (OR = 1.14; 95% CI, 1.03-1.26) and emergency speeding (OR = 1.65; 95% CI, 1.06-2.57) were also associated with increased odds of crash. The final LASSO risk index model had a sensitivity of 73% and specificity of 57%. CONCLUSIONS: Harsh braking and excessive speeding were driving behaviors most associated with crash in the fire service. Telematics may be a useful tool for monitoring driver safety in the fire service.

Occupational PAH exposures during prescribed pile burns.

Wildland firefighters are exposed to particulate matter and gases containing polycyclic aromatic hydrocarbons (PAHs), many of which are known carcinogens. Our objective was to evaluate the extent of firefighter exposure to particulate and PAHs during prescribed pile burns of mainly ponderosa pine slash and determine whether these exposures were correlated with changes in urinary 1-hydroxypyrene (1-HP), a PAH metabolite. Personal and area sampling for particulate and PAH exposures were conducted on the White Mountain Apache Tribe reservation, working with 21 Bureau of Indian Affairs/Fort Apache Agency wildland firefighters during the fall of 2006. Urine samples were collected pre- and post-exposure and pulmonary function was measured. Personal PAH exposures were detectable for only 3 of 16 PAHs analyzed: naphthalene, phenanthrene, and fluorene, all of which were identified only in vapor-phase samples. Condensed-phase PAHs were detected in PM2.5 area samples (20 of 21 PAHs analyzed were detected, all but naphthalene) at concentrations below 1 microg m(-3). The total PAH/PM2.5 mass fractions were roughly a factor of two higher during smoldering (1.06 +/- 0.15) than ignition (0.55 +/- 0.04 microg mg(-1)). There were no significant changes in urinary 1-HP or pulmonary function following exposure to pile burning. In summary, PAH exposures were low in pile burns, and urinary testing for a PAH metabolite failed to show a significant difference between baseline and post-exposure measurements.

Exercise alters serum pneumoprotein concentrations.

To determine the effect of exercise on serum levels of Clara cell protein (CC16) and surfactant-associated protein A (SP-A), serum was collected from 14 healthy subjects 1 h after maximal and sub-maximal exercise. Healthy volunteers participated on separate occasions in a control (no exercise) session, simulated firefighting tasks for 30 min (n=14), and intermittent treadmill exercise at near maximal heart rates for 60 min (n=10). Serum samples and induced sputum samples were collected 1 h post exercise. Induced sputum fluid was analyzed for tumor necrosis factor alpha (TNF-alpha), an inflammatory mediator produced by pulmonary macrophages. Serum CC16 levels increased significantly with both firefighting tasks (15+/-13 microg/L vs. 9+/-4 microg/L, P=0.047) and treadmill exercise (15+/-8 microg/L vs. 9+/-4 microg/L, P<0.01). Serum SP-A concentrations did not change compared to control with either firefighting tasks (247+/-106 microg/L vs. 247+/-96 microg/L, P=0.84) or treadmill exercise (251+/-89 microg/L vs. 285+/-87 microg/L, P=0.44). TNF-alpha concentrations in sputum supernatant showed no significant difference from controls. These results show an increase in serum CC16 after exercise. This must be considered when utilizing serum CC16 to determine the presence of lung injury in settings that combine exercise and toxic exposures.

Phosphine exposure from a methamphetamine laboratory investigation.

BACKGROUND: Law enforcement personnel may be exposed to a variety of hazardous materials during investigation of clandestine methamphetamine laboratories. CASE REPORT: A 28-year-old forensic specialist investigating a methamphetamine lab was exposed to phosphine without respiratory protection at approximately 2.7 ppm for 20-30 minutes. Shortly following exposure she developed dizziness, cough, headache, and diarrhea, although initial medical evaluation within 1-2 hours was unremarkable. Pulmonary examination at 4 and 7 days postexposure revealed bilateral rhonchi. The cough was worse with exertion, and persisted despite beta-agonist and steroid inhaler treatment. CONCLUSIONS: This is apparently the first published case of symptomatic occupational phosphine exposure in a law enforcement officer during investigation of a methamphetamine laboratory. If phosphine exposure is suspected, the possibility of delayed pulmonary toxicity should be recognized.

Risk factors for adverse health effects following hazardous materials incidents.

