For this assignment, you are required to read the article entitled “HazMat Emergencies: Decontamination and Victim Chain of Survival,” by Gunderson, Helikson, and Heffner (2014), and write a review.  Your review must include the following:

 Summarize the key points presented in the article.

 Describe the key elements of a solid emergency response program.

 Discuss why proper decontamination of victims is important.

 Discuss your opinion or what you can conclude from the article.

*******ARTICLE ATTACHED*******

Your response must be at least 800 words in length. All sources used, including this article, must be referenced. Paraphrased and/or quoted materials must have accompanying in-text and reference citations in APA format.

Program Development Peer-Reviewei

HazMat era

K ^ ences

Decontamination & Victim Chain of Survival By Scott Gunderson, Cameron Helikson & Michael Heffner

Consider the following hypothetical sce-narios of workplace emergency decon-tamination incidents involving hazardous materials:

BRIEF •HazMat emergencies represent a sig- nificant response challenge, especially when employees are exposed and the response involves a victim. í •A growing body of literature and I standards guides emergency medical – services (EMS) and hospital profes- sionals in HazMat victim response and treatment. But, the SH&E professional must navigate separate standards: HazWOPER for HazMat emergencies and standard first aid for HazMat victim response. »What strengths each standard may have in isolation are lacking when [ coupled with each other or as explicit ‘ preparation for the more advanced re- sponse that follows when EMS arrives. •The authors review these standards and integrate several key concepts for effective response to HazMat victim emergencies in the workplace to make the most of the critical time hetween employee exposure and EMS arrival.

A pressurized hose recir- culating potassium goid cyanide into a clean room eiectroplating bath breaks ioose from the ciamps hold- ing it against the bath wall. The hose whips around and sprays the corrosive iiquid onto a nearby em- pioyee. She hits the emer- gency “off” button, and as the chaos quiets, she and her coworkers realize she is standing in a puddie of plat- ing solution, with the liquid dripping from her clean- room clothing. Her first im- pulse is to go change her clothes in the locker room, but her supervisor orders her to an enclosed emer- gency shower stail with a drain. She walks from the puddle to the shower, trail- ing a path of wet footprints.

At another company, an employee ioses his hold of a heavy product and

drops it into an acid etching tank. The fuii- front 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 com- plicated 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 em- ployee 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 emer- gencies, 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 opera- tions. Transportation involves potential exposure to the nonoccupational general public, and in the case of highway incidents, the absence of read- ily available emergency decontamination facili-

IScott Gunderson, CSP, CHMM, is asafet}’ compliance officer at Oregon OSHA,with prior workplace emergency responseexperience 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.

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

been published in Professional Safety. He- likson 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 certi- fied 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.

4 0 ProfessionalSafety MARCH 2014 www.asse.org

fies such as emergency showers. Addifionally, law enforcement, military or other potential mass ca- sualty emergencies, such as terrorist attacks with chemical weapons, involve even more issues, such as significant public exposure, potentially long pe- riods wifh unidenfified contaminants and ongoing tactical threats (e.g., acfive shoofer and secondary explosives timed for arrival of emergency respond- ers).

Magnitude of Problem Agency for Toxic Substances and Disease Reg-

isfry (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 vic- tims, 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 fa- cilities and manufacturing represenfed the highest (99% and 27%, respectively). These fixed facili- ties again reported the highest number of victims (83%), with employees representing 10% (ATSDR, 2009).

mediately reducing contamination of individuals in potentially life-threafening situafions with or with- out 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 emer- gency medical service (EMS) personnel arrive, and it is the primary focus of this article.

2) Gross decontamination. This may be an ini- tial part of emergency decontamination of victims, or the first step in technical deconfaminafion of re- sponders 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 pro- cess of reducing or removing surface contaminants from large numbers of vicfims in pofentially life- threatening situations in the fastest time possible” (NFPA, 2008b). This may be an emergency decon- tamination or a gross decontamination, and simply describes the fact that more than one person un- dergoes decontamination. Although typically per- formed by FMS personnel, the authors are aware of two separate workplace incidents with two ex- posed employees each, forcing fhem to each walk to separate emergency showers; in one incident.

