Best Practices for

Protecting EMS Responders

during Treatment and Transport of

Victims of Hazardous Substance Releases

OSHA 3370-11 2009
Occupational Safety and Health Act of 1970

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Best Practices for

Protecting EMS Responders

during Treatment and Transport of

Victims of Hazardous Substance Releases

Occupational Safety and Health Administration

U.S. Department of Labor

OSHA 3370-11

2009

Cover photo courtesy of Dr. John Hick
This document is not a standard or regulation, and it creates no new legal obligations. It contains

recommendations as well as descriptions of mandatory safety and health standards. The recommendations are advisory in nature, informational in content, and are intended to assist employers in

providing a safe and healthful workplace. The Occupational Safety and Health Act requires that

employers to comply with safety and health standards promulgated by OSHA or by a state with an

OSHA-approved state plan. In addition, the Act’s General Duty Clause, Section 5(a)(1), requires

employers to provide their employees with a workplace free from recognized hazards likely to cause

death or serious physical harm. Employers may be cited for violating mandatory safety and health

standards or other OSH Act requirements, including the General Duty Clause.

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Occupational Safety and

Health Administration

Acknowledgements

Numerous individuals, agencies and organizations

assisted in the development of this publication.

OSHA wishes to express its deepest appreciation to

the following for their significant contributions to this

guide.

American Ambulance Association

American Medical Response

Agency for Toxic Substances and Disease Registry,

Emergency Response

Boston Emergency Medical Services

Department of Homeland Security,

Federal Emergency Management Agency,

National Emergency Training Center

Emergency Nurses Association

EnMagine, Inc.

Hennepin County Medical Center,

Dept of Emergency Medicine

Elsevier Public Safety,

Journal of Emergency Medical Services

National Association of EMS Educators

National Association of EMS Physicians

National Institute for Occupational Safety and

Health

New York City Fire Department

North Shore – LIJ Health System,

Center for Emergency Medical Services,

Special Operations Division

Objective Safety, LLC

U.S. Department of Health and Human Services

U.S. Department of Transportation

U.S. Environmental Protection Agency

The following agencies and organizations reviewed

and provided comments:

Emergency Nurses Association

EnMagine, Inc.

Hennepin County Medical Center,

Department of Emergency Medicine

National Association of EMS Educators

National Association of EMS Physicians

National Association of State EMS Officials

National Institute for Occupational Safety and

Health, Emergency Preparedness and

Response Coordination Office

New Jersey Department of Health and Senior

Services, Division of Epidemiology

Environmental and Occupational Health

New York City Fire Department,

Office of Medical Affairs

National Institutes of Health/National Institute

of Environmental Health Sciences,

Worker Education Training Branch

North Shore – LIJ Health System,

Center for Emergency Medical Services

Objective Safety, LLC

U.S. Agency for Toxic Substances and Disease

Registry, Emergency Response

U.S. Department of Homeland Security,

Federal Emergency Management Agency

U.S. Department of Health and Human Services

U.S. Department of Transportation
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 3

Contents

Acronyms 6

Executive Summary 7

Introduction 9

Scope and Objectives 9

Purpose 11

Organization of this Guide 11

Determinants of Training and PPE:

Personnel Roles, Hazard Assessments

and Emergency Response Plans 12

EMS Responder’s Role in the Community 12

Defining the EMS Responder Role in

Community Response: Factors to

Evaluate, Contacts, Information Sources

and Special Considerations 12

The Value of Open Dialogue 14

The EMS Hazard Assessment 14

Requirement and Purpose 14

Sources of Hazard Assessment Information

in the Community 15

Include EMS Responder Health and Safety

Experience in Hazard Assessments 16

Incorporating EMS Responder Preparation

into an Effective Emergency Response Plan 16

Training 18

Background 18

Summary of Existing Training Guidelines

for EMS Responders 18

Applicability of HAZWOPER Training to

EMS Responders 18

EMS Responder Roles Requiring

HAZWOPERTraining 20

First Responder Awareness Level Training 20

Training Duration,Topics and Competencies 20

Annual Refresher Training 21

First Responder Operations Level Training 21

Training Duration 21

Option to Demonstrate Competence 22

Topics for Training or Demonstration

of Competency 22

Annual Refresher Training 22

Associated Training 22

Associated Training – PPE 23

Associated Training – Respiratory Protection 23

Sources of Training and Curricula 23

EMS Responder Roles that Require

No HAZWOPER Training 24

Skilled Support Personnel 24

Relevance of Other HAZWOPER Training

Levels to EMS Responders 25

Conclusions Regarding EMSTraining 25

Personal Protective Equipment 26

Using OSHA’s Rationale for Hazard

Assessment and PPE Selection 26

PPE Selection Based on Reasonably

Anticipated Worst-Case Scenarios 26

Required Written Documentation for

Respirator and PPE Selection Processes 27

Assessing the Need for Respiratory Protection 27

Respiratory Protection Required for EMS

Responders 27

Types of Respiratory Protection Available 27

National Institute for Occupational Safety

and Health (NIOSH) Approval and Chemical,

Biological, Radiological, Nuclear (CBRN)

Certifications 28

Respiratory Protection for an Identified or

Characterized Hazard 28

Other Requirements Related to Respiratory

Protection 28

Gloves, Boots and Garments 28

Gloves and Boots 28

Protective Garments 29

Modifying PPE Selections Based on

Available Information 30

Proper Size and Fit of PPE 31

Considerations for Effectively Using,

Maintaining and Storing PPE 31

Conclusions Regarding Personal Protective

Equipment 31

Summary of OSHA’s Recommendations

for Training and PPE 32

Best Practices for Pre-Transport Patient

Decontamination 35

Removing Contaminated Clothing and

Personal Effects 35

Cleansing with Soap and Water 35

Assistance for Non-Ambulatory and

Ambulatory Patients 36
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Occupational Safety and

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Decontamination in Low Water Situations 37

Vehicle and Equipment Decontamination 38

Discovering that a Patient in the Ambulance

is Contaminated 38

Detection Equipment 39

Detection Instruments 39

Ionizing Radiation Meters 39

Chemical and Biological Agent Detection

Equipment 40

Methamphetamine Detection Equipment 42

Conclusion 44

Appendix A

Glossary 45

Appendix B

References 48

Appendix C

Additional Sources of Information 54

Appendix D

Examples of Mutual Aid Agreements

and Templates 55

Appendix E

Using Hazardous Substances Emergency

Events Surveillance System (HSEES)

Information in Community Hazard

Evaluations – A Review 56

Evaluation of Data from the Early 1990s 57

Rural/agricultural area compared to all

other non-rural areas 58

Appendix F

Special Considerations for Responses

Involving Methamphetamine Laboratories 59

Appendix G

Clandestine Drug Labs –

First Responder Awareness Card 64

Appendix H

Training Curricula Options 66

Training Curricula for EMS Responders 66

Tips for Successful EMS Responder

HAZWOPER Training Programs 68

Appendix I

Hospital Incident Command System 69

Excerpt from Hospital Incident System

Guidebook 69

Appendix J

Summary of Respirator Types and

Selection Information 71

Summary of Respirator Types and

Characteristics 71

Advantages and Disadvantages of Various

Types of Respiratory Protection 72

Advantages and Disadvantages of Various

Respirator Facepiece Styles 73

OSHA Assigned Protection Factors for

Respiratory Protective Devices 74

Respirators for IDLH Atmospheres 75

Respirators for Atmospheres that are

Not IDLH 75

Appendix K

Thermal Stress: Working in

Hot or Cold Environments 76

Heat Stress and Strain 76

Cold Stress and Hypothermia 76

Appendix L

Decontamination Foam and

Barrier Cream 77

Appendix M

Examples of PPE Donning

and Doffing Sequences 78

Appendix N

General Description and Discussion of

the Levels of Protection and Protective

Gear 79

Appendix O

Occupational Health Hazard

Experience of EMS Responders 83

Background/Overview 83

Review of the Literature on Risks to

EMS Responders 83

Experience of EMS Responders Exposed

to Hazardous Substances 83

EMTs at the Tokyo Subway Sarin

Gas Attacks 83

Hazardous Substances Emergency

Events Surveillance (HSEES) Data

for EMS Responders 84

Other Reports of EMS Responder Injury

during Hazardous Substance Releases 88

Risk to EMS Responders of Injury and

Illness from Causes Other than Hazardous

Substance Exposure 89
Appendix P

Industry Characteristics that Affect

How EmployersTrain and Protect

Their Employees 92

The Roles of NHTSA and States 92

Applicability of Federal and State OSHA

HAZWOPER Standards and Other

Regulations 93

The Influence of Overlapping Organizational

Demographics of EMS Responders 93

Appendix Q

Sources of Help in Addressing

Biological Agent Issues 95

Concern about Needlesticks and Biological

Agents 95

List ofTables

Table 1. Results of Simulation Tests on

Several Chemical Suits 30

Table 2. Training, Respiratory Protection,

and PPE for EMS Responders 32

Table E-1. HSEES Reported Event Parameters

During 1993-2000 58

Table F-1. Reported Methamphetamine

Laboratory Seizures, 1997-2005 59

Table F-2. Number and Percentages of

First Responders Who Sustained Injuries

during Emergency Events Associated

with Illicit Methamphetamine Laboratories

by Type of Injury 61

Table F-3. Chemical Hazards Encountered at

Methamphetamine Laboratories 62

Table J-1. Summary of Respirator Types

and Characteristics 71

O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 5

Table J-2. Advantages and Disadvantages

of Various Types of Respiratory Protection 72

Table J-3. Advantages and Disadvantages

of Various Respirator Facepiece Styles 73

Table J-4. Assigned Protection Factors 74

Table N-1. PPE Levels of Protection 80

List of Figures

Figure 1. How to Use Table 2 34

Figure 2. How to Do a Survey for Radiation 41

Figure F-1. Distribution of U.S. Clandestine

Methamphetamine Lab Incidents by

State – 2004 60

Figure O-1. HSEES Injury Disposition –

for Hazardous Substances Emergency

Events Surveillance in 2004 85

Figure O-2. Release Type for Incidents at

Which EMS Responders Were Injured

(HSEES 2002-2007) 86

Figure O-3. Frequency of Specific Symptoms

Among EMT/EMS Injured at Scenes with

Hazardous Substance Release (HSEES

2002-2006) 87

Figure O-4. Chemical Categories Associated

with Hazardous Substance Release –

Scenes at Which EMT/EMS Were Injured

(HSEES 2002-2006) 87

OSHA Assistance 97

OSHA Regional Offices 99
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Occupational Safety and

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Acronyms

APF Assigned protection factor

APR Air-purifying respirator

ASR Atmosphere supplying respirator

ATSDR Agency for Toxic Substances and

Disease Registry

CBRN Chemical, biological, radiological, or

nuclear [agent or substance]

CBRNE Chemical, biological, radiological,

nuclear, or explosive [agent or substance]

CDC Centers for Disease Control and

Prevention

CERCLA Comprehensive Environmental

Response, Compensation, and

Liability Act

CFR Code of Federal Regulation

EMS Emergency Medical Services

EMT Emergency medical technicians

[of all levels]

ERP Emergency response plan

HAZCOM Hazard Communication

(29 CFR 1910.120)

HAZMAT Hazardous material

HAZWOPER Hazardous Waste Operations and

Emergency Response (29 CFR

1910.120)

HEPA High efficiency particulate air

[filtration system]

HICS Hospital Incident Command System

HSEES Hazardous Substances Emergency

Events Surveillance

HVA Hazard vulnerability analysis

IDLH Immediately dangerous to life

or health

ICS Incident command system

IC Incident commander

JCAHO Joint Commission on Accreditation

of Healthcare Organizations

LEPC Local emergency planning committee

LERP Local emergency response plan

NFPA National Fire Protection Association

NHTSA National Highway Traffic Safety

Administration

NIOSH National Institute for Occupational

Safety and Health

NIMS The National Incident Management

System

NRC Nuclear Regulatory Commission

PPE Personal protective equipment

PAPR Powered air-purifying respirator

SCBA Self-contained breathing apparatus

SAR Supplied-air respirator

SERP State emergency response plan

TB Tuberculosis

TSCA Toxic Substances Control Act of 1976

See Appendix A for glossary of terms
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 7

Executive Summary

In 2005, OSHA published the Best Practices for

Hospital-Based First Receivers guide that provided

guidance for those healthcare facilities that receive

and treat victims of hazardous substance releases.

At the request of stakeholders that participated in

the development of that guide, OSHA has developed a similar guide for emergency medical service

(EMS) responders who provide medical assistance

during an incident involving a hazardous substance

release. This guide is intended for employers of

EMS responders and discusses the measures these

employers need to take to protect their EMS responders from becoming additional victims while on the

front line of medical response.

Scope

EMS responders are broadly defined here as the

individuals who provide pre-hospital emergency

medical care and patient transportation. Some EMS

responders are also assigned duties that support

patient care, including patient decontamination. For

the purpose of this guide, the term EMS responder

refers to all levels of emergency medical personnel

involved in incident response (e.g., emergency medical technicians [EMTs], paramedics, and others who

perform similar duties). While many EMS responders are cross-trained (e.g., EMT and firefighter),

this guide applies to these workers only when they

are functioning as EMS responders.

