Infection Connection

Before the dust settles:
Respiratory care when disaster strikes

by Susan Cantrell, ELS

When the windows of the World Trade Towers were shattered by terrorist-piloted airplanes on September 11, 2001, thousands of lives were shattered along with it, sometimes including those who survived as well as those who, sadly, did not. Imagine, if you can, what you would have experienced if you had been among the first responding to the disaster.


Inovel N95 respirator

Imagine choking on churning smoke released by almost 180,000 gallons of burning jet fuel,1 smoke from fires so intense they burned for 3 months after the tragedy. Imagine breathing toxic fumes from more than 400 chemicals2 released by thousands of items as they burned around you, including 2,000 tons of asbestos and 50,000 computers encased in plastic, containing 200,000 pounds of lead.1 Imagine being engulfed in clouds of swirling dust so thickly loaded with debris from 424,000 tons of pulverized concrete, glass, steel, sheet rock, fiberglass, and other materials that it’s more like breathing construction stew than air.1 Imagine 1.2 million tons of dust raining down on you,1 piling by inches blocks away from the 16-acre disaster zone, dust so thick it takes weeks for the air to clear.

Now imagine how the lungs of those who breathed the dust, debris, and smoke must feel as they strive valiantly to save lives against time.

Afterward, first responders and caregivers suffered many symptoms, including wheezing, shortness of breath, newly diagnosed asthma; throat irritation; sinus problems, nose irritation, and postnasal irritation; eye irritation; hearing problems or loss; psychological distress; severe headaches; stroke; heartburn, indigestion, or reflux; skin rash or irritation; and, very commonly, "World Trade Center cough (WTC)."3 The CDC described the WTC cough as "a persistent cough so debilitating that persons who had it required at least 4 weeks of medical leave."3 One study found that WTC rescue workers, on average, lost the equivalent of 12 years of aging in lung function.2 Fortunately, to some degree, it has shown to be reversible in many cases. Of note, the study also mentioned that "only 22% of workers who first arrived to the disaster site wore masks," and use "never topped 50% among responders who arrived later."

"At the World Trade Center disaster, only surgical or paper masks were available at first. Studies show that wearing these types of masks probably didn’t do much good in this extreme situation.1,3" Even when respirators were made available, unfortunately many either didn’t understand the importance of wearing them, found them too uncomfortable under the circumstances, or were reluctant to slow down long enough to use them, which is understandable give the urgency and scope of the disaster.


Inovel 3100 single-strap respirator

A federal lawsuit was filed last month on behalf of more than 8,000 fire fighters, police officers and private workers who were exposed to toxic substances at or near ground zero. Lawyers said there was no central distribution point for respirators, no single organization responsible for giving them out, and no one with the power to make sure respirators that were distributed got used, and used properly.4

Preparing for the worst

Much of being prepared for large-scale disaster involves having emergency equipment and supplies readily available as well as first responders and caregivers who are knowledgeable and trained in how and when to use the equipment and supplies properly. Some reports indicate that public officials could have been better prepared in, and more forceful in insisting on, safe practices for workers.1-3

"There was a lot of television footage [during the 9/11 disaster] that showed caregivers running around with no air-filtration protection at all," remembered Dennis Cook, president of Medline (Mundelein, IL)’s respiratory-care division. "It is more difficult to breathe wearing an N95 respirator. If you’re excited and trying to breathe and having a hard time breathing anyway, it’s just a natural reaction to take it off so you can breathe more easily. You just have to stop yourself from doing that." Cook advised, "No matter how uncomfortable it may be, keep your breathing filtration mask on. If it’s available take advantage of it, take the time."

Inovel (Culver City, CA), as the exclusive licensee of Moldex, manufactures masks and respirators. Jeffrey Birkner, vice president technical services, offers some insight on disaster preparedness as it relates to respiratory care. "Although masks and respirators were available during the cleanup of the WTC disaster, there is some question as to whether responders were properly trained and fit-tested as to their use. We would encourage state, local, and federal agencies that are preparing respon-ders or caregivers for disasters — such as that of 9/11, the anthrax letters, Hurricane Katrina, or other terrorist or natural disasters — that they adequately prepare these personnel on the appropriate use and fit testing of a variety of respiratory protection."