To identify risk factors for persistent morbidity, we conducted a prospective study of individuals involved in hazardous materials incidents reported to the Washington Poison Center. Between December 1997 and October 1999, 202 subjects in 87 incidents were surveyed by telephone. Medical symptoms persisting for a minimum of 8 days after the incident were reported in 51 (25%) subjects, and 18 (9%) left work or school for more than 2 days because of the exposure. Medical intervention was reported in 46 (58%) of 79 subjects for whom medical records were available, and objective abnormalities were found in 57 (72%). Multiple logistic regression analysis indicated that subjects with dermal exposures, three or more alcoholic drinks per week, and previous use of psychiatric medications were more likely to report persistent symptoms. Divorced, widowed, or separated subjects, asthmatic subjects, and those having initial dermal symptoms were more likely to miss work or school for more than 2 days. Of patients evaluated at a health care facility, subjects with preexisting hypertension were more likely to receive medical treatment or have objective medical findings, whereas those with inhalation exposures and those decontaminated at the scene were less likely to be treated or have abnormalities. In our study, both incident and individual factors were predictive of adverse health effects, and these findings should be considered in planning the care of patients involved in hazardous materials incidents.

Adverse respiratory effects following overhaul in firefighters.

Overhaul is the stage in which firefighters search for and extinguish possible sources of reignition. It is common practice not to wear respiratory protection during overhaul. Fifty-one firefighters in two groups, 25 without respiratory protection and 26 wearing cartridge respirators, were monitored for exposure to products of combustion and changes in spirometric measurements and lung permeability following overhaul of a structural fire. Testing at baseline and 1 hour after overhaul included forced vital capacity (FVC), forced expiratory volume in one second (FEV1), serum Clara cell protein (CC16), and serum surfactant-associated protein A (SP-A). Overhaul increased CC16 in both groups, indicating increased alveolarcapillary membrane permeability. Contrary to expectations, SP-A increased and FVC and FEV1 decreased in the firefighters wearing cartridge respirators. Changes in FEV1, CC16, and SP-A were associated with concentrations of specific products of combustion or carboxyhemoglobin levels. Firefighter exposures during overhaul have the potential to cause changes in spirometric measurements and lung permeability, and self-contained breathing apparatus should be worn during overhaul to prevent lung injury.

Hazardous materials events: evaluation of transport to health care facility and evacuation decisions.

The study objective was to analyze hazardous materials event and victim factors associated with transportation of victims to a health care facility, and evacuation or shelter-in-place of nearby populations. A retrospective review was conducted on hazardous materials events in Washington State from 1993 to 1997. Bivariate and multiple logistic regression were used to identify risk factors for transportation, evacuation, and shelter-in-place. Over five years, 2,654 victims from 457 events were reported, with 1,859 (70%) transported to a health care facility. Evacuation occurred in 279 (61%) events and shelter-in-place in 14 (3%) events. After excluding 14 deaths, regression analysis indicated that victims with trauma (OR 5.87, 95% CI 1.41-24.5), thermal burns (6.90, 1.15-41.3), dizziness/other CNS symptoms (1.59, 1.00-2.54), and headache (1.54, 1.01-2.35) were most likely to be transported. Chemical releases inside buildings (2.09, 1.06-4.10, compared with transportation events), and involving 3-5 victims (2.86, 1.54-5.31, compared to 1 victim) or > or =6 victims (8.74, 4.01-19.0), were most likely to involve evacuation or shelter-in-place. Events involving sulfuric acid (0.15, 0.05-0.49) and sodium hydroxide (0.19, 0.04-0.94) were least likely to involve evacuation or shelter-in-place. Prehospital decisions to transport victims to a health care facility and evacuate or shelter-in-place nearby populations are associated with event and victim factors. Further research is needed to determine if these factors also predict need for medical care or removal from exposure, and to develop evidence-based prehospital care protocols for hazardous materials exposure victims.

Characterization of firefighter exposures during fire overhaul.