The Employer’s Role

Preplanning helps employers ensure that their

workers have adequate training and personal protective equipment (PPE) for the incidents in which

the workers are expected to participate. Critical

steps for the employer involve determining the EMS

responder’s expected role in a reasonably anticipated worst-case scenario, identifying the hazards that

are associated with the EMS responder’s assigned

duties, and developing an emergency response plan

(ERP) that spells out how the EMS responder will be

prepared (through training and PPE) to safely fulfill

those duties (OSHA Instruction CPL-02-02-073,

Emergency Responses to Hazardous Substance

Releases, Aug. 27, 2007).

OSHA’s Recommendations

OSHA’s recommendations on minimum training

and PPE for EMS responders assisting patients at

hazardous substance release sites generally follow

regulatory requirements contained in paragraph (q)

of OSHA’s Hazardous Waste Operations and

Emergency Response (HAZWOPER) standard (29

Code of Federal Regulations [CFR] 1910.120) and

associated guidelines and interpretive letters. In

some instances, OSHA also recommends that, as a

best practice, employers consider offering instruction to certain EMS responders who would not otherwise receive HAZWOPER training under regulatory requirements, but who OSHA believes might find

themselves in a situation where this training would

allow them to make better decisions to protect both

themselves and other EMS personnel.

Table 2 at pg. 32 of this guide summarizes these

requirements and best practices for EMS responders who might be assigned to assist patients under

certain situations.

For example, if an EMS responder would be

assigned to provide:

• medical assistance in an environment that is

potentially immediately dangerous to life and

health (IDLH), whether in the hot or the warm

zone, then the employer must provide HAZWOPER first responder operations level training, a

self-contained breathing apparatus (SCBA) as

respiratory protection and Level A or Level B

PPE, in accordance with OSHA requirements (29

CFR 1910.120(q)(3)(iv) and Appendix B of that

standard). This level of protection may be modified by the incident commander (IC) as information becomes available. By definition, activities

such as treating contaminated patients and

decontaminating patients occur in the warm

zone. The hot, warm, and cold zones are defined

in Appendix A.

• medical assistance only in the cold zone, assisting uncontaminated or thoroughly decontaminated patients during a hazardous substance

release event, then OSHA strongly recommends

that, as a minimum, employers provide HAZWOPER first responder awareness level training.

OSHA also suggests that the next higher level of

HAZWOPER training, first responder operations

level, be provided to these workers as an appropriate “best practice” because of the possibility

of incomplete decontamination or inaccurate

triage performed by others. Regardless of the

level of training, the minimum respiratory protection for workers in the cold zone would be

only that needed for infection control purposes.

• emergency transport for uncontaminated

patients during emergencies involving an IDLH

environment or the release of an unknown/
8

Occupational Safety and

Health Administration

uncharacterized hazardous substance, then

OSHA strongly recommends HAZWOPER first

responder awareness level training or, preferably

first responder operations level training.

• uncontaminated patient transport at an incident

only after the hazardous substance is adequately

characterized, OSHA recommends that these

workers receive hazard communication training,

or as a best practice, first responder awareness

level training. The minimum respiratory protection would be only that needed for infection control purposes.

• inter-facility transport only (i.e., never respond to

911 calls), then if such a worker is unexpectedly

called upon to respond to an emergency involving a hazardous substance release, OSHA

requires that the worker must be trained as

“skilled support personnel” (29 CFR

1910.120(q)(4)). The employer should confirm

that no contracts or cooperative arrangements

exist that could result in workers responding to

the site of an emergency involving a hazardous

material. Such agreements would indicate that

these duties are expected, and, therefore, the

responders should be appropriately trained in

advance.

Best Practices Guide Content

The first section of this guide offers employers suggestions for obtaining information that will help

them determine the roles that their workers may

play in an emergency response. This section also

provides information to help employers assess the

hazards their workers may encounter in the event of

a hazardous substance release incident. This section

concludes with identifying information that should

be included in the ERP.

The next two sections provide best practices on

training and equipping EMS responders during

treatment and transport of potentially contaminated

victims. Table 2 presents best practice recommendations for levels of training and PPE for EMS

responders. Employers may incorporate these training and PPE levels into their ERPs, citing this best

practices document as the basis for those selections.

A final section addresses hazardous substance

decontamination. Although EMS responders might

not be assigned to a community’s decontamination

team, they should understand the process if they

are to recognize ineffective decontamination procedures that could result in improperly decontaminated patients – patients that EMS responders could be

expected to treat and/or transport. Furthermore,

OSHA believes that during a mass casualty incident,

EMS responders could be assigned to assist with

decontamination and would need to know how to

perform effective patient decontamination.

Appendices to this guide provide supplemental

information and examples related to issues raised

by this guide.

The Web site URLs cited in this document were

effective as of the date of publication. Be aware

that URLs are often changed. If the Web site

URL does not work, go to the home page of the

organization. This can usually be done by

deleting all of the URL characters after the first

forward slash. For instance, if the site is

http://www.cdc.gov/niosh/docs/2005-100/, the

home page would be located at www.cdc.gov.

You may then be able to find the web page of

interest by following links on the home page.
Introduction

Emergency medical services (EMS) responders are

a critical part of the nation’s emergency response

system and the front line of medical response. They

provide medical treatment at the scene of an incident and are often among the first group of responders to arrive. As a result, EMS responders are also

likely to be present on the scene before hazards are

brought fully under control and before situational

awareness is complete. Incident sites routinely contain evolving hazards that can harm emergency

responders. This Best Practices document addresses the special conditions presented by dangerous

substances released at the site of an emergency

response and discusses the measures employers

need to take to protect their EMS responders from

becoming additional victims at sites involving hazardous substances.

This guide offers the employers of EMS responders suggestions on how to determine the roles

their workers will perform in the event of a hazardous substance release incident. Employers are

expected to protect their EMS responders by

preparing them for their roles in hazardous substance response with appropriate training and PPE.

Worker training and PPE provided should correspond, so that each EMS responder is equipped

with PPE that will allow that employee to work safely in the role for which he or she is trained.

The basic steps for achieving appropriate EMS

worker protection include:

1) The employer determines the EMS responder’s

expected role in reasonably anticipated worstcase scenarios.

2) The employer conducts a hazard assessment to

identify the anticipated hazards associated with

the EMS responder’s role.

3) The employer develops an ERP that spells out

how the EMS responder will be prepared to

safely perform the responder’s anticipated role.

The plan should indicate the level of training

that the EMS responder should receive and the

type of PPE that will be provided to that responder.

This document consolidates existing OSHA policy and guidance on training and PPE for EMS

responders and is intended to help EMS responders save lives without becoming additional victims.1

Scope and Objectives

EMS responders are broadly defined here as the

individuals who provide pre-hospital emergency

medical care. EMS responder activities can encompass all levels of patient emergency care, treatment,

or transport provided at the incident location or

between that location and the receiving hospital or

other healthcare facility (i.e., inter-facility transportation). Depending on the community in which they

serve, some EMS responders are also expected to

assist with other related duties that support patient

care, including patient decontamination.

EMS Responders: For the purposes of this document, the term EMS responder refers to all levels of

emergency medical personnel involved in incident

response. This

group includes

emergency medical

technicians (EMTs)

of various levels,

paramedics, and

others who perform

the duties of an

EMT or paramedic,

regardless of their job title or employment status.

These individuals serve as the “public’s emergency

medical safety net” and will continue to do so as

the EMS system evolves in the future (NHTSA,

2000).2

These recommendations are best suited for

those individuals for whom providing medical

care is a primary mission. Others may benefit

from these recommendations, but might also

have additional training that expands their capabilities during emergencies involving hazardous

materials.

This best practices document is not intended to

advise other responders (e.g., firefighters,

police) when they perform work beyond the

duties of an EMS responder.

All Workers Functioning as EMS Responders:

This guide is intended for employers of EMS

responders of all types. This document is equally

relevant to EMS responders who are volunteers,

full- or part-time workers, and personnel of agenO S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 9

1 The existing OSHA policy and guidance appear in OSHA

standards and letters of interpretation cited throughout this

document.

2 From: NHSTA, undated. EMS Education Agenda for the

Future. Last accessed May 19, 2007. Available at www.nhtsa.

dot.gov/people/injury/ems/EdAgenda/final/agenda600.htm#core

.

Photo courtesy of Jennifer Lyden
cies, fire departments, or hospitals while they are

providing the services of an EMS responder at an

incident site or during patient transport.3 Al-though

many EMS responders are cross-trained or hold

multiple qualifications (e.g., EMT and firefighter or

HAZMAT team member), OSHA considers this

guide relevant to these individuals only while they

are performing the duties of an EMS responder. It is

not applicable when an EMS responder who is

cross-trained as a firefighter or HAZMAT team

member is performing work to fight a fire or “handle or control actual or potential leaks or spills of

hazardous substances requiring possible close

approach to the substance.”

Hazardous Substance Release: Emergency

response to a hazardous substance release is

defined here as it is in OSHA’s Hazardous Waste

Operations and Emergency Response (HAZWOPER)

standard:

“...a response effort by employees from outside the immediate release area or by other

designated responders (i.e., mutual aid

groups, local fire departments, etc.) to an

occurrence which results, or is likely to result,

in an uncontrolled release of a hazardous substance. Responses to incidental releases of

hazardous substances where the substance

can be absorbed, neutralized, or otherwise

controlled at the time of release by employees

in the immediate release area, or by maintenance personnel are not considered to be

emergency responses within the scope of this

[HAZWOPER] Standard. Responses to releases

of hazardous substances where there is no

potential safety or health hazard (i.e., fire,

explosion, or chemical exposure) are not considered to be emergency responses” (29 CFR

1910.120(a)(3)).

OSHA acknowledges the dynamic tension that

exists between the need to provide expedient

medical treatment (including taking patients to a

site where they can receive more advanced care)

and the need to protect the medical care provider.

This document focuses on reasonably anticipated worst-case scenarios with the understanding

that these situations will be relatively rare.

Nevertheless, the associated preparation will

benefit employers and EMS responders any time

patients require emergency medical assistance at

the scene of a hazardous substance release.

Hazards and Routes of Exposure: This guide

specifically covers protection for EMS responders

during responses to releases of chemicals, radiological particles, and biological agents that result in

patients who may need emergency on-scene medical care, decontamination, and/or transportation

from the scene of the release to the hospital. When

such hazardous substances are present, EMS

responders may become exposed to the substances through direct airborne or physical contact

with the contaminant at the scene, or through secondary contact while caring for a patient who

became contaminated with the substance at the

scene.4

At the Scene of the Release: This guide focuses

on protecting EMS responders who answer requests for emergency medical care at (or in close

proximity to) the scene of the hazardous substance

release. For this purpose, OSHA has placed an

emphasis on EMS response to a release of harmful

chemicals, radiological materials, or biological

agents – such as an anthrax spore powder – during

the initial release (i.e., when the release is discovered at the time of the incident). This document

does not address cases where the scene of the

release is unknown, or where the scene was identified only later through epidemiological methods,

when EMS responders would no longer be required

at the scene. Furthermore, this document does not

cover EMS responder protections for infectious

agents when a release is identified retrospectively

only after the identification of sick individuals. This

latter category includes infectious agents such as

those causing highly pathogenic avian influenza,

severe acute respiratory syndrome (SARS), plague,

smallpox, or tularemia, when spread by natural,

insidious, or clandestine release.5 In these cases,

OSHA recommends that employers consult CDC for

1 0

Occupational Safety and

Health Administration

3 See Appendix P for further discussion of OSHA jurisdiction

over public employees.

4 Hazardous substance is defined as any substance exposure

that may result in adverse effects on the health or safety of

employees. This includes substances defined under Section

101(14) of CERCLA; biological or disease-causing agents that

may reasonably be anticipated to cause death, disease, or

other health problems; any substance listed by the U.S.

Department of Transportation as hazardous material under 49

CFR 172.101 and appendices; and substances classified as hazardous waste. See 1910.120(a)(3).

5 As a special case, release of an infectious disease would be

covered by this document if a known intentional or accidental

release occurred at a known location, so that an incident scene

is recognized at the time of the release. As a rule of thumb, a

key test is the question: “Would immediate surface or victim

decontamination affect the course of the incident?” If the

answer is “no”– because victims who were at the scene have

already become infected – then CDC guidelines for handling

infectious disease incidents will be more relevant than these

best practices from OSHA.
information on EMS responder protections. For a

brief discussion of biological agents and a list of

useful Web sites, see Appendix Q – Sources of Help

in Addressing Biological Agent Issues.

Purpose

Employers of EMS responders will find this document useful during development of hazard evaluations and ERPs. The purpose of this guide is to

establish best practices that EMS employers can

implement to help EMS responders save lives without becoming additional victims. To this end, the

document will help inform employers about:

• The relevance of OSHA’s HAZWOPER standard

to EMS responders.