HazMat Victim Decontamination

Decontaminat ion practices have evolved since the NFPA 472 standard was created and replaced NFPA 471, which spent much of its decontaminafion section on standard- ized procedures for controlled entry and exit through an estab- lished corridor linking the operational areas of the hot zone (e.g., exclusion or contami- nation area), warm zone (e.g., transition or contamination re- ducfion area) and cold zone (e.g., support or clean area). Although this separation of op- erational areas is ideal in principal, NFPA 472 acknowledges the more realistic pofenfial for chaos as emergency responders arrive, with five categories of de- contaminafion.

1) Emergency de- contamination. “The physical process of im-

rMaximizing HazMat Victim CareTransitioning 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 emer- gency response program should at a minimum include the following:

•Hardware. Functioning and appropri- ately 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 hard- ware must be inspected regularly, maintained and tested periodically.

•Information. Safet)’ data sheets and a site- specific 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 work- place 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 sys- tems, 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 loca- fion 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 communica- tion to EMS during an emergency. Workplace emergency responders must also understand the role of EMS and how workplace respond- ers and EMS can best work together on site.

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rTable 1HazMat Emergency & Victim Decontamination Responsibilities Personnel Workplace emergency responders Emergency medical services (EMS) personnel

Hospital personnel

Role Initial response; notify EMS; emergency decontamination Arrive at scene; assume control of response; emergency, mass, gross and/or technical decontamination; emergency medical treatment; transport victim(s) Receive victim(s); definitive decontamination and treatment

Expected levels of contamination High, both scene and victim(s)

High, transitioning to as IOVÍÍ as possible for victim(s)

Low, with exception of self- transported “walking wounded”; emergency and technical decontamination capabilities but preference for receipt of decontaminated victim(s)

the spill size in the facility was doubled with drops and wet footprints from the emergency scene to the two showers.

4) Technical decontamination. This may de- scribe either the controlled decontamination of responders leaving through the decontamination corridor (NFPA, 2008a), ot thorough decontami- nation of HazMat victims for emergency medical treatment on site and/or prior to releasing for frans- portation and further treatment (NFPA, 2008b). Technical decontamination of HazMat victims typically involves significantly more surface rins- ing than occurs in a workplace emergency shower, and may involve use of brushes, cleaning agents

rTable 2Summary 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

•^dical care first

Combined priorities

Medical care first

Medically unstable Decontaminate first

Combined priorities

Decontaminate first

Medical care first

Medically stable Decontaminate first

Combined priorities

Decontaminate first

Combined priorities

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 life- threatening trauma or bums. Medically unstable is defined as shortness of breath, unstable vital signs, altered lev- els 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

such as soaps and detergents, and, depending on the proto- cols of the responding agency, irrigation and/or suction of na- sal and oral cavities as needed. The transition from emergency decontamination of HazMat victims by workplace emer- gency responders to techni- cal decontamination by EMS personnel is discussed in more detail.

5) Definitive decontami- nation. This is performed in the hospital as part of treat- ment, and it is outside the scope of this article, as well as outside the scope of NFPA 472 and NFPA 473.

Table 1 summarizes typical roles, responsibilities and ex-

pectations for each level of decontamination from workplace emergency responders to EMS person- nel and, finally, to hospital personnel.

HazMat Victim Care The following sections describe HazMat vic-

tim care in reverse chronological order to provide context for the final section on emergency decon- tamination by workplace emergency responders. The authors believe that workplace emergency responders perform better if they understand the expectations and actions of the higher-level re- sponders with whom they will interact.