Previous studies have characterized firefighter exposures during fire suppression. However, minimal information is available regarding firefighter exposures during overhaul, when firefighters look for hidden fire inside attics, ceilings, and walls, often without respiratory protection. A comprehensive air monitoring study was conducted to characterize City of Phoenix firefighter exposures during the overhaul phase of 25 structure fires. Personal samples were collected for aldehydes; benzene; toluene; ethyl benzene; xylene; hydrochloric acid; polynuclear aromatic hydrocarbons (PNA); respirable dust; and hydrogen cyanide (HCN). Gas analyzers were employed to continuously monitor carbon monoxide (CO), HCN, nitrogen dioxide (NO2), and sulfur dioxide (SO2). Area samples were collected for asbestos, metals (Cd, Cr, Pb), and total dust. During overhaul the following exceeded published ceiling values: acrolein (American Conference of Governmental Industrial Hygienists [ACGIH] 0.1 ppm) at 1 fire; CO (National Institute for Occupational Safety and Health [NIOSH] 200 ppm) at 5 fires; formaldehyde (NIOSH 0.1 ppm) at 22 fires; and glutaraldehyde (ACGIH 0.05 ppm) at 5 fires. In addition, the following exceeded published short-term exposure limit values: benzene (NIOSH 1 ppm) at two fires, NO2 (NIOSH 1 ppm) at two fires, and SO2 (ACGIH 5 ppm) at five fires. On an additive effects basis, PNA concentrations exceeded the NIOSH recommended exposure limits (0.1 mg/M3) for coal tar pitch volatiles at two fires. Maximum concentrations of other sampled substances were below their respective permissible exposure limits. Initial 10-min average CO concentrations did not predict concentrations of other products of combustion. The results indicate that firefighters should use respiratory protection during overhaul. In addition, these findings suggest that CO should not be used as an indicator gas for other contaminants found in this atmosphere.

Hazardous materials events: an industrial comparison.

Identifying industries at high risk for hazardous materials releases can facilitate prevention and preparation for such events. A retrospective review by Standard Industrial Classification (SIC) codes was conducted on non-petroleum hazardous materials emergency events from 1993 to 1995 and collected by the Washington State Department of Health in a program supported by the Agency for Toxic Substances and Disease Registry. Annual US Census data were used to determine the number of facilities and employees by SIC code in the state of Washington. SIC codes with the most total events and events per 10,000 employees were ranked and characterized by type of releases. In 3 years, 1269 events were recorded, with 294 involving human victims. Industries with the highest average annual number of events per 10,000 employees were agricultural chemical manufacturing (142); petroleum refining (122); industrial and miscellaneous chemical manufacturing (56); electric light and power (54); and pulp, paper, and paperboard mills (39). Industries with high rates of hazardous materials emergency events should continue to develop methods of preventing these releases.

Fumigant-related illnesses: Washington State's five-year experience.

OBJECTIVE: Exposure to fumigants may have severe or persistent health effects. Washington State's fumigant-related illnesses were reviewed to better understand the circumstances surrounding exposure and resultant health effects. METHODS: Fumigant-related illnesses reported to and investigated by the Washington State Department of Health were reviewed. Illnesses considered by Department of Health to be definitely, probably, or possibly related to pesticide exposure were then analyzed. RESULTS: From 1992-1996, 39 (3.3%) of 1192 definite, probable, or possible cases of pesticide-related illnesses involved exposures to fumigants. Fumigant exposures during this period were to aluminum phosphide (15), methyl bromide (12), metam-sodium (9), and zinc phosphide (3). Symptoms included respiratory problems and eye and/or skin irritation for the majority of exposures, and no deaths were reported. The nature of exposure for these cases included exposure to applicators (17), reentry into a fumigated structure (9), improper storage or disposal (6), reentry into treated agricultural fields (4), drift from treated fields (2), and other (1). CONCLUSIONS: Review of fumigant exposures should be used to prevent future events through continued enforcement of established regulations and training of applicators.

Hyperventilation following a large-scale hazardous-materials incident.

Actual or perceived exposure to hazardous materials may result in physiologic and psychological effects. However, hyperventilation following such exposures has not previously been reported. After a large-scale industrial release of oxides of nitrogen, five (29%) of 17 patients evaluated at a major trauma center were hyperventilating, as defined by arterial PCO2 <33 mm Hg, and nine patients (53%) had arterial PCO2 <37 mm Hg. First responders (rescue team members and paramedics) had a higher rate of hyperventilation than other occupational groups. Age, gender, marital status, decontamination, and mode of arrival were not significantly associated with hyperventilation, although marital status approached significance. This study suggests that hyperventilation may be a common reaction after hazardous-materials incidents, and that certain populations may be at increased risk for this condition.

Emergency department hazardous materials protocol for contaminated patients.

Emergency department handling and treatment of chemically contaminated patients can have potentially serious consequences. Medical staff can be exposed to hazardous chemicals through dermal contact or inhalation of volatile compounds or particulate matter. Exposure can result in symptomatic illness from either a direct chemical toxic effect or an odor-mediated psychologic response. Either situation can severely affect ED function and lead to facility evacuation. The Joint Commission on Accreditation of Healthcare Organizations standards and the Occupational Safety and Health Administration regulations for participation in community hazardous materials incident emergency response plans require hospital EDs to prepare for hazardous materials incidents. This study provides a template protocol for ED preparation for and treatment of patients exposed to hazardous materials.