"It is also imperative that each agency have an adequate supply of respirators," noted Birkner. "Since the type of disaster that might occur in the future is largely unknown, we would suggest that each agency develop a comprehensive respiratory-protection program in accordance with OSHA 1910.134, as a minimum. This would include, but not be limited to, appropriate medical evaluation, training, and fit testing. Each responder or caregiver should be trained on several types of respiratory protection, since it is impossible to determine in advance what types of respiratory protection will be required. 

Additionally, a selection plan should be developed, based on likely scenarios, providing guidance to the agencies as to the type of respiratory protection that might be deemed appropriate for some of the more likely eventualities."

Michael Wang, product manager for Bio-Medical Devices International, Irvine, CA, advised: "We understand that, in a state of emergency, saving lives is the number one priority; however, proper precautions such as air sampling must not be overlooked." Vince Gonzalez, general manager, offered further insight: "The first rule of thumb is to identify the specific hazard with which you are dealing, then to respond accordingly with the appropriate respiratory protection equipment. Proper training should ensure that correct procedures are followed and that all personnel are fully informed as to how to respond properly to emergencies, so as to reduce the risk of injury to emergency-response personnel and those whose lives they are there to save. Independent studies have shown that surgical face and N95 masks offer minimal protection. In fact, many healthcare workers have a false sense of security, believing that they are better protected than they actually are."

Steps for donning a respirator
from Kiberly-Clark Healthcare.

The importance of preparing first responders and caregivers prior to the need for respiratory protection was reiterated by David Parks, general manager, global infection control products & medical devices, Kimberly-Clark, Roswell, GA, "Given the very diverse conditions that a first responder may encounter, there are no absolute rules that can be followed. However, there are ASTM standards indicating levels of mask performance; there are CDC standards and recommendations for medical exposure risks; and there are recommendations in APIC’s Handbook of Infection Control. Recommendations would include (1) Have an emergency preparedness plan. (2) Educate first responders and caregivers about the plan and practice it. (3) Have the necessary supplies stockpiled to support the plan; when in doubt, use the highest level of protection available (ie, N95 respirators or higher). (4) Have an ‘owner’ and back-up to coordinate the execution of the plan when it is needed."

Respirators, masks, and more 

"Our standard mask portfolio, surgical and procedure masks, provides the level of filtration necessary to protect first responders from particles and pathogens in most situations," Park advised. "However, in situations such as the 9/11 terrorist attacks, the level of protection of N95, or higher, respirators would be recommended to provide the sealed fit to the face necessary in conditions of high concentrations of airborne contaminants."

The 9/11 disaster spurred not only public officials but also manufacturers and vendors to investigate how they could best answer first responders’ and caregivers’ needs for respiratory care when catastrophe strikes. Medline, in partnership with Versimed, responded by developing IVent, a ventilator to protect patients and healthcare workers alike from biological and chemical attack. "We came up with a design to protect patients because you can’t always move them out of danger," said Cook. "We outfitted a ventilator with a specific 3M filter so that all the air going to the patient passes through this filter with a chemical and biological air-filtration system. It could be used by first responders or it could be used in a facility setting. We have a kit that includes a backpack so the caregiver can breathe off the machine, too. At 22 lbs it’s very light. It comes with a battery that lasts 2 hours. It’s actually an ICU ventilator with a transport battery. It’s the only one of its kind, and the air-filtration system is the only one that’s adaptable to a ventilator as well. It’s a very specific combination of ventilator and air filtration."

At $15,000 to $24,000 apiece, depending on configuration, it may sound pricey, but consider this, Cook said: "Compared to an ICU ventilator, it’s a bargain. They generally run 40% to 80% higher than that." The best part is that it can be used in a disaster situation until the patient can be transported to a facility. "It’s a self-contained life-support system, a mechanical ventilator. It would be suitable for a very big catastrophic event. A biological or chemical attack could cover a large area. The government has inquired about stockpiling IVent in strategic locations, Capitol Hill, primarily, in case there were to be an attack."
MAXAIR from Bio-Medical Devices International


Another product developed for respiratory care in disaster settings is MAXAIR, by Bio-Medical Devices International. Green explained that "MAXAIR is for use after first responders determine there are no chemical threats and for when patients are transported to the ‘cold zone.’ Cold zones are temporary facilities that accommodate patients brought in by first responders during a disaster."