• Methods for obtaining information on the types

of hazardous substance release events that the

local community is preparing to address.

• The importance of identifying responder roles

and responsibilities in the community (including

those under mutual aid agreements).

• Important topics to consider while developing

an ERP.

• OSHA’s recommendations and requirements for

training and PPE when EMS responders’ roles

include the potential for response to incidents

involving hazardous substance(s).

Organization of this Guide

OSHA’s Best Practices for Protecting EMS

Responders during Treatment and Transport of

Victims of Hazardous Substance Releases is

organized into seven sections, including this

introduction and a brief conclusion.

The next sections provide background and

support for OSHA recommendations on training

and PPE (including respiratory protection) for

EMS responders who could reasonably be anticipated to respond to an event involving a hazardous substance release.

A summary of training and PPE is then provided with a summary table (Table 2) to look up the

recommended minimum training and PPE needed

for EMS responders assigned to specific roles and

under a range of anticipated conditions. Employers may cite this information when conducting

hazard evaluations required by OSHA standards

on respiratory protection and PPE. See Figure 1 at

pg. 34 for simple instructions on using the summary table.

The final section reviews topics related to

patient and responder decontamination. Although

EMS responders in many communities are not

routinely assigned to decontamination teams,

they need to be prepared to identify improper or

inadequate decontamination in patients they

receive. Additionally, OSHA believes that it is

naive to assume that some EMS responders

would not be tasked with decontamination during

an event that involves mass casualties.

This guide is supplemented with appendices

that provide additional details on topics introduced in the text, including a detailed glossary

and a list of the references cited throughout the

document and its appendices.

O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 1 1
Determinants of Training

and PPE: Personnel Roles,

Hazard Assessments and

Emergency Response Plans

OSHA considers appropriate worker preparation to

encompass both training and PPE. To determine

necessary training and PPE, the employer must

understand all workers’ roles and the associated

hazards. EMS responders should be adequately

trained for their role in emergency response during

hazardous substance events. Furthermore, each

worker’s training and PPE should be compatible, so

that the EMS responder is equipped with PPE that

will allow that individual to work safely in the role

for which that he or she is trained.

The basic steps for determining necessary training and PPE include:

1) The employer determines the EMS responder’s

expected role in a reasonably anticipated worstcase scenario.

2) The employer conducts a hazard assessment to

identify any anticipated hazards associated with

the EMS responder’s role during such a response.

3) The employer develops an ERP that spells out

how the EMS responders will be prepared to

safely perform their anticipated roles. The plan

should indicate the level of training that the EMS

responders should receive and the type of PPE

that will be provided to those responders.

This section outlines regulations, information

sources and prudent practices that shape employers’ decisions about EMS responder preparation.

The decisions that employers make about EMS

responder roles, training and PPE should be outlined in the employers’ ERPs.

EMS Responder’s Role in the Community

OSHA standards and letters of interpretation

require employers to tailor EMS responder training

and PPE to (1) the duties that EMS responders are

“expected” to perform, and (2) the expected hazards that EMS responders can reasonably be anticipated to encounter while performing those duties.

Thus, both the duties and the hazards must be

defined in order to reasonably establish training

and protection for an EMS responder.

If multiple persons are down (i.e., incapacitated)

in a public area and there is no obvious trauma,

then [a HAZWOPER trained EMS responder]

should immediately suspect a chemical exposure or attack. EMS responders without proper

PPE should never enter such an area, or if they

do enter before realizing the problem, they

should immediately exit while only removing

those closest to the exit (OSHA Stakeholder

Comments, 2006).

Specifically, in a 1991 letter of interpretation

OSHA clarified that EMS personnel should be

trained in accordance with the responsibilities they

will be expected to assume during an emergency

response as described in the community emergency response plan (OSHA, 1991-McNamara).

Furthermore, OSHA’s Personal Protective

Equipment standard requires that the employer

select appropriate PPE based on the hazards that

are present, or likely to be present, including foreseeable emergencies (see Personal Protective

Equipment for additional information on required

written documentation associated with the PPE and

respiratory protection selection processes). When

specific hazards cannot be identified in advance,

OSHA expects that employers will consider the reasonably anticipated “worst-case employee exposure scenarios” (OSHA, 2002-Hayden).

The following two sections discuss factors that

employers of EMS responders should consider

when evaluating their workers’ roles in emergency

response events and the hazards that EMS responders encounter while performing their jobs.

Defining the EMS Responder Role in Community

Response: Factors to Evaluate, Contacts,

Information Sources and Special Considerations

The employer is ultimately responsible for determining the duties to which individual EMS responders could be assigned. By defining workers’ roles

to address community expectations, the employer

will be better able to anticipate how to prepare their

EMS responders for these roles and any associated

hazardous conditions.

As a first step toward identifying EMS responder

roles, the employer should determine whether or

not its workers would be made available to respond

to an emergency. For some employers of EMS

responders involved in 911 response this is an easy

decision. Other employers might find this more dif1 2

Occupational Safety and

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ficult to answer. For instance, some employers

might employ EMS responders who never respond

to an emergency, but rather work as inter-facility

transport EMTs, transferring patients between medical facilities. As a guideline, OSHA recommends

that employers train and prepare their workers to

respond to an emergency if the employers are

party to existing contracts (e.g., with the county or

municipality) that call for the employers to participate in emergency response in the event of a disaster. Furthermore, if employers are covered by a disaster mutual aid agreement or cooperative arrangement with other emergency services providers or

communities, then the employers should prepare

their workers accordingly.

Having determined that their workers might

respond to an emergency, employers should find

out how and under what circumstances the community expects the EMS providers to respond. This

information will help employers determine the roles

to which they will assign their personnel.

“The emergency response plan for the jurisdiction

should clearly define who will be responsible for

decontaminating victims during an emergency

response.The emergency medical service personnel should be trained in accordance with the

responsibilities they will be expected to assume

during an emergency response as described in the

community emergency response plan.” (OSHA,

1991-McNamara).

Employers of EMS responders can easily

describe their workers’ day-to-day duties, but they

might find it more difficult to anticipate the actions

and hazards associated with EMS responder duties

in the event of a mass casualty event, in the face of

a new threat, or during a large-scale disaster involving several communities. These roles are typically

based on community emergency response planners’ decisions, which are in part based upon perceived risks, resources, availability of other responders, and to some extent, the influence or perceptions of the broader community (e.g., citizens, businesses, news media).

By understanding the needs and expectations of

community leaders, emergency planners, other

responders, and typical citizens, employers can better anticipate how and where they may be asked to

engage their workers under various emergency circumstances.

The expectations of the community (as expressed by its emergency planners) may be assessed

from several perspectives:

• What role does the community expect an individual EMS service provider to fill?

• What actions and tasks does the community

expect EMS responders to fill?

• Under what circumstances will these responsibilities be performed?

• Where within the continuum of hazard response

zones does the community expect EMS responders to respond?

• What actions does the community expect the

EMS responder to take when they encounter

contaminated patients?

• Does the community provide detection equipment and expect EMS responders to use it (e.g.,

ionizing radiation detectors, chemical detectors)?

• How many EMS

responders, if any,

need to be prepared to function

in the most dangerous areas (e.g.,

the hot zone) compared to the numbers of EMS

responders needed in areas with reduced or no

potential for hazardous substance exposure? Are

an adequate number of properly trained and

equipped fire- or HAZMAT-team based EMS

responders available to fill this need?

• What additional training is required to prepare

EMS responders to meet possible situations

they could encounter during emergency

response?

• Who will treat patients in the warm zone?

Specifically, the EMS employer should work

with the local emergency management agency,

Local Emergency Planning Committee (LEPC), fire

O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 1 3 Photo courtesy of Frank Califano Photo courtesy of Jennifer Lyden
department, HAZMAT team, police, and other

response partners consistent with the state and

local government structure, to determine:

• Who will be performing decontamination activities and to what extent?

• Who will remove victims from the hot zone?

• Who will treat victims trapped in a dangerous

area? 6

• Who will transport patients removed from the

scene once first responders assess them?

• Who will be available as backup, if needed?

As an additional step, it is important to work

with the community to define expectations of where

in the danger continuum (from release site to a safe

and clean area) the EMS responders could perform

their designated tasks.

Unless they have addressed these questions in

advance with the community, employers of EMS

responders will find themselves making difficult

decisions at the last minute under emergency conditions. Undefined or unwritten expectations can

hinder EMS providers’ ability to make good decisions and might result in responders arriving on the

scene unprepared or poorly equipped.

“Whatever roles are chosen, it should be clear

that SOME agency in the community has the

responsibility and training to provide patient

care in the warm zone (at least) and is properly

equipped to do so. This could be an issue if the

community has a fire department without medical responsibilities/training and they are the only

ones with Level B PPE.” (OSHA Stakeholder

Comments, 2006).

The Value of Open Dialogue

Community planners should ensure that EMS

responders participate in discussions of emergency

preparedness and exercises involving mutual aid.

The better the community’s organizations and its

citizens understanding of the strengths and limitations of their EMS system, the more realistic the

community’s expectations will be during an actual

emergency. Additionally, employers that foster

open and trusting dialogue between themselves

and these community groups during day-to-day

operations will find it easier to share valuable information in times of crisis. In the midst of a disaster,

that shared information might help remind community members of both the greatest strengths and

the realistic limitations of their EMS responders.

This could help protect employers from being pressured by the demands of unrealistic community

expectations into providing EMS responders for

activities for which they are not properly trained or

equipped.

Background information for media might include

answers to:

• Why are some responders equipped and

trained to one level, while others are prepared

at a different level? How does this benefit the

community?

• What are the benefits and limitations of different types of protective equipment that an EMS

responder might use?

• Which categories of responders provide rescue

in hazardous areas, and why were they selected for this role?

A specific example of a proactive practice for

communication would be employers who promote

dialogue with the media. Emergency responders,

including EMS responders, can help media representatives before a disaster occurs by providing

useful background information to help the media

understand how EMS responders work and what

conditions put them at undue risk. It is also important for citizens to understand how the risk to the

community increases when EMS responders and

ambulances must be taken out of commission due

to contamination, injury, or illness. Employers

might consider training media spokespersons who

can help disseminate this message. During an

emergency, however, communication with the

media must be with one voice through the incident

command system (ICS) structure.7

The EMS Hazard Assessment

Requirement and Purpose

Employers must conduct hazard assessments to

identify the expected hazards associated with EMS

1 4

Occupational Safety and

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6 Also attempt to answer questions such as, “In this community, where is the line drawn between attempting to save a victim and maintaining the safety and health of the EMT (...and of

the second EMT who would attempt to save the first EMT)?” Is

that line set at a realistic point? Clearly defined expectations

help employers communicate these expectations to employees, who may require supportive training. It is counterintuitive

for a medic (regardless how unqualified) to stand back and

NOT respond to a victim in need of rescue. In a hazardous substance incident, however, the danger may be increased if

unqualified individuals respond unsafely. EMS responders

must be trained and equipped to safely perform their duties in

the environments they will encounter.

7 The Hospital Incident Command System (HICS), an ICS for

hospital/healthcare organizations is described in Appendix I.
responders’ roles in responses to reasonably anticipated worst-case scenarios in the community. These

hazard assessments are required, for example, by

OSHA’s Personal Protective Equipment standard

(1910.132(d)(2)) and give the employer the information needed to select PPE (i.e., eye, hand, foot, head

protection) that is suitable for the EMS responders’

work conditions. The employer must produce a

written certification that the hazard assessment has

been conducted (see page 27 for further discussion

of the necessary documentation).

EMS responders must also consider anticipated

airborne hazards when selecting respiratory protection for EMS responders. Factors to consider

include identifying the substance, making a reasonable estimate of exposure levels, and predicting the

contaminant’s chemical state and physical form.

When it is not possible to identify the contaminant

or estimate worker exposure levels, the employer

must consider the atmosphere to be immediately

dangerous to life and health (IDLH). (29 CFR

1910.134(d)(1)(iii)). As discussed in the section,

Summary of OSHA’s Recommendations for Training

and PPE, both PPE and respiratory protection are

prescribed for IDLH environments by the HAZWOPER standard, which requires an SCBA respirator and

Level A or Level B PPE, as defined by Appendix B of

the HAZWOPER standard.

Not all EMS responders must be equipped to

work in an IDLH environment. In particular, EMS

responders may wear lower levels of respiratory

protection and PPE in areas where the Incident

Commander has determined that an IDLH environment does not exist. In that case, EMS responders

must wear respiratory protection and PPE at least as

protective as that which the Incident Commander

has determined necessary to protect them from the

hazards that exist in the area. Frequently, the PPE

and respiratory protection permitted at these times

is less cumbersome, more comfortable, and less

costly than that required for work in IDLH environments.