Hospital Definitive treat-

ment varies with the severity of ex- posure, the hazard of fhe substance, positive idenfifi- caüon of the sub- stance and the treating physician’s diagnosis. Whether simple observation and evaluation, or more advanced de- contamination and treatment, it wiU most likely occur in the hospital (Cur- rance, Clements & Bronstien, 2007). EMS operating un- der written pres- tanding orders and medical direction typically include

f Table 3Transition Issues Between Workplace Emergency Responders & EMS

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.

One critical issue for the hospital is secondary con- tamination, which occurs when hospital personnel, other patients and prop- erty are exposed to hazard- ous 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 decon- tamination, due to the assumption that EMS per- sonnel will perform proper decontamination prior to transportation (OSHA, 2005; 2008b).

Strong communication between EMS and hospi- tal personnel, as well as good technical decontami- nation practices in the field, can prevent secondary contamination (Horton, Berkowitz & Kaye, 2003). NFPA 473 strongly emphasizes HazMat victim de- contamination 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” (Trebi- sacci, 2008, p. 485).

Emergency Medical Services Horrific case studies of ambulance contamina-

tion following a fatal exposure to hydrofluoric acid and an emergency department shutdown follow- ing the arrival of a pesticide-contaminated patient illustrate the reasons why healthcare professionals emphasize early and thorough victim decontami- nation (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 per- form an initial scene size-up on arrival for their own safety and to prevent increasing the mag- nitude of the emergency by having responders become additional victims. The actions and com- munications of workplace emergency responders before and during EMS arrival can either facilitate a smooth transition or cause delays as EMS per- sonnel review the scene for their own protection.

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

Delayed or incomplete scene size-up by EMS upon arrival Delayed or incomplete first impression by EMS of HAZMAT victim upon arrival

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 decontamina- tion. 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.

Photo 2: Technical decon- tamination of EMS respond- er. EMS responders render their PPE safe by system- atically rinsing, washing and re-rinsing with soap and water in the warm zone of a decontamination corridor.

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f Table 4Standards Related to HazMat Emergencies & HazMat Victim Response Standard Hazard Communication OSHA 1910.1200

Emergency Action Plan OSHA 1910.38 Medical and First Aid OSHA 1910.151

Hazardous Waste Operations and Emergency Response OSHA 1910.120

Contingency Plan and Emergency Procedures EPA 265 Subpart D

NFPA471 NFPA472

NFPA 473

Target audience All workplace employees

All workplace employees

Workplace emergency responders

Workplace emergency responders

Workplace emergency responders

Workplace and public emergency responders Emergency medical service (EMS) personnel

Summary Basic training requirements on safe use as well as emergency response to hazardous materials in the workplace

Basic emergency requirements (e.g., notification, evacuation) Requirements for first-aid supplies, first-aid training and emergency eyewash/showers (see also ASTM 2009 and ANSI 2009) Detailed requirements for HazMat emergency response, including long-term cleanup of contaminated sites Detailed requirements specific to hazardous waste, including documentation of plans and advanced communications with local authorities (e.g., fire, EMS)

Withdrawn (see NFPA 472 and NFPA 473) Competencies for HazMat emergency responders Competencies for EMS personnel responding to HazMat incidents, with emphasis on HazMat victim care at emergency site and during transportation to hospital

Photo 3: Technical de-

contamination of victim

(training exercise

with manikin). EiVIS

responders have re-

moved and contained

the victim’s clothing

and jewelry to signifi-

cantly 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 receiv-

ing hospital.

Photo 4: Definitive de-

contamination 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 sec-

ondary contamination

of hospital personnel,

other patients and

equipment.

4 4 ProfessionalSafety MARCH 2014 www.asse.org

The authors have witnessed EMS personnel refuse to en- ter HazMat emergenq? scenes because they were not con- fident about the accuracy of information from workplace emergency responders, result- ing in delayed medical care to HazMat victims.