Calls on reproductive and developmental toxicants to a regional poison center.

We sought to characterize calls received by a regional Poison Center concerning reproductive hazards and to assess the quality of the responses. Data was extracted for a 3 mo period from all calls regarding reproductive or in utero developmental effects. The Poison Center responses were evaluated based on completeness of information gathered and final recommendations made. Two hundred seventy-one calls regarding 335 products were received. Ninety-seven percent of the calls concerned exposures during a pregnancy. Fifty-nine percent of the substances of concern were drugs; 32% were other chemicals; 7% were biological agents. Eleven percent of the exposures were occupational; 22% were environmental. Thirty-four percent of the exposures had not yet occurred. Sixty-two percent were characterized as no or minimal risk. For 13% of exposures, callers were advised to avoid initiating or continuing the exposure. Callers were referred to physicians or specialty services for 11% of exposures. The majority of responses were felt to be appropriate. Problematic areas included inconsistent advice and lack of referral. Discussion of exposures in light of other risk factors for and background rates of adverse reproductive outcomes, as well as more frequent referral to a specialist with expertise in reproductive toxicology was recommended.

Hospital evacuations due to hazardous materials incidents.

In a previous study 12 Washington State hospitals reported evacuations due to hazardous materials incidents. A telephone survey was conducted to further describe these incidents. Ten hospitals responded to the survey, including one institution reporting two incidents. The incidents included threatened explosions or releases in three cases and actual chemical exposures in eight cases. The actual exposures included irritant gases from mixtures of cleaners in two cases, an unknown exposure in one case, and a variety of other chemicals or products in the remaining cases. Seven of the 11 incidents resulted in emergency department (ED) evacuation. Two incidents involved secondary contamination of ED staff from treatment of patients with chemical exposures who were not decontaminated prior to arrival. Fire department personnel assisted in the majority of incidents. Review of these cases provides useful information for planning drills to test emergency preparedness as required under Joint Commission on Accreditation of Healthcare Organizations standards.

Longitudinal decline in measured firefighter single-breath diffusing capacity of carbon monoxide values. A respiratory surveillance dilemma.

Seattle firefighters participate in a voluntary annual medical surveillance program including measurements of ventilatory capacity (FVC and FEV1) and single-breath diffusing capacity of carbon monoxide (DLCO). From 1989 to 1996, average % predicted DLCO (Crapo) for all participating firefighters declined from 94.4% (95% confidence interval [CI]: 93.4% to 95.5%) to 87.3% (95% CI: 86.2% to 88.3%), with no significant change in average FVC or FEV1. A random-effects regression model based on data from 812 firefighters with at least two annual sets of DLCO measurements showed the expected associations between DLCO and age, height, gender, race, ventilatory capacity, and smoking. In addition, two important temporal changes were observed, including, for an average firefighter, a large mean decline in DLCO of -1.02 ml/min/mm Hg associated with year of measurement, and a relatively smaller decline of -0.006 ml/min/mm Hg associated with number of fires fought. Although the stability of ventilatory capacity over time is reassuring, the marked temporal decline in diffusing capacity among this population of firefighters raises issues of concern. Interpretation of the observed decline poses a dilemma in terms of the reliability and efficacy of diffusing capacity as a screening tool, in whether DLCO is subject to unacceptable technical variability or whether it might provide more sensitive detection of early adverse respiratory effects of smoke inhalation.

Zolpidem-associated hallucinations and serotonin reuptake inhibition: a possible interaction.

BACKGROUND: Zolpidem (Ambien) is a sedative believed to act exclusively at the benzodiazepine omega 1 receptor. Sporadic case reports of zolpidem-associated hallucinations have appeared over the past 5 years, and over the past 2 years, the Washington Poison Center received five reports of prolonged visual hallucinations associated with zolpidem. CASE REPORTS: All five patients reported experiencing visual hallucinations lasting from 1-7 hours soon after taking zolpidem. Most had been taking zolpidem for less than a week and all five were concurrently taking an antidepressant: sertraline, desipramine, fluoxetine, bupropion, or venlafaxine; two sought assistance at a hospital. DISCUSSION: The precise mechanism of zolpidem-associated hallucinations remains unknown. In some previously published cases, the zolpidem-associated hallucinations have been short in duration, lasting at most 30 minutes. In contrast, the five patients in our series and in five previously reported cases, the hallucinations were more persistent, lasting up to 7 hours. Of these ten cases with persistent symptoms, nine were concurrently taking antidepressants that inhibit serotonin-reuptake, despite the fact that zolpidem has no known serotonin-mediated mechanisms. CONCLUSIONS: These cases, plus prior case reports, suggest that a pharmacodynamic interaction between serotonin reuptake inhibition and zolpidem may lead to prolonged zolpidem-associated hallucinations in susceptible individuals.