It is for the purpose of identifying protective

equipment suitable for these reduced hazard situations that the employer must perform the most

detailed hazard assessments and respiratory hazard

evaluations. The information they gather will help

employers who wish to equip their EMS responders

in this manner with the information needed to

choose respiratory protection and PPE that will provide reasonable protection under the range of nonIDLH conditions workers are most likely to

encounter in their assigned roles. Fortunately,

although the employer is ultimately responsible for

ensuring that its EMS responders are adequately

protected, much of the information needed to select

the protective equipment is available from other

sources within the community.

Sources of Hazard Assessment Information

in the Community

Numerous resources are available to employers of

EMS responders regarding hazards for which the

community expects to prepare. In seeking hazard

assessment information, employers should place

emphasis on obtaining information most relevant to

EMS responders. One particularly good place to

start, which does not require original research, is

with a local hospital’s Hazard Vulnerability Analysis

(HVA).8 Drawing on the hazard assessment findings

of other organizations and experts will save time

and speed the process of determining what training

and PPE are necessary, as well as aiding in the creation of the employers’ ERP.

LEPCs are community planning organizations

that most likely have as members employers of

EMS responders and other experts involved in

emergency management.9 There is no requirement

for a community to form an LEPC, but there are a

number of benefits including access to low or nocost training and other preparedness activities. One

of the requirements LEPCs must fulfill is to conduct

a community hazard assessment. The Hazardous

Materials Emergency Planning Guide, published

by the National Response Team and available at:

www.nrt.org, provides guidance on how to perform

these assessments. This process may help employers prepare their own hazard assessment if necessary. Where mutual aid agreements increase the

possibility of EMS personnel responding to other

8 The Joint Commission on Accreditation of Hospital

Organizations (JCAHO) requires that accredited hospitals

develop and review an HVA. In a 2004 survey, 84 percent of

575 hospitals reported having completed a collaborative threat

and vulnerability analysis of the community (Barbara et al.,

2006). When asked, “Do you perceive your hospital to be at

increased risk for any of the following hazards or threats

(check all that apply),” 76 percent of the 575 respondents listed

“hazardous materials” as a perceived risk at their hospital,

while 47 percent listed “terrorism” and 26 percent listed

“nuclear concerns.” For comparison, risks associated with

severe weather (e.g., floods, tornados, and winter storms)

were mentioned by 42 percent, 62 percent, and 67 percent of

the hospitals, respectively. Describing a weakness of the study,

the authors reported that slightly more than half of the hospitals that responded to the survey were located in urban areas

and 35 percent were trauma centers. Small, rural, and unaccredited hospitals were less likely to have responded and so

they were underrepresented in the survey results. A lack of historic experience with certain types of events (e.g., terrorism)

also limits the strength of this subjective information.

9 Visit http://yosemite.epa.gov/oswer/lepcdb.nsf/Home

Page?openForm to see listings for LEPCs by location.

O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 1 5
communities, employers should also consider the

hazards which those other communities perceive as

increased risks.

Information provided by community members

can be used to concentrate or supplement areas of

concern suggested by public information sources,

such as the Hazardous Substances Emergency

Events Surveillance (HSEES) system database.10

Review of these data suggest the types of substance

release incidents most likely to result in exposures

and casualties (Hall et al., 1994; Hall et al., 1995; Hall

et al., 1996; Berkowitz et al., 2004; Kaye et al., 2005).

Appendix E contains a summary of these analyses.

When reviewing the HSEES information, however,

employers should note that some of the HSEES

data analyses and similar sources predate the

September 11, 2001 attack on the World Trade Center

and do not include consideration of terrorism.

Other sources of information on community hazards include:

• Local HAZMAT teams.

• EPA’s Envirofacts (www.epa.gov/enviro/index_

java.html).

• The spill reports database of the National

Response Center (available through www.nrt.org

or at www.nrc.uscg.mil/index.html).

• Community right-to-know information available

from the LEPC or the State Emergency Response

Commission.

• National Fire Incident Reporting System available from the U.S. Fire Administration at

www.usfa.dhs.gov/fireservice/nfirs.

Other local organizations can also provide information gathered from their activities. Examples of

these resources include the local or state fire marshal, local health authorities, and county agriculture

agents. On a national scale, the Homeland Security

Council and U.S. Department of Homeland Security

have published a list of 15 scenarios, considered

“the worst-case” situations for which the nation

needs to prepare. Hazardous substance release is

among them (Homeland Security Council, 2005).

While these scenarios may be too broad for individual employers to use in planning to protect EMS

responders, the employers may find these scenarios

referenced in community plans.

Include EMS Responder Health and Safety

Experience in Hazard Assessments

OSHA permits the use of industry and company

experience in the hazard assessment. Appendix O –

Occupational Health Hazard Experience of EMS

Responders – contains information on the published

experiences of EMS responders, both during hazardous substance release events and during routine

responses. When conducting hazard assessments

for EMS responders, employers may draw upon this

information, then supplement it with information

related to anticipated local conditions. These

employers may also incorporate information on

their own health and safety experience (e.g., from

occupational injury and illness records or other

employer records).

Incorporating EMS Responder

Preparation into an Effective

Emergency Response Plan

Emergency response plans describe policies and

procedures developed by employers, based on the

roles EMS responders will serve and the hazard

assessments associated with these roles in the community. An OSHA compliance instruction notes that

if employers have chosen to have their own workers

respond to releases that would require an emergency response, the employers must develop emergency response capabilities that are appropriate to

their individual situations (OSHA, 2007-CPL-02-02-

073). Employers’ ERPs must describe the steps that

the employers have taken to prepare all of their

workers (in this case EMS responders) who would

be expected to respond in the event of a hazardous

substance release.

Employers must have an ERP that explains what

steps are being taken to be sure that all of their

EMS responders:

• Are adequately trained for their intended job

duties.

• Are properly equipped for the intended tasks.

• Are capable of responding in a safe manner.

• Are managed by competent leaders.

(OSHA CPL-02-02-073, 2007)

In evaluating ERPs, OSHA looks for signs of an

effective program, including (but not limited to):

10 Also in 1989, the Agency for Toxic Substances and Disease

Registry (ATSDR) implemented an active state-based hazardous substances emergency events surveillance system

(HSEES) in an attempt to adequately characterize the public

health consequences of hazardous substance releases. A hazardous substance emergency event is defined as uncontrolled

or illegal releases or threatened releases of chemicals or their

hazardous by-products. The HSEES database collects information on events, chemicals, victims, injuries and evacuations.

Analysis of the HSEES data helps identify risk factors associated with hazardous substances releases.

1 6

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O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 1 7

• Pre-emergency planning and coordination, such

as integration with a local or state emergency

response plan (LERP or SERP).

• Identification of the types of hazardous substance release emergencies that would require

response.

• Clearly defined personnel roles.

• Clear lines of communication.

• Worker training that is consistent with their

roles.

• Procedures to be followed if personnel or equipment require decontamination.

• Selection of PPE for personnel performing

decontamination.

• An inventory of PPE and emergency response

equipment, including instructions for use, their

limitations, and the circumstances under which

they will be used.

• Procedures for critiquing responses (to help

improve future responses).

The previous sections suggested methods employers can use to identify their workers’ anticipated

roles in emergency responses involving hazardous

substance releases. The following sections are intended to help employers consider the HAZWOPER

training and PPE needs of their EMS responders

based on their anticipated roles and responsibilities.
1 8

Occupational Safety and

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Training

Background

Summary of Existing Training Guidelines

for EMS Responders

The U.S. Department of Transportation’s (DOT),

National Highway Traffic Safety Administration

(NHTSA) developed a National Standard

Curriculum (NSC) for EMTs at all provider levels.

These guidelines constitute the basic national

entry-level training requirements for EMS responders, accepted by most states, while leaving the

option for state and local authorities to tailor the

guidelines to best meet local needs. NHTSA’s NSC

introduces the topic of hazardous substances and

response associated with hazardous substance

releases, but does not automatically prepare EMS

responders to meet the expected levels of competence required by OSHA’s HAZWOPER standard,

nor does it provide information relevant to local

community emergency response plans (OSHA,

2004-Gantt). To meet the requirement for emergency first responder HAZWOPER training at either

the awareness or operations level, the trainer must:

• Augment the NSC with additional hazardous

substance response information.

• Tailor the training to the individual worker’s

assigned duties.

• Augment the operations level training duration

to meet minimum HAZWOPER requirements

(see Training Duration, below [for First

Responder Operations Level]).

Other organizations also offer supplemental

training for EMS responders. Examples include the

training activities for DOT’s Hazardous Materials

Emergency Preparedness program, the Federal

Emergency Management Agency’s (FEMA)

Emergency Management Institute course offerings,

and the National Institute of Environmental Health

Sciences’ (NIEHS) Worker Environmental Training

Program. These programs also require tailoring to

include local community response plans to ensure

that EMS responders understand their assigned

duties.

Applicability of HAZWOPER Training to

EMS Responders

The scope of paragraph (q) of OSHA’s HAZWOPER

standard (or the parallel state standards in states

with OSHA-approved State Plans) covers “emergency response operations for releases of, or substantial threats of releases of, hazardous substances without regard to the location of the hazard.” (29 CFR 1910.120(a)(1)(v)). Specifically, paragraph (q) covers employers whose workers are

engaged in emergency response no matter where it

occurs, unless those workers are engaged in hazardous waste site operations.11

HAZWOPER paragraph (q) outlines requirements for advance planning, training, medical

monitoring and PPE for emergency responders.

Several specific categories of emergency response

personnel are defined in this paragraph, including

first responder awareness level and first responder

operations level. OSHA’s compliance directive for

paragraph (q) specifically includes “emergency

medical services” responding to a hazardous substance release area.

OSHA has clarified that the HAZWOPER standard

only applies to emergency releases, or substantial

threats of releases, of hazardous substances.

“HAZWOPER does not necessarily apply to every

incident in which an individual requiring medical

treatment is contaminated with [a] hazardous substance. OSHA cannot require HAZWOPER training

for incidents outside the scope of the standard,

although such training may be beneficial.” (OSHA,

1995-Nechis). The scope of the HAZWOPER standard does not cover “incidental releases,” releases

that are limited in quantity and pose no emergency

or significant threat to the safety and health of

workers in the immediate vicinity.

An example is a tanker truck receiving a load

of HAZMAT at a tanker truck loading station.

At the time of the accidental spill, the product

can be contained by employees in the imme11 The exceptions indicate that paragraph (q) does not apply to

activities at uncontrolled hazardous waste sites that are on

EPA's National Priority Site List (NPL), cleanup operations at

sites covered by the Resource Conservation and Recovery Act

of 1976 (RCRA), voluntary cleanup operations at sites recognized by federal, state, local or other governmental bodies as

uncontrolled hazardous waste sites, and operations involving

hazardous waste that are conducted at treatment, storage, disposal (TSD) facilities regulated by 40 CFR Parts 264 and 265

pursuant to RCRA; or by agencies under agreement with U.S.

EPA to implement RCRA regulations (see paragraphs (a)(1)(i)

through (a)(1)(iv) of 29 CFR 1910.120). The standard goes on to

state that only paragraph (q) of the standard applies to emergency response activities unless the response involves an

identified hazardous waste site (29 CFR 1910.120(a)(2)(iv)).

Other provisions of the HAZWOPER standard do not apply to

emergency response operations except where paragraph (q)

specifically refers to the other provisions.
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 1 9

diate vicinity and cleaned up utilizing

absorbent without posing a threat to the safety and health of employees.Thus, this situation is considered an incidental release, not an

emergency release covered by HAZWOPER

(OSHA, 2007-CPL-02-02-073).

The principles of risk assessment, PPE, decontamination and training apply equally.

As further clarification, OSHA explains in

Appendix A of the HAZWOPER compliance

directive that personnel responding to an

overturned aircraft leaking jet fuel would likely

be performing emergency response due to the

significant and uncontrolled hazards posed by

the aircraft and jet fuel.These personnel would

be conducting operations such as fire fighting,

passenger rescue and working to stop the

release of jet fuel. However, a fuel spill from a

tanker truck that can be absorbed, neutralized

or otherwise controlled by employees in the

immediate release area through the placement

of absorbent pads may qualify as an incidental

release, providing that there are no significant

health or safety hazards (OSHA, 2007-CPL-02-

02-073).12

Regarding acts of terrorism and natural disasters, an OSHA directive on the HAZWOPER standard explains that, while employers are not

required to prepare specifically for terrorist events

(which are considered unforeseeable workplace

emergencies),13 employers must prepare for emergencies that release hazardous substances, regardless of the cause of the release.

The release of chemicals or hazardous substances into a workplace, whether caused by

an accidental release or by a terrorist event

would...be considered a hazardous substance

(HAZMAT) incident. All emergency responders

and employees performing emergency

response efforts for such releases would,

therefore, fall under 1910.120(q).The level of

emergency responder training must be based

on the duties and functions to be performed

by each responder.

Workplaces located in areas prone to natural

phenomena, such as earthquakes, floods, tornadoes, and hurricanes, and potentially subject to a ‘substantial threat of release of hazardous substances’ are covered by 1910.120.