Once confident that they can safely respond, EMS per- sonnel will assume control of the scene for entry and re- sponse, including victim care. For HazMat victim emergen- cies. Table 2 (p. 42) summariz- es the priorities for immediate decontamination, immedi- ate medical care or combined priorities.

Workplace emergency re- sponders can either facilitate or delay EMS response. The authors believe that early at- tention to proper emergency

decontamination and accurate information will permit EMS personnel to more quickly begin med- ical care for victims. Additionally, preplanning, in- cluding 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 re- lationships, and improves communications and efficiency during the critical transition between workplace responder and EMS control of emer- gency operations (Table 3, p. 43).

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 stan- dard contributes to emergency prevention and response, and it is the knowledge of facility em- ployees 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 thor- oughly covers HazMat scene safety and directs attenfion to issues such as spill response and re- covery, its coverage of emergency decontamination and HazMat victim care is limited, even though the standard contains provisions that require planning for medical monitoring and first aid.

Where HazWOPER lacks specifics on emer- gency decontamination and HazMat victim care, standard first aid and other emergency decontami- nation references provide few details on these sub- jects and typically exclude reference to site control and the wider response. First-aid training courses

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 boil- erplate 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 equip- ment 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 vic- tim 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 sur- vival provides a comparison for cardiac emergen- cies; 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.

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 de- layed 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 emergen- cies can fall into tunnel vision performing immedi- ate 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 de- layed second starting emergency decontamination allows hazardous materials to injure exposed em- ployees by burning, absorption or inhalation. The span between these first and second steps should be as short as possible, and preferably done simul- faneously by multiple employees and/or workplace emergency response team members.

3) Early scene control and HazMat characteriza-

Figure 1

Emergency Decontamination Performance Support Tool for Site Emergency Responders Location address:

Location phone number:

Department/Area:

Primary entry/EMS arrival location:

Name(s] of exposed employee(s):

Name(s) of exposed chemical(s):

Time employee(s) in emergency shower/eyewash:

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:

1234 Street, City, State

(555) 555-5555

Metal Finishing

Shipping/receiving

Name Time

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 hy- drofluoric acid exposure, topical application of polyefhylene glycol for phenol exposure, adminis- tration of hydrogen cyanide antidote or other ap- plicable treatments.

4) Accurate communication to EMS: Gaps in in- formafion, if unresolved on EMS arrival, can cause furfher delays in technical decontamination, medi- cal stabilization, ambulance transportation, defini- tive decontamination and treatment.

Like the cardiac chain of survival, the HazMat victim chain of survival is relatively simple, facili- fafing fraining and retention for workplace emer- gency 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, first- aid kits) mounted at walls near emergency eye- wash and shower equipment.

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Conclusion Consider this concluding example: A nonroutine task with inadequate energy iso- lation results in a pressurized chemical pipe spraying liquid onto an employee. He screams and staggers into an emergency shower as others close the valve. His colleagues refer to a checklist posted outside the shower, begin to page site emergency responders and call 9-1-1. The supervisor directs one employee to print the safety data sheef, another employee to mark the floor contamination with traffic cones and caution tape, and another employee to go to the primary entrance to direct EMS per- sonnel to the emergency scene. The supervi- sor and other employees tell the victim to stay in the shower and that EMS is on the way.

When EMS personnel arrive, they drive to the employee waving at the primary entrance. In- side, the supervisor briefs EMS personnel on the emergency and the hazardous material in- volved, points out the marked spill zone and hands them the safety data sheet. Aware of the hazards, the hazardous area and the amount of time the victim has been in the shower, EMS personnel begin their response in an environ- ment of rapid emergency decontamination and clearly communicated information promot- ing responder safety and prompt victim care.