Sulfhemoglobinemia after dermal application of DMSO.

A 43-y-old Caucasian female applied 4 ounces of dimethyl sulfoxide (DMSO) to her lower abdomen for treatment of interstitial cystitis. Within 24 h she developed fatigue, cyanosis and dyspnea with mild exertion. She sought medical attention 10 d later, at which time initial laboratory tests revealed a methemoglobin level of 47%. Two doses of 1 mg methylene blue/kg i.v. were given without significant improvement in either her cyanosis or methemoglobin level. Repeat analysis the day following admission using an outside lab demonstrated a sulfhemoglobin level of 6.2% and a methemoglobin level of < 0.1%. No prior reports have associated sulfhemoglobin formation with DMSO application. Carbon monoxide-oximetry may falsely identify sulfhemoglobin as methemoglobin; sulfhemoglobinemia should be considered in cases of methemoglobinemia refractory to methylene blue therapy.

Hazardous materials incidents: the Washington Poison Center experience and approach to exposure assessment.

Hazardous materials incidents include gas and vapor releases, spills, explosions, and fires. Incidents involving human exposure are challenging for most health care providers because of the vast number of potential chemicals involved, frequently incomplete incident information, and limited experience in exposure assessment. To facilitate improved evaluation and treatment of patients with chemical exposures, the Washington Poison Center established the Hazardous Materials Exposure Information Service in 1994. During the first 33 months of operation, this service has provided information on 70 incidents, involving a total of 1120 exposed individuals, including 501 patients treated in medical facilities. This paper reviews these incidents, the process used to collect information from the incidental scene, and selected techniques for evaluating the extent of individual chemical exposure.

Hazardous materials exposure information service: development, analysis, and medical implications.

The Hazardous Materials Exposure Information Service (HMEIS) was established at the Washington Poison Center (WPC) to rapidly provide information to medical professionals who treat victims of hazardous-materials exposure. Incident description and exposure information is collected from on-site hazardous-materials teams and immediately analyzed by WPC medical toxicologists. Diagnostic and treatment recommendations are provided to prehospital personnel and receiving physicians. Over the first 22 months of operation, 50 calls were received that met HMEIS criteria. Of the 466 individuals exposed, 256 (55%) were transported to a medical facility for treatment. When the WPC was contacted before the decision to transport a patient to a medical facility, 28 of 185 exposure victims (15%) were transported, compared with a transport rate of 81% of exposure victims (66% change; 95% confidence interval [CI], 60% to 72%) in all other concurrent incidents and a historical transport rate of 63% (25% change; 95% CI, 14% to 36%) before the establishment of the HMEIS. These findings, although preliminary and subject to potential confounding, suggest that the HMEIS reduces health care costs through more efficient use of medical resources.

Hospital preparedness for hazardous materials incidents and treatment of contaminated patients.

Hospital-based facilities providing emergency care in the state of Washington were surveyed to determine their level of preparedness for hazardous materials incidents including the treatment of contaminated patients. Responses to a faxed questionnaire were received from 95 (94%) of the 101 emergency care facilities in Washington State. Only 42 (44%) of the facilities reported the ability to receive any chemically exposed patient. Of the 95 responding emergency care facilities, 39 (41%) had no designated decontamination facilities; 67 (70%) had protocols for handling chemical contamination and possible evacuation from hazardous materials spills, and 52 (55%) had protocols for handling medical facility contamination and possible evacuation from treating chemically contaminated patients. Twelve (13%) facilities had evacuated their emergency department or other part of the hospital for contamination incidents in the past 5 years. Despite the frequent occurrence of hazardous materials incidents, most emergency care facilities in Washington State are not fully prepared to handle contaminated patients and chemical spills. This may have important implications for the care of persons with exposure to hazardous materials and for implementing Joint Commission on Accreditation of Healthcare Organizations standards and federal Occupational Safety and Health Administration regulations.