The ERP required in 1910.120(q)(1) must include responses to emergencies caused by

such natural phenomena.The requirement of

the ERP clearly states in paragraph (q)(1), that

emergency response plans ‘shall be developed and implemented to handle anticipated

emergencies prior to the commencement of

emergency response operations.’ This means

that employers in areas prone to natural phenomena should anticipate whether such natural phenomena are likely to cause releases of

hazardous substances and, if so, to incorporate emergency response procedures to such

natural phenomenon in their ERP (OSHA CPL

02-02-073, 2007).

Medical personnel, including EMS responders,

are not typically first on the scene, but because

EMS responders do usually respond in the first

phase of an incident, they are likely to be involved

at the scene of an emergency during the initial risk

assessment, rather than having the advantage of a

fully characterized hazard assessment when they

arrive. Although many scenes initially considered

to potentially involve a hazardous substance release can be quickly reclassified, EMS responders

sent to the scene of an emergency must be appropriately trained to work in a suspect environment.

This means that EMS responders need instruction

on how to think beyond the confines of “medical

care” so they can work safely and function as part

of the incident command system (ICS). At any

evolving emergency scene, EMS responders’ duties

might range from keeping themselves out of situations that present a hazard and are beyond the

capacity of their level of training or available protective equipment, to contributing observations and

information about the patient’s condition that will

influence triage decisions and help decision-makers

better characterize the hazards at the site.14 These

considerations point to the need for first responder

awareness level training as a minimum.

12 Other OSHA standards will still apply, such those as for hazard

communication (29 CFR 1910.1200), permissible exposure limits

(29 CFR 1910.1000), respiratory protection (29 CFR 1910.134), and

personal protective equipment (29 CFR 1910.132).

13 “OSHA does not consider terrorist events to be foreseeable

workplace emergencies for purposes of standards requiring

employers to anticipate and prepare for such emergencies.”

(OSHA, CPL 02-02-073, 2007).

14 For example, patients treated by the EMS responder might

exhibit signs and symptoms that suggest the presence or identity

(i.e., raise the index of suspicion) of a hazardous substance

release.
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First on the Scene

The situation of an EMS responder arriving first

on the scene could arise more or less frequently

depending on the experience and practices in

that community.

For example, first responders in some communities may be obliged to stop if they happen

upon a transportation accident that has just

occurred. The accident might involve a hazardous substance release. Furthermore, some

communities dispatch EMS responders, rather

than police or firefighters, to certain medical

911 calls, but it is possible that those calls could

involve hazardous substances that were not

reported during the 911 call.

If, in the initial stages of a response, the EMS

responder could temporarily be the decisionmaker at the site until a more qualified incident

commander arrives, then that EMS responder

requires both first responder operations level

training [29 CFR 1910.120(q)(6)(ii)] and incident

commander training (29 CFR 1910.120(q)(6)(v)).

Some EMS responders should have additionallevels of training. Although not normally the case,

occasions exist when EMS responders could be the

first to arrive on a scene (see above text box, First

on the Scene). In this case, the EMS responder

could have interim authority as the initial incident

commander (IC) for the brief period between incident discovery and the time that a correctly trained

IC arrives at the scene. The EMS responders who

could find themselves performing this role need

additional instruction on how to think beyond the

confines of medical care (see above box “First on

the Scene”). Furthermore, specific EMS responders

might be designated to provide special services,

such as rescue, decontamination, or treatment of

trapped patients in an area of higher hazard. These

individuals also require, at a minimum, first

responder operations level training. Online training

resources on the National Incident Management

System (NIMS) and the Incident Command System

(ICS) are available through the Federal Emergency

Management Agency (FEMA) Website.15

EMS Responder Roles Requiring

HAZWOPER Training

First Responder Awareness Level Training

First responder training at the awareness level is the

minimum level of training required for EMS responders who respond to emergencies (including 911

calls) and might be first on the scene of an emergency, but would not be expected to treat or handle

a contaminated patient (OSHA, 1991-McNamara).

These EMS responders would not be designated to

serve in any capacity on a decontamination team at

the site of the emergency release, nor would they

enter an area where contaminants could be present.

This group of EMS responders would be responsible

for notifying authorities if they encountered suspect

hazardous substances at a scene and are expected

to stay alert to signs that a release might have

occurred, but would not attempt to rescue patients

or treat contaminated patients (OSHA, 1991-

McNamara). Rather, these EMS responders would

wait for other properly trained and equipped first

responders to bring thoroughly decontaminated

patients to a safe area where the EMS responders

could treat them. A higher level of training (HAZWOPER first responder operations level training) is

required if an EMS responder could be assigned to

rescue, treat, or participate in decontamination of

victims of a hazardous substance release, or provide

these services under any mutual aid agreement or

employer contract with the community. OSHA does

not believe that all EMS responders need to be

trained to treat contaminated victims (OSHA, 1992-

Chapman); however, those who will perform this

service must be properly trained to do so. First

responder awareness level training should adequately prepare EMS responders to use professional

judgment to distinguish between the situations for

which the responder is qualified to act and those

which require a higher level of training and PPE.

Training Duration,Topics and Competencies

First responder training requirements for the awareness level appear under 29 CFR 1910.120(q)(6)(i).

This section does not require a specific minimum

training duration, but outlines topics that must be

covered (competencies the worker must acquire). In

the HAZWOPER compliance directive, OSHA mentions that although the standard does not set a minimum number of hours for this training, “such

courses often run from 4 to 12 hours” (OSHA, 2007-

CPL-02-02-073). The HAZWOPER standard allows an

alternative to the first responder awareness level

training requirement. Training can be waived if the

worker has had sufficient experience to objectively

demonstrate competency in specific areas. The

required training topics (or areas of competency)

are listed in 29 CFR 1910.120(q)(6)(i), or the parallel

State Plan standards, and include: 15 To access NIMS and ICS online training, go to

http://www.fema.gov/emergency/nims/nims_training.shtm#0.
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 2 1

fulfill the refresher training requirement.

First Responder Operations LevelTraining

Employers must provide HAZWOPER first responder operations level training to designated EMS

responders who are expected to treat patients

before they are thoroughly decontaminated. This

includes EMS responders who perform decontamination, which could bring the EMS responder into

contact with contaminated individuals (OSHA, 1991-

McNamara; OSHA, 1992-Levitin). It also includes

EMS responders who “enter the danger area to

perform rescue or treat contaminated victims.”

(OSHA, 1995-Nechis).

Training Duration

Training requirements for first responder operations

level appear under 29 CFR 1910.120 (q)(6)(ii), which

indicates a minimum training duration of 8 hours

and outlines topics to be covered (competencies

the worker must acquire). Both the required competencies and training time for medical personnel

trained at first responder operations level were confirmed in an interpretive letter (OSHA, 2003-Bolt).

OSHA, however, allows these topics (but not the

minimum training time) to be tailored to better

meet the needs of first responders. Training that is

relevant to the required competencies counts

toward the 8-hour requirement, even if the training

is provided as a separate course. For example,

training on PPE that will be used during patient

decontamination activities may be applied towards

the 8-hour minimum first responder operations

level training requirement, regardless of whether

the PPE training is conducted as part of a specific

HAZWOPER training course or as part of another

training program (OSHA, 1992-Levitin).

First responder awareness level training completed by a worker also counts towards that individual’s 8-hour requirement for first responder training

at the operations level. This point is clarified in a

letter of interpretation issued by OSHA:

“...if you spend two hours training employees

in the required competencies for First

Responder Awareness Level as described in 29

CFR 1910.120(q)(6)(i)(A)-(F), then you would

need to spend at least six additional hours training employees in the required competencies for

First Responder Operations Level as described

in 29 CFR 1910.120(q)(6)(ii)(A)-(F). Depending on

the employees’ job duties and prior education

and experience, more than eight hours of training may be needed.” (OSHA, 2003-Bolt).

• An understanding of what hazardous substances

are, and their associated risks during an incident.16

• An understanding of the potential outcomes

associated with an emergency created when

hazardous substances are present.

• The ability to recognize the presence of hazardous substances in an emergency.

• The ability to identify the hazardous substances,

if possible.

• An understanding of their role in the employer’s

emergency response plan, including site security

and control and the DOT Emergency Response

Guidebook.

• The ability to realize the need for additional

resources and to make appropriate notifications

to the communications center.

Although not required, OSHA recommends as a

best practice that training include information on

risk assessment and risk management to enable

EMS responders to understand and identify the limitations of their expected role.

• Recognizing the types of situations that could

include a hazardous substance release.

• Placards, labels, common hazard rating schemes

(e.g., National Fire Protection Association [NFPA]

hazard warning diamond) and other indicators

of hazardous substances.

• Recognizing signs or symptoms of hazardous

substance exposure in patients and responders.

• The steps the EMS responder is expected to take

if a scene or patient is discovered to be contaminated with a hazardous substance (or substance

suspected of being hazardous).

• The extent and limitations of the EMS responder’s training and PPE (what they are and are

not prepared to do).

Annual RefresherTraining

Annual refresher training is required for workers

trained at the first responder awareness level. The

class content must be adequate to maintain the

EMS responder’s competence, and the employer

must document the training or the method used to

demonstrate the EMS responder’s competence.

Employers may also use actual or drill responses to

16 As noted previously, a hazardous substance is any substance

to which exposure may result in adverse effects on health or

safety of workers. This includes biological agents, substances

listed by U.S. DOT as hazardous materials, and substances classified as hazardous wastes. See Appendix A – Glossary for a more

detailed definition.
• Recognizing signs and symptom of exposure to

hazardous substances that they could encounter

at emergency response scenes in jurisdictions

they might cover (including those areas covered

by mutual aid agreements).

• Assessing site safety, including risks to EMS

responders.

• Specific training on hazardous risk assessment

during encounters with contaminated patients.

• Selecting and using appropriate PPE. (See paragraphs below titled AssociatedTraining – PPE

and AssociatedTraining – Respiratory

Protection.)

• Employing patient decontamination procedures.

(See Best Practices for Pre-ambulance Patient

Decontamination, below.)

Annual RefresherTraining

Annual refresher training at the first responder

operations level is required under 1910.120(q)(8)(i),

or the parallel State Plan standards; however, the

length of the refresher training is not specified.

Instead, the standard requires that workers trained

at the first responder operations level shall receive

annual refresher training of sufficient content and

duration to maintain their competencies, or shall

demonstrate competency in those areas at least

yearly. Employers may also use actual or drill

responses to fulfill the refresher training requirement.

Documenting HowTraining Requirements Are

Met: Employers of EMS responders must document that initial and refresher training was performed, or alternatively, keep a record of how the

EMS responder demonstrated competence in the

required areas. This is particularly important whenever workers are allowed to satisfy any portion of

the training requirement through other related

training or through demonstration of competence.

The HAZWOPER standard requires, and an OSHA

letter of interpretation confirms, that the employer

must certify in writing the comparable training or

demonstrated competencies (OSHA, 2003-Bolt).

AssociatedTraining

The following subsections briefly describe training

that employers must provide EMS responders who

use PPE and/or respiratory protection. This training

can count towards the 8-hour requirement for first

responder operations level training.

Option to Demonstrate Competence

As with first responder awareness level training, the

HAZWOPER standard allows workers to demonstrate competence in specific areas as an alternative

to the 8-hour training requirement (29 CFR

1910.120(q)(6)(ii)). OSHA reaffirmed this point in a

letter of interpretation (OSHA, 2003-Bolt). However,

it is important to recognize that in the typical EMS

responder setting, it might be difficult to ensure

that workers have sufficient experience to waive all

the training requirements. Many EMS responders

lack extensive experience with higher levels of respiratory protection along with, as the studies cited

in Appendix O demonstrate, performance of decontamination activities.

Topics forTraining or Demonstration

of Competency

The HAZWOPER standard requires that workers

trained at the first responder operations level shall

have received at least 8 hours of training or have

had sufficient experience to objectively demonstrate competency (e.g., in exercises and drills) in

the following areas (1910.120(q)(6)(ii)):

All of the topics previously listed for first responder training at the awareness level, plus the additional topics listed here.

• Knowledge of the basic hazard and risk assessment techniques.

• Knowledge of how to select and use proper PPE.

[A critical aspect is knowing both when PPE is

useful, and under what circumstances it will

NOT provide adequate protection.]

• An understanding of basic hazardous materials

terms.

• Knowledge of how to perform basic control,

containment, and/or confinement operations

within the capabilities of the resources and PPE

available.

• Knowledge of how to implement basic decontamination procedures.

• An understanding of the relevant standard operating procedures and termination procedures.

Although not required, OSHA recommends as

a best practice that training topics be tailored to

reflect EMS responders’ anticipated duties and

might include details such as:

• Understanding the community emergency operations plan and EMS responders’ role in the

response, including who will provide decontamination services.

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O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 2 3

It is also important that the level of training be

compatible with the PPE that is provided to EMS

responders. Over-equipping workers may

encourage them to attempt activities beyond the

level for which they are trained. If workers

require a higher level of protection, consider

whether a higher level of training, including

HAZWOPER training, is also needed.