MAXAIR is a "hose-free powered air-purifying respirator (PAPR) that allows freedom of movement and provides healthcare workers with HEPA-level protection for the entire face, head, and neck," explained Gonzalez. "With bacterial and viral filtration efficiency to 99.97% and the ability to filter particles down to .1 micron, it provides protection from dust and mist particles, as well as aerosolized and bloodborne pathogens. The MAXAIR system provides healthcare workers with an assigned protection factor (APF) of 1,000, as compared to N95 dust masks and surgical masks, which have an APF of 5. MAXAIR is the first and only hose-free PAPR system receiving both NIOSH approval and FDA allowance for the industrial and healthcare fields."

Green added: "MAXAIR is easy and quick to don. The system is lightweight and has a battery pack that will last greater than 8 to 10 hours in most situations, allowing caregivers to work for extended periods of time." Other features include a quiet motor for improved hearing and communication, unobstructed sight, reduction in potential for cross-contamination in a crime-scene setting, and—here’s cause for rejoicing—no need for fit testing.

"MAXAIR is currently being used by numerous U.S. governmental agencies, as well as private research facilities, for use in infection-control environments. The system is ideal for protecting workers facing strains of SARS, tuberculosis, avian influenza, Hantavirus, and other communicable diseases," said Gonzalez.

Conclusion

First responders and caregivers can’t wait weeks for dust, debris, toxins, pathogens, and smoke to clear; they’re in the thick of it, quite literally in some cases. Wouldn’t you want them to have the best personal protective equipment available if they were saving your life? Wouldn’t you want them to understand just how important it is to use that equipment, so they can stay healthy enough to save lives another day? You have to admire someone who is so intent on saving lives that they forego protecting their own. Nevertheless, first responders and caregivers shouldn’t have to sacrifice their lives or health to save others’ when it can be prevented. HPN

References:

1.Lyman F. Messages in the Dust. http://www.neha.org/9-11%20report/index-FContents.html.

2.Banauch GI, Hall C, Weiden M, Cohen HW, Aldrich TK, Christodoulou V, et al. Pulmonary function after exposure to the World Trade Center in the New York City Fire Department. Am J Respir Crit Care Med 2006 Apr 27; [Epub ahead of print].

3.Centers for Disease Control and Prevention. Surveillance for World Trade Center disaster health effects among survivors of collapsed and damaged buildings. In: Surveillance Summaries, April 7, 2006. MMWR 2006:55(No.SS-2).

4. "Air Masks at Issue in Claims of 9/11 Illnesses" by Anthony DePalma, The New York Times, June 5, 2006.

 

July 2006


 

 

 

Emergencies incite innovation

The disasters that the United States has
experienced in the past few years have spurred the medical manufacturing field to explore new ways to address catastrophes, man-made and natural, that may befall us. The powerful hurricanes that ripped up the Gulf Coast last year, the anthrax scares, the spectre of an avian influenza pandemic, and the 9/11 terrorist attack revealed to the nation in no uncertain terms that we need to be better prepared.

After Hurricane Katrina had her way with the Gulf Coast, people were left in dire straits for such a long time. Those who had generators thought they were the lucky ones, but sometimes the generators weren’t used correctly and carbon monoxide sneaked in. Some who survived the hurricane and flooding didn’t survive the carbon monoxide poisoning. Carbon monoxide poisoning, which is the number one cause of deaths due to poisoning in the United States, is easy to misdiagnose—or miss entirely—because its symptoms are flu-like: headache, vomiting, drowsiness, dizziness, fatigue, labored breathing, and so forth. Masimo (Irvine, CA) developed a product, the Rainbow SET Rad-57 Pulse CO-Oximeter, that can assist in diagnosing carbon monoxide poisoning by measuring and trending blood  carboxyhemoglobin  levels.