Workplace emergency responders who complete such a performance support tool, have all the ele- ments in place for rapid notification to internal and external responders, rapid emergency decontami- nation of HazMat victims and accurate information to arriving EMS personnel who can proceed to vic- tim care with fewer delays for self-protective scene evaluation. PS

References

Agency for Toxic Substances and Disease Regis- try (ATSDR). (2009). Hazardous substances emergency events surveillance: Annual report 2009. Retrieved from www.atsdr.cdc.gov/HS/HSEES/HSEES%202009%20 report%20final%2008%2017%2011_9.pdf

ANSI/ISEA. (2009). American national standard for emergency eyewash and shower equipment (ANSI/ ISEA Z358.1-2009). Arlington, VA: Author.

ASTM International. (2009). Standard guide for de- fining the performance of first-aid providers in occupa- tional settings (ASTM F2171-02). West Conshohocken, PA: Author.

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 Quly- Sept. 2004).

Currance, P.L., Clements, B. & Bronstein, A.C. (2007). Emergency care for hazardous materials exposure. St. Louis, MO: Mosby Elsevier.

Horton, D.K., Berkowitz, Z. & Kaye, W.E. (2003). Secondary contamination of ED personnel from hazard- ous materials events, 1995-2001. The American Journal of Emergency Medicine, 21(3), 199-204.

Koenig, K.L. (2003, Sept.). Strip and shower: The duck and cover for the 21st century. Annals of Emer- gency Medicine, 42(3), 391-394.

Markenson, D., Ferguson, J.D., Chameides, L., et al. (2010). Part 17: First aid: 2010 American Heart Association and American Red Cross guidelines for first aid. Circulation, 322(suppl 3), S934-S946.

NAEMT & American College of Surgeons Com- mittee on Trauma (2007). PHTLS: Prehospital trauma life support. Burlington, MA: Jones & Battlett Learning.

NFPA. (2002). Recommended practice for responding to hazardous materials incidents (NFPA 471). Quincy, MA: Author.

NFPA. (2008a). Standard for competence of respond- ers to hazardous materials/weapons of mass destruction incidents (NFPA 472). Quincy, MA: Author.

NFPA. (2008b). Standard for competencies for EMS personnel responding to hazardous materials/weapons of mass destruction incidents (NFPA 473). Quincy, MA: Author.

OSHA. (2005). Best practices for hospital-based first receivers of victims from mass casualty incidents involv- ing the release of hazardous materials (QSHA 3249-98N). Retrieved from www.osha.gov/Publications/osha3249 .pdf

OSHA. (2006). Best practices guide: Fundamentals of a workplace first-aid program (QSHA 3317-06N). Retrieved from www.osha.gov/Publications/OSHA3317first -aid.pdf

OSHA. (2008a). Hazardous waste operations and emer- gency response (QSHA 3114-07R). Retrieved from www .osha.gov/Publications/OSHA3114/OSHA-3114-haz woper.pdf

OSHA. (2008b). Hospitals and community emer- gency response: What you need to know (QSHA 3152- 3R). Retrieved from www.osha.gov/Publications/ OSHA3152/3152-hospitals.pdf

OSHA. (2009). Best practices for protecting EMS responders during treatment and transport of victims of hazardous substance releases (OSHA 3370-11). Retrieved from www.osha.gov/Publications/OSHA3370-pro tecting-EMS-respondersSM.pdf

Travers, A.H., Rea, T.D., Bobrow, B.J., et al. (2010). Part 4: CPR overview: 2010 American Heart Associa- tion guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, n2(suppl 3), S676-S684.

Trebisacci, D. (Ed.). (2008). Hazardous materials/ weapons of mass destruction response handbook. Quincy, MA: NFPA.

Vogt, B.M. & Sorensen, J.H. (2002). How clean is safe? Improving the effectiveness of decontamination of structures and people following chemical and biological incidents (Report No. ORNL/TM-2002/178). Retrieved from http://emc.ornl.gov/publications/PDF/How _Clean_is_Safe.pdf

Disclaimer The opinions in this article are those of the authors and do not represent official positions of Oregon OSHA or any affiliated agency.

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