AssociatedTraining – PPE

The first responder operations level training related

to the use of PPE must include topics as required by

OSHA’s PPE standard (29 CFR 1910.132). Under this

standard, training must be provided to each worker

who is required to use PPE. At a minimum, that

training must cover the following:

• Recognizing when PPE is necessary.

• Identifying what PPE is necessary.

• Demonstrating how to properly put on, remove,

adjust, and wear PPE.

• Understanding the limitations and hazards of

PPE.

• Understanding the proper care, maintenance,

useful life and disposal of PPE.

Workers must demonstrate their understanding

of the training by showing that they can use the PPE

properly, prior to wearing it in the workplace.

Refresher training is required when the worker cannot demonstrate proficiency in the proper care and

use of the PPE, when changes in the workplace render the previous training inadequate, or when

changes in the type of PPE to be used render the

previous training inadequate. The employer must

maintain a written record of worker PPE training. It

is the employer’s responsibility to assess the full

range of the EMS responder’s expected duties and

provide PPE and PPE training accordingly. This

assessment must include the worker’s expected role

during reasonably anticipated worst-case scenarios.

AssociatedTraining – Respiratory Protection

First responder training at the operations level also

must include training required by OSHA’s

Respiratory Protection standard (29 CFR 1910.134),

or the parallel State Plan standards. Specifically, any

worker who must wear a respirator must be trained

in the proper use and limitations of that device prior

to its use in the workplace. The training must be

comprehensive enough that the worker is able to

demonstrate knowledge of the seven training topics

specified in the standard and outlined below. The

worker also must be able to demonstrate competence in wearing the complete PPE ensemble,

including respirator, protective garment, gloves,

boots, and any other safety equipment required for

the worker’s role. Refresher training is required at

least annually, or sooner if changes in the workplace

or type of respirator render previous training inadequate. Refresher training is also required if the

worker does not demonstrate proficiency in the

proper care and use of the respirator, or at any

other time when retraining appears necessary to

ensure safe respirator use.

At a minimum, training under OSHA’s

Respiratory Protection standard must cover the following topic areas:

• The nature of the respiratory hazard, and why a

respirator is needed.

• Respirator capabilities, limitations and consequences if the respirator is not used correctly.

• How to handle respirator malfunctions and other

emergencies.

• How to inspect, put on, remove, use and check

seals on the respirator.

• How to maintain the respirator face/face seal

integrity (e.g., through proper grooming, cleaning, and correct use).

• Maintenance and storage procedures.

• When to change cartridges on air purifying respirators (APRs).

• Additional prescribed procedures relating to

SCBAs (if used), such as monthly inspections

and ensuring breathing air quality.

• How to recognize medical signs and symptoms that

may limit or prevent effective use of a respirator.

• General requirements of the respiratory protection program.

Sources of Training and Curricula

Several examples of HAZWOPER first responder

operations level training curricula are available for

employers preparing EMS responders to conduct

decontamination activities. Examples include the

Hazardous Materials andTerrorist Incident

Prevention Curriculum Guidelines (HMEP, 1996).

However, these curricula are not necessarily

designed as 8-hour presentations. Many curricula

are longer, while others are shorter and intended for

use when workers are able to demonstrate competence in specific areas. See Appendix H for an additional discussion on options for first responder training at the awareness and operations levels for EMS

personnel.
2 4

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If employees who only provide inter-facility transport are unexpectedly called on to aid a contaminated victim, those individuals may be considered skilled support personnel and receive special

on-the-spot training.

However, if repeatedly called upon to treat accident victims contaminated from HAZWOPER incidents, the EMS employer must train and designate the employees to the First Responder

Operations Level (OSHA, Nechis, 1995).

(See the related discussion of skilled support personnel, below).

First responder training is offered at both the

awareness and operations levels through a number

of public and private organizations. An increasing

number of hospitals offer (or coordinate) local classes tailored to medical personnel.17

EMS Responder Roles that Require

No HAZWOPER Training

As noted previously, if an employer has not agreed

to be designated in a state or local emergency

response plan to respond to a hazardous substance

release, then the employer may not have any obligation to train workers under the HAZWOPER standard

(OSHA, 1995-Nechis). For example, employers are

not obliged to provide HAZWOPER training to an

EMS responder whose work involves only patient

transport between medical treatment facilities, as

long as no agreements exist that could increase

the EMS responder’s involvement in emergency

response including hazardous substances.

It also bears repeating that employers may not

designate an EMS responder as exempt from HAZWOPER training if it is anticipated that the EMS

responder could suddenly be activated to provide

911 response. This prohibition holds even for “strictly medical” 911 calls – since some of these calls can

involve unanticipated hazardous substance release

(e.g., scenes that upon arrival are discovered to

involve a methamphetamine laboratory). Similarly,

an EMS responder cannot be exempt from HAZWOPER training if the employer has entered into a

mutual aid agreement that could result in the EMS

responder responding to an emergency or a 911 call,

or if the employer has signed support contracts or

made arrangements with the community, local

organizations, or neighboring communities that

could result in the EMS responder being sent to the

site of an emergency.

Because a worker without HAZWOPER training

might not be equipped to identify the presence of a

hazardous condition and make the decision to stay

away, an untrained EMS responder who happens

upon the scene of an emergency should not approach the site.

Skilled Support Personnel

The HAZWOPER standard allows for the case where

a worker is not expected to serve in an emergency

response capacity, but nevertheless is suddenly

called upon (e.g., as a one-time occurrence) to provide emergency care at a scene involving hazardous

substance release. When this occurs, the worker is

termed skilled support personnel. An EMS responder who has been exempt from HAZWOPER training

by the employer (such as those discussed above),

but is unexpectedly called on to aid a contaminated

patient, or perform other work at the scene of a hazardous substance release, is considered skilled support personnel. Other examples of skilled support

personnel include a medical specialist or a trade person, such as an electrician. These individuals must

receive expedient orientation to site operations,

immediately prior to providing such services (OSHA,

1997-Whittaker). An EMS responder without HAZWOPER training might treat and transport patients

that have been “...totally and thoroughly decontaminated and removed from the danger zone. However,

in this case, while working as skilled support personnel, these EMS responders should be given an initial

briefing at the site...” prior to providing this service

(OSHA, 1991-McNamara). This briefing would also

be needed for EMS responders trained at the first

responder awareness level, who are suddenly called

upon to provide decontamination services, which

would require first responder training at the operations level. The briefing for skilled support personnel

is intended to provide the individual with information necessary to safely do a specific job at a specific

incident site and typically assumes no prior HAZWOPER training.

The following quotation from an OSHA letter of

interpretation emphasizes this important point:

“...if an EMS [squad] is not designated in any

emergency response plan, but finds that they are

repeatedly called upon to treat accident victims

contaminated from a HAZWOPER incident, these

workers cannot be considered skilled support

personnel and the EMS employer must train and

designate the workers to the First Responder

Operations Level.” (OSHA, 1995-Nechis).

17 Additional resources to assist with the development of training

can be found at: www.osha.gov/SLTC/emergencypreparedness/

index.html.
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 2 5

When an EMS responder is unexpectedly called

upon to respond to a hazardous substance incident

as skilled support personnel, the EMS responder

must receive an orientation that provides information on:

• Nature of the hazard (if known).

• Expected duties.

• Appropriate use of PPE.

• Other appropriate safety and health precautions

(e.g., decontamination procedures).

If a respirator will be needed, these personnel also

must be medically cleared for respirator use before

the respirator is worn. An acceptable fit test and

proper grooming to ensure a good face/facepiece

seal is required if the responder will wear a tight-fitting respirator. These steps are required by 29 CFR

1910.134 (Respiratory Protection), or the parallel

State Plan standards.

While a just-in-time briefing during the response

is the only required training for these personnel,

time and resource limitations inherent in a crisis likely will diminish the effectiveness of such training.

This is another reason why employers of EMS

responders should diligently consider the broad

range of conditions under which their workers

might be called to serve and provide an appropriate

level of HAZWOPER training.

An employer cannot allow workers to be designated as skilled support personnel as an alternative to providing appropriate, initial, and refresher HAZWOPER training.

Relevance of Other HAZWOPER Training

Levels to EMS Responders

An OSHA letter of interpretation discusses the roles

of EMS responders and other emergency responders at the scene of a hazardous substance release.

“Standard emergency medical practice dictates that

EMS personnel are to survey the accident scene and

remain away from the hazard area until it is safe to

approach. In the case of a HAZWOPER roadway

emergency, the incident needs to be brought under

control by more highly skilled emergency responders before it would be permissible for EMS personnel, including those certified at the first responder

operations level, to enter to perform rescue or provide medical treatment.” (OSHA, 1995-Nechis).

First responder training beyond the operations

level is not necessary for worker activities that are

restricted to medical treatment and decontamination. However, many EMS responders have qualifications at higher levels of HAZWOPER training.

These are EMS personnel who elect to be crosstrained to serve an expanded role (e.g., firefighter,

HAZMAT team member), and might receive other

levels of HAZWOPER training as needed in support

of those additional roles. For example, firefighters

commonly obtain additional education to qualify as

EMS responders (in addition to continuing to qualify

as firefighters) and some EMS personnel are trained

at the Hazardous Materials Technician or Hazardous

Materials Specialist level to serve on special HAZMAT teams. Any HAZWOPER training that an EMS

responder receives beyond the first responder operations level would be to support the role of firefighter or HAZMAT team member. The EMS responder

might, in the capacity of firefighter, enter dangerous

areas to perform non-medical activities such as controlling a hazardous substance release or performing

rescue, for which the higher level of HAZWOPER

training is required.

Conclusions Regarding EMS Training

Employers must use the information at their disposal

to make informed decisions regarding suitable levels

of HAZWOPER training for their EMS personnel.

Although there may be some EMS personnel for

whom HAZWOPER training is not necessary, OSHA

believes that after a critical review of community

expectations and community threats, most employers

will find that at a minimum first responder awareness

level training is appropriate for all their EMS responders and that some of these personnel also require

first responder operations level training. In some

communities, contract language referring to HAZWOPER initial and refresher training will promote

EMS personnel qualifications in this regard.
Personal Protective

Equipment

Using OSHA’s Rationale for Hazard

Assessment and PPE Selection

The best practices presented in this document indicate the minimum PPE that OSHA generally anticipates will be needed to protect EMS responders

under various conditions. However, as with any

generalized protection, OSHA’s PPE selection for

EMS personnel offers more protection against

some hazards than others. If an employer or incident commander determines that EMS responders

could reasonably anticipate encountering a specific

known hazard, the employer or incident commander also must determine whether this generalized

protection must be supplemented to more fully

protect against the specific hazard.

In order to complete the hazard assessment and

PPE selection process, each employer must consider the role the EMS responders will play in the

communities in which they might be called upon to

operate. Employers should also consider additional

information available from community sources

regarding the range of hazards that EMS responders could encounter during reasonably anticipated

worst-case scenarios (OSHA, 2002-Hayden). When

these sources point to a specific substance or situation from which the employer should protect EMS

responders, the employer must confirm that PPE

selection provides effective protection against that

hazard. In rare situations, the employer may find it

necessary to augment the PPE specified in this document for unknown hazards in order to help ensure

protection against specific known hazards (e.g., by

tailoring glove selection to address an identified,

specific hazard, or by stocking additional supplies).

Employers must adopt a more specialized level

of protection (such as atmosphere-supplying respirators [ASR]) when the EMS responder’s role in the

community or hazard assessment indicates that a

higher level of protection is necessary, such as

when EMS responders could be subjected to an

environment immediately dangerous to life and

health (IDLH).

PPE Selection Based on Reasonably

Anticipated Worst-Case Scenarios

PPE selection will vary based on the working conditions of EMS personnel. OSHA suggests that

employers of EMS personnel provide workers

with the minimum PPE that will offer protection

against a reasonably anticipated worst-case sce2 6

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nario, including catastrophic or terrorist incidents.

It is important to note, however, that the minimum PPE for the reasonably anticipated worstcase scenario may differ between locales. For

example, after evaluating (1) the roles that these

responders could be called upon to fill in the

community and (2) the reasonably anticipated

hazards that EMS responders could encounter in

their community, an EMS employer should review

these best practices and select the minimum PPE

that would protect against the most serious credible situations.

“If only one level or type of PPE will be available, it is appropriate for that PPE to cover

the worst-case situation. EMS agencies might

also wish to provide other types of PPE for

less-than worst-case situations (e.g., the hazard is identified and risk is reduced). If an

adequate level of PPE is not carried on the

ambulance, the agency needs to have a provision for getting it to the site where it is

needed.” (OSHA Stakeholder Comments,

2006)

For most employers of EMS responders, the

reasonably anticipated worst-case scenario is likely to involve the release of unidentified or uncharacterized hazardous substances with potential for

secondary contamination. In many areas, the

worst case could include the possibility that the

unidentified substance would be a CBRNE substance. Where community expectations restrict

the EMS responders to treating patients only after

the hazardous substance is characterized, or to

treating only patients who have been thoroughly

decontaminated by other EMS personnel (e.g.,

properly equipped HAZMAT team members), then

the most serious exposure scenario might only

involve characterized or identified hazardous substances, or possibly limited quantities of partially

characterized hazardous substances. OSHA, however, believes that in most communities, certain

EMS responders cannot be assured of such a limited role during a widespread mass casualty incident. As a result, PPE selection for EMS responders in these communities should be based on

the need to provide decontamination at the scene

of the incident and the need to offer emergency

medical services before the hazardous substance

has been characterized. The number of EMS

responders who should be trained and equipped
with PPE allowing them to provide decontamination services will depend on the community’s

expectations and Hazard Vulnerability Analysis.