Masimo Rainbow
SET Rad-57 Pulse
CO-Oximeter

The monitor also can be used to detect methemoglobin in the blood. This condition, called methemoglobinemia, inhibits the blood’s ability to carry and unload oxygen. Many drugs can induce methemo-globinemia, as can inhalation of car exhaust and exposure to burning plastics or wood, certain industrial chemicals, resins and rubber adhesives, food additives and preservatives, and more. Methemoglobinemia can be life-threatening, but fortunately it’s treatable if caught in time. The challenge lies in diagnosing it, because, like carbon monoxide, it’s a silent killer. The Rainbow SET Rad-57 Pulse CO-Oximeter is a hand-held continuous monitor that analyzes data from an eight-wavelength finger sensor to measure arterial oxygen saturation, carboxyhemoglobin, methemoglobin, and pulse rate noninvasively. Because it’s rugged and lightweight, it’s ideal for field or hospital settings.

AeroClave, Orlando, FL, has developed a new emergency-management solution that is intended to respond to large-scale, worst-case scenarios. Originally developed to decontaminate commercial and military aircraft of viruses and other pathogens, AeroClave uses computer-controlled heat and humidity manipulation to alter internal environments to levels lethal to most viruses, such as SARS, avian influenza, or smallpox, demonstrating a 99.99% kill rate in less than 1 hour. It sports an on-board 500 kW generator with its own 24-hour fuel supply, which enables it to supply power, air conditioning, and heat, and to provide satellite and WI-FI communications before, during, and after natural disasters. Requiring only 30 minutes and a two-person crew to connect the AeroClave system to interior spaces, the mobile unit can be transported quickly and easily to emergency shelters, such as the Louisiana Superdome.


The AeroClave mobile unit performs a decontamination test at a public building.  
Testing contracted by the Air Transportation Center of Excellence for Airliner Cabin Environment Research (ACER) shows AeroClave’s decontamination process
achieves a kill rate of 99.99 percent of test sample viruses in less than one hour.

"Our goals were simple when we started the AeroClave development process," said AeroClave founder Ronald Brown, MD. "We wanted to develop a quick, efficient, and cost-effective way to decontaminate transportation assets in the event of a pandemic outbreak. . . . We believe we have developed a vital piece of our nation’s defense against the ravages of large-scale natural disasters. From pandemic influenza to hurricanes, tornadoes, or earthquakes, AeroClave will help communities prepare, respond, and recover from the worst that man or nature can throw at us." HPN
 
WTC Health Registry tracks survivor illnesses

The World Trade Center Health Registry (WTCHR) was launched on September 5, 2003, to track the health of those who were directly exposed to the collapse of the World Trade Center. More than 70,000 people are enrolled in the Registry, making it the largest-ever effort in the U.S. to systematically monitor the health of people exposed to a large-scale disaster.

According to survey findings released in April 2006, based on WTCHR data, survivors of buildings that collapsed or were damaged as a result of the World Trade Center attack reported having substantial physical and mental health problems when interviewed in 2003 and 2004.

More than half (57%) of the 8,500 building survivors in the survey reported experiencing new or worsening respiratory symptoms, and almost all evacuees of damaged or collapsed buildings said they witnessed at least one event with potential for psychological trauma.

Presence in the dust or debris cloud caused by the collapse of the World Trade Center was the strongest factor associated with physical and mental health effects, according to the analysis. More than 62% of building survivors reported being caught in the cloud, with sinus problems, nose irritation or postnatal irritation the most commonly reported new or worsening respiratory symptom (46% compared to 25% in those not in the dust cloud). Survivors caught in the dust cloud were twice as likely to report newly diagnosed asthma after September 11, 2001 than those who reported not being in the cloud.

Last month, New York City health officials announced a plan to resurvey more than 70,000 people who first reported their symptoms to the WTCHR two years ago. Officials hope to find out whether the large number of respiratory and mental health problems described in the original survey have persisted, or worsened, since then. The information will be used by city and federal officials to determine medical trends, to improve treatment options and to provide insight into the long-range consequences of exposure to the smoke, dust and trauma of the attack. HPN

For more information on the registry, go to http://www.wtcregistry.org.