Employers should keep in mind that once a

hazardous substance is identified or characterized, the PPE can be adjusted to appropriate levels, as determined by the incident commander.

Employers should be prepared to provide adjusted PPE suitable for the most common anticipated

situations in the community.

Required Written Documentation for

Respirator and PPE Selection Process

Employers selecting respiratory protection and

PPE must consider factors outlined in OSHA’s

Respiratory Protection standard (29 CFR 1910.134)

and Personal Protective Equipment standard (29

CFR 1910.132). For both respirators and PPE, a

primary selection factor is the hazards that workers are likely to encounter and both standards

contain requirements for written documentation

(see text box - Written Documentation of Hazard

Assessment for PPE Selection). Several other

selection factors are listed in the following subsections and details on all factors are provided in

the respective OSHA standards.

Written Documentation of Hazard

Assessment for PPE Selection

Under 1910 Subpart I, the employer must

perform a hazard assessment to select appropriate personal protective equipment for the

hazards that are present, or likely to be present, including foreseeable emergencies. The

hazard assessment must be in the form of a

written certification as described in 29 CFR

1910.132(d)(2).

The employer shall verify that the

required workplace hazard assessment

has been performed through a written

certification that identifies the workplace

evaluated; the person certifying that the

evaluation has been performed; and the

date(s) of the hazard assessment.The

written certification must also clearly

identify the document as the certification

of hazard assessment.

The hazard assessment provision applies

only to 29 CFR 1910.133 (eye and face protection), 1910.135 (head protection), 1910.136

(foot protection), and 1910.138 (hand protection). Although it does not apply to 29 CFR

1910.134 (respiratory protection) and

1910.137 (electrical protective devices), the

O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 2 7

Respiratory Protection standard does contain

specific requirements for evaluating respiratory hazards. The employer must include

procedures for selecting respirators in the

written respiratory protection program as

described in 29 CFR 1910.134. As part of the

selection process:

The employer shall identify and evaluate

the respiratory hazard(s) in the workplace;

this evaluation shall include a reasonable

estimate of employee exposures to respiratory hazard(s) and an identification of

the contaminant's chemical state and

physical form. Where the employer cannot identify or reasonably estimate the

employee exposure, the employer shall

consider the atmosphere to be IDLH. (29

CFR 1910.134(d)(1)(iii))

Assessing the Need for

Respiratory Protection

Respiratory Protection Required for

EMS Responders

Respiratory protection requirements are well

defined for specific emergency response situations.

OSHA’s HAZWOPER standard and letters of interpretation dictate the levels of protection that OSHA

requires for EMS responders in cases of high hazard and when the hazard is very low. The respiratory hazard evaluation that employers conduct helps

them define the types of respiratory protection that

incident commanders are most likely to designate

at scenes once the hazard is adequately characterized. Employers of EMS responders who could be

called upon to play a role in emergency response

must equip their workers to work safely in their

assigned roles (OSHA, CPL 02-02-073, 2007).

Types of Respiratory Protection Available

Appendix J provides an overview of respiratory

protection types, facepieces, and their associated

advantages and disadvantages. Employers of EMS

responders should consult Appendix J while considering the respiratory protection that their workers would need to perform specific emergency

response roles. Practical matters, such as how to

ensure that the correct respiratory protection is

available at the scene, need to be considered as

part of the emergency response plan. OSHA

believes that EMS responders will not be able to

work safely if they are designated to fill roles for

which the required PPE will not necessarily be on

hand.
National Institute for Occupational Safety

and Health (NIOSH) Approval and Chemical,

Biological, Radiological, Nuclear (CBRN)

Certifications

Respiratory protection for EMS responders must

always be of a type approved by NIOSH. Additionally, in any location where CBRN substances are a

threat, the respirator should also be NIOSH-rated

for use in CBRN environments. In addition, CBRN

respirators offer advantages of having passed additional testing to assure ruggedness and structural

durability.

Respiratory Protection for an Identified

or Characterized Hazard

The incident commander is responsible for determining an appropriate level of respiratory protection for EMS responders at emergency scenes

involving the release of a known hazardous substance(s), or entry into the dangerous area of the

scene after the substance is characterized. However,

in some circumstances, OSHA’s HAZWOPER standard prescribes the level of protection. Specifically,

an SCBA respirator is required when an IDLH

atmosphere is present, including occasions when

the hazardous substance is unidentified or information is inadequate to rule out an IDLH environment.

OSHA’s Respiratory Protection standard requires

that for an IDLH environment the SCBA must be

configured as a full facepiece pressure demand

SCBA certified by NIOSH for a minimum service life

of thirty minutes, or as a combination full facepiece

pressure demand supplied-air respirator (SAR) with

auxiliary self-contained air supply (29 CFR 1910.134

(d)(2)(i)(A) and (B)). Furthermore, Appendix B of the

HAZWOPER standard indicates that where an IDLH

environment is present, Level A or Level B PPE are

required, depending on whether the hazard

includes a substance that can be absorbed or is

hazardous to the skin (requiring Level A) or not

(Level B permitted). For a description of these PPE

levels, see Appendix N – General Description and

Discussion of the Levels of Protection and

Protective Gear.

Other Requirements Related to

Respiratory Protection

If EMS responders will need to wear respiratory

protection, OSHA requires that the employer develop a respiratory protection program that explains

how the employer meets the requirements outlined

in OSHA’s Respiratory Protection standard (29 CFR

1910.134). The program must cover topics such as

the procedures used for selecting respirators; how

medical evaluations and fit testing are provided;

methods for ensuring that respirators are properly

used, cleaned and maintained; worker training; and

how the program’s effectiveness is evaluated.

Gloves, Boots and Garments

As is the case with respiratory protection, the actual

conditions will dictate the level and type of PPE

required to protect an EMS responder. Some considerations for gloves, boots and protective clothing

are presented in the following sections. Regardless

of the selection, the provisions of the Bloodborne

Pathogens standard (29 CFR 1910.1030) would

apply. As previously discussed, the employer must

certify that a hazard assessment has been performed as part of the PPE selection process.

Gloves and Boots

No single glove or boot material will protect against

every substance. Base the selection on the type and

extent of anticipated contact with hazardous substances. Consider the type of substances, the effect

of dermal exposure, patient symptoms, and the

likely interventions that contaminated patients

might require, then select protective gear that best

allows critical patient treatments while fully protecting the EMS provider.

Most glove manufacturers offer detailed guides

to glove materials and their chemical resistance.

Butyl rubber gloves generally provide better protection than nitrile gloves for chemical warfare agents

and most toxic industrial chemicals that are more

likely to be involved in a terrorist incident, although

the converse applies to some industrial chemicals.

Foil-based gloves are highly resistant to a wide

variety of hazardous substances and could also be

considered when determining an appropriate protective ensemble. Employers of EMS responders

must select materials that cover the specific substances that the employer has determined that EMS

responders reasonably might encounter. However,

given the broad scope of potential contaminants,

OSHA considers it important for employers to

select materials that protect against a wide range of

substances. A double layer of gloves, made of two

different materials, or foil-based gloves will resist

the broadest range of chemicals.

A combination of gloves, for example, butyl

gloves worn over inner nitrile gloves, is often the

best option for use by EMS responders during

emergencies and mass casualties involving hazardous substances. However, responders are

advised to select the combination that best meets

2 8

Occupational Safety and

Health Administration
their specific needs. Between gloves that offer adequate worker protection, select the model(s) that

minimize impact on delivering the types of patient

interventions that are most likely to be needed.

Glove thickness is measured in mils, with a

higher number of mils indicating a thicker glove (1

mil equals 1/1000 of an inch). Using common

examples, exam gloves are often approximately 4

mil, while general-purpose household (kitchen)

gloves are 12–16 mil, and heavy industrial gloves

might be 20 to 30 mil.

Depending on the dexterity needed by the EMS

responder, the glove selection can be modified to

allow for the use of a glove combination that is

thinner than that usually recommended for the best

protection. As an example, the U.S. Army Center

for Health Promotion and Preventive Medicine

(USACHPPM) recommends that medical personnel

working with patients potentially contaminated with

chemical warfare agents or toxic industrial chemicals wear a combination of chemical protective

gloves, such as butyl rubber gloves over inner

nitrile gloves (USACHPPM, 2003a). Because thicker

gloves offer greater protection, USACHPPM recommends a butyl glove with a minimum thickness of

14 mil (over a 4 or 5 mil nitrile glove). However,

with increased thickness comes greater loss of

manual dexterity and hand fatigue. When advanced

medical procedures must be performed before

decontamination, thicker gloves might be too awkward, and, therefore, it might be necessary to use a

butyl rubber glove of 7 mil over the nitrile glove, or

a 14 mil butyl rubber glove alone (USACHPPM,

2003a).

When manual dexterity is required, a 14 mil

butyl glove, or a 7 mil butyl glove over a 4 to

5 mil nitrile glove, may be the best options;

however, these gloves should be changed

frequently to minimize the chance of exposure if gloves tear, abrade, or are chemically

degraded. (OSHA Stakeholder Comments,

2006).

Hendler et al. (2000), as cited in USACHPPM

(2003a), conducted a study to determine the effect

of full PPE (including 12-mil “tactile” gloves and a

full facepiece mask) on intubation performance.

Clinicians wearing this equipment could perform

endotracheal intubation effectively (i.e., the tube

was inserted in sufficient time), but the procedure

did take longer than it would have without PPE.

Intubation delays would cause subsequent decontamination procedures and medical treatment to be

delayed by a corresponding amount of time. Some

incidents may have injured patients in such a way

that routine emergency care cannot be rendered

until the patient is decontaminated to assure adequate protection to the medical team.

If sterility is required and decontamination is not

possible before performing medical procedures, a

double layer of disposable 4 to 5 mil nitrile gloves

might be the best option (USACHPPM, 2003a). Not

all sources recommend double gloves; for example,

the U.S. Army Soldier and Biological Chemical

Command’s (SBCCOM) [now called the Research,

Development and Engineering Command, or RDECOM] Domestic Preparedness Program (DPP) recommends butyl rubber gloves for personnel performing decontamination operations and casualty

care (SBCCOM, 2000). Among the sterile gloves

readily available, those made of nitrile offer the best

resistance to the widest range of substances.

Thinner gloves fail (deteriorate, tear, rip) more rapidly than thicker gloves and, therefore, if they must

be used, these gloves should be inspected and

changed more frequently. Thinner gloves should be

changed when contaminated or as soon as feasible

if they are torn, punctured, or when their ability to

function as a barrier is compromised.18

In general, the same material selected for gloves

will also be appropriate for boots. Because boot

walls tend to be thicker than gloves, boots of any

material are likely to be more protective than

gloves of the same material. Military vinyl overshoes (designed to be worn over combat boots) are

now commercially available at competitive costs

and have been approved by the military for protection against chemical warfare agents.

Protective Garments

The optimal garment material for EMS responders will

vary depending on the

responder’s role and should

be a subject of the employer’s hazard assessment.

Except for particularly harsh

climates, standard uniforms

may be sufficient for EMS

responders in the cold zone.

As discussed below, the

selection is more complex for responders who

could find themselves in the warm zone. See

Appendix K for links to additional information on

O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 2 9

18 For additional information on recommended glove materials

and chemical breakthrough of specific substances, see the

NIOSH Recommendations for Chemical Protective Clothing: A

Companion to the NIOSH Pocket Guide to Chemical Hazards.

Available at www.cdc.gov/niosh/ncpc/ncpc2.html

Photo courtesy of Frank Califano
associated with an actual first responder chemical

response (but did not involve physical acts, such as

patient handling or handling needles and injections,

that would likely be required of EMS responders)

(SBCCOM, 2003). Results are summarized in Table 1.

Table 1.

Results of SimulationTests on Several Chemical Suits

Suit Configuration # SuitsTested Protection Factor

Standard [Police] Uniform 2 2

Tyvek® Protective Wear Suit 4 4

Tychem® 9400 Protective

Suit 4 17

Kappler® Tychem CPF4

Protective Suit 4 18

Tychem® SL Protective Suit 5 24

Tyvek® ProTech F Protective

Suit 5 42

Source: SBCCOM, 2003.

The ability of protective garment fabric to withstand physical abrasion and tearing is also important. If their role could involve assisting non-ambulatory contaminated patients or victims trapped in

the hot zone, EMS responders might subject the

protective garments to physical stresses that should

be considered in garment selection. The NFPA

Standard No. 1994 on Protective Ensemble for First

Responders to CBRN Terrorism Incidents offers criteria for evaluating the performance of protective

garments, including detailed specifications for

bursting, puncture and tear resistance, as well as

garment seam specifications (NFPA, 2007).

Additionally, the Interagency Board has begun

publishing a list of standard products, including

PPE, for use in national emergencies (IAB, 2007).

As a rule of thumb, if the employer has determined that an EMS responder’s role in a response

could involve using SCBA, the responder should

also be outfitted with broad spectrum chemical

protective clothing. However, chemical protective

clothing is generally semi- or impermeable. Anytime an EMS responder wears semi-permeable

or impermeable clothing, the risk of heat stress

increases substantially. See Appendix K for a discussion of thermal stress on EMS responders working in hot and cold environments.

Modifying PPE Selections Based on

Available Information

Flexibility in prescribing respiratory protection and

PPE is particularly important. Employers of EMS

responders must be prepared to provide their work3 0

Occupational Safety and

Health Administration

thermal stress and working in cold and hot conditions, including working in chemical protective

suits.

In the warm zone, EMS responders will need

garments that protect against a wide range of

chemicals in liquid, solid, or vapor form (phase).

Because EMS responders might become contaminated with liquid or solid (dust) contaminants

through physical contact with a contaminated

patient, the ideal fabric will repel chemicals.

Additionally, the optimal garment will restrict the

passage of vapors, both through the suit fabric and

through openings in the suit. Finally, optimal clothing is also sufficiently flexible, durable, and lightweight for long-term wear (up to several hours)

during physically active work.

A variety of broad-spectrum protective fabrics

and designs may be appropriate, depending on the

situations and hazards that the employer anticipates EMS responders reasonably might be expected to encounter. Several commercially available

products include: Tyvek® F, Tychem® CPF3, Tychem®

CPF4, Tychem® BR, Tychem® LV, Tychem® SL,

Zytron® 100, Zytron® 200, Zytron® 300, Zytron® 400,

Zytron® 500, and Zytron® 600, ProVent® 10,000, and

DuraVent® 2.8. Note, however, that OSHA does not

test, endorse, or recommend specific products.

Before selecting products or materials, contact the

manufacturer for specific application guidance.

Fabric and suit manufacturers can provide laboratory testing information regarding specific materials.19 For example, Tyvek® F has been tested extensively by military organizations and accredited testing laboratories. As another example, the SBCCOM

(now called RDECOM) DPP tested vapor-blocking

properties of six different protective suits in a simulated, high-vapor environment. In the results tabulated below, the Tyvek® F suit (ProTech model)

offered a protection factor of 42 (vapor levels outside the suit were 42 times higher than inside the

suit), which was approximately twice the protection

than was provided by the next best performing

suits. Traditional Tyvek® (protection factor of 4) was

twice as protective as a standard police uniform

(protection factor of 2). These suits were tested by

placing sensors for the test vapor under the suits at

17 specific body locations. Volunteers wore the protective gear while performing the activities normally

19 Some chemical-protective fabric manufacturers provide Webbased services for comparing their products. For example, chemical permeation and recommended usage charts for DuPont’s

Tychem® line and related fabric types appear at www2.dupont.

com/NOWApp/DPPRequestGateway/0/pct/?command=ACProduct

ComparisonHome and Kappler’s Zytron fabrics are compared at

www.kappler.com/techdata_main.html.
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 3 1

ers with respiratory protection and PPE that is at

least as effective as that which the incident commander might dictate for the situations EMS

responders could reasonably be expected to encounter in their designated roles. The employer’s

ERP should include information on the PPE that the

employer will make available to workers. Because

this guide recommends Levels A and B for most situations involving EMS responders, such protection

provides adequate eye protection. Therefore, additional discussion on eye protection is not warranted.

Proper Size and Fit of PPE

The size and fit of PPE is as important as selecting

appropriate materials and configurations. Poorly fitting respirators, gloves, footwear, or protective clothing offer a reduced level of protection. Specifically,

ill-fitting equipment might gape, leak, fall off, cause

tripping, or create other serious safety hazards.

Employers must consider fit in the selection of protective gear for EMS responders, as required by

OSHA’s General Requirements for personal protective equipment (29 CFR 1910.132(d)(1)(iii)). EMS

responders who wear tight-fitting respirators must be

fit tested before the first time they wear the respirator

in the field and again each year. See Respiratory

Protection for an Identified or Characterized

Chemical Hazard, above, for a summary of additional requirements associated with respiratory protection.

Considerations for Effectively Using,

Maintaining and Storing PPE

Once PPE decisions have been made, the employer

should obtain PPE in adequate

quantities and sizes to meet the

needs of those EMS responders

who will wear the equipment.

Consider protective gear compatibility when making purchases, so that one piece of equipment does not interfere with the

functioning of another. PPE used

to prevent hazardous material

exposure (e.g., a respirator)

must be compatible with other

safety equipment required for injury prevention (e.g.,

protective eyewear or a helmet). However, planning

and purchasing decisions alone will not protect EMS

responders.

Many types of PPE, such as respiratory protection

(excluding filtering facepieces) require ongoing

inspection, maintenance, worker training, medical

monitoring, and recordkeeping. For additional information on this topic, consult OSHA’s standard on

Respiratory Protection (29 CFR 1910.134) and OSHA’s

Small Entity Compliance Guide for Respiratory

Protection at www.osha.gov/Publications/sec

grevcurrent.pdf.

EMS responders who are asked to perform activities or work in areas for which they are not

equipped should bring this to the attention of the

IC (or designated safety officer).

In accordance with OSHA’s PPE standards, and as

discussed in the Training section of this guide, workers must be trained to use PPE effectively and to recognize when PPE will not provide adequate protection. EMS providers risk injury if they become

exposed to dangerous substances due to a false

sense of security when using incorrect PPE, or when

wearing PPE improperly (Hick, 2007).

Community expectations for EMS providers’ activities and the areas in which they will work must take

into consideration each employer’s decision about

workers’ roles, how PPE is distributed, where equipment is stored, and how the employer determines the

manner in which personnel are trained to react.

Experience has shown that when proper PPE is not

readily available, EMS responders are reluctant to pull

back and wait for better equipped providers to arrive.

Instead, EMS personnel tend to provide medical rescue and care without appropriate PPE, thus exposing

themselves to a higher risk (rather than compromising patient care, they compromise their own safety)

(Hick, 2007). Personnel training must be adequate to

ensure that EMS providers fully understand their limitations (and those of their training and equipment). If

EMS providers might encounter contaminated

patients seeking medical assistance, provide medical

care in a contaminated area or to contaminated

patients, or be called upon to support fire department

decontamination efforts, these individuals must be

trained and equipped to do these jobs safely.

Conclusions Regarding Personal

Protective Equipment

Carefully considered EMS responder PPE goes

hand-in-hand with the responder’s training; only

with proper training will EMS responders be able to

identify hazardous substance release conditions and

understand the limits within which they can work

safely with their available PPE. Determining training

and PPE needs in advance through a hazard assessment will permit employers of EMS responders to

ensure that their workers are prepared for the incidents in which they are expected to participate. The

PPE offered to EMS responders should correspond

to both the type of training they are provided and to

Photo courtesy of Frank Califano
Summary of OSHA’s

Recommendations for

Training and PPE

OSHA’s recommendations are based on the roles that

EMS responders could be assigned during emergencies

involving hazardous substance releases. OSHA’s recommendations on minimum training and PPE for EMS

responders assisting patients at hazardous substance

release sites generally follow regulatory requirements

contained in paragraph (q) of OSHA’s Hazardous Waste

Operations and Emergency Response (HAZWOPER) standard (29 CFR 1910.120) and associated interpretive letters.

In some instances, OSHA also recommends that employers consider offering instruction to certain EMS respon3 2

ders who would not otherwise receive any HAZWOPER

training under regulatory requirements, but who OSHA

believes might find themselves in a situation where this

training would allow them to make better decisions to

protect both themselves and other EMS personnel.

Table 2 summarizes OSHA’s recommendations and

requirements. In the table, the required training and PPE

are presented in a matrix, with additional recommendations indicated as relevant. To use the table, locate a typical EMS responder role along the top of the table and a

specific hazardous substance response scenario down

the left-hand side. Employers may locate the appropriate

training and PPE in the cell at the intersection of the designated EMS responder role column and selected scenario row. Figure 1, which follows Table 2, offers simple

instructions for using the table.

ZONE►

(EMS Responder

Assigned Role) ►

▼ Scenario

CBRNE agent or

substance generating IDLH environment at the site[B]

Unknown

substance -

could be a serious

hazard [H]

Partially characterized hazard, available information

suggests low or

moderate hazard

Known substance,

low or moderate

hazard

No emergency

response

HOT ZONE

(Rescue/Life support)

[A] [G]

When a skin hazard

is present...

Training: Operations

level[C]

Respirator: SCBA[E]

PPE: Level A[D]

No skin hazard...

Training: Operations

level[C]

Respirator: SCBA[E]

PPE: Level B[D]

Training: Operations

level[C]

Respirator: SCBA[E]

PPE: Level A[D,F]

Training: Operations

level[C]

Respirator: SCBA, or

as indicated by IC

based on site characterization.[E]

PPE: Level B, or as

indicated by Incident

Commander[F] based

on site characterization.[I]

Training: Operations

level[C]

Respirator & PPE:

As per Incident

Commander (IC)[E] [F, J]

Not applicable

WARM ZONE

(Decontamination/

treatment in warm

zone)

When a skin hazard

is present...

Training: Operations

level[C]

Respirator: SCBA[E]

PPE: Level A[D]

No skin hazard...

Training: Operations

level[C]

Respirator: SCBA[E]

PPE: Level B[D]

Training: Operations

level[C]

Respirator: SCBA[E]

PPE: Level A[D]

Training: Operations

level[C]

Respirator & PPE:

As per Incident

Commander[E, F I, J]

Training: Operations

level[C]

Respirator & PPE:

As per Incident

Commander (IC)[E] [F I, J]

Not applicable

COLD ZONE

(Treat

uncontaminated/

decontaminated

patients in clean area)

Training: Awareness

level strongly recommended[K] (Operations

level recommended).[L]

Respirator & PPE:

Only as needed for

preventing infection.

Training: Awareness

level strongly recommended[K] (Operations

level recommended).[L]

Respirator & PPE:

Only as needed to

prevent infection.

Training: Awareness

level strongly recommended[K] (Operations

level recommended).[L]

Respirator & PPE:

Only as needed to

prevent infection.

Training: Awareness

level strongly recommended[K] (Operations

level recommended).[L]

Respirator & PPE:

Only as needed to

prevent infection.

Not applicable

EMERGENCYTRANSPORT FOR 911 CALLS

(Transport nominally

clean or cleaned

patients)[K]

Training: Awareness

level strongly recommended[K] (Operations

level recommended).[L]

Respirator & PPE:

Only as needed for

preventing infection.

Training: Awareness

level strongly recommended[K] (Operations

level recommended).[L]

Respirator & PPE:

Only as needed to

prevent infection.

Training: HazCom[M]

(Operations level recommended).[L]

Respirator & PPE:

Only as needed to

prevent infection.

Training: HazCom[M]

(Operations level recommended).[L]

Respirator & PPE:

Only as needed to

prevent infection.

Not applicable

INTER-FACILITY

TRANSPORT ONLY

(Never respond to 911

calls. No mutual aid

agreements for emergency response)

Not applicable

Not applicable

Not applicable

Not applicable

Routine HazCom training.[M] PPE only as

needed to prevent

infection.

Table 2.Training, Respiratory Protection, and PPE for EMS Responders
TABLE ENDNOTES:

[A] This table addresses EMS entry into contaminated areas only

to provide medical assistance to patient(s). Entry for other

purposes (e.g., controlling the release of a hazardous substance or rescue operations) requires an additional level of

competency and implies cross-training with another specialty,

such as firefighter or hazardous materials technician. Individuals

performing activities other than (or in addition to) patient

medical care are covered by other requirements beyond the

scope of this document.

[B] IDLH Definition: Immediately dangerous to life or health

(IDLH): An atmosphere that poses an immediate threat to life,

would cause irreversible adverse health effects, or would

impair an individual's ability to escape from a dangerous

atmosphere. OSHA Definition

[C] Operations level is appropriate for: (1) EMS responders who

must enter the danger zone to provide medical assistance

(OSHA, 1995-Nechis); (2) EMS responders expected to treat

contaminated patients at the release area but at a safe distance from the point of release (OSHA, 2007-CPL-02-02-073).

[D] Select Level A when: (1) The hazardous substance has been

identified and requires the highest level of protection for skin,

eyes, and the respiratory system based on either the measured (or potential for) high concentration of atmospheric

vapors, gases, or particulates; or the site operations and work

functions involve a high potential for splash, immersion, or

exposure to unexpected vapors, gases, or particulates of

materials that are harmful to the skin or capable of being

absorbed through the skin; (2) Substances with a high degree

of hazard to the skin are known or suspected to be present,

and skin contact is possible; or (3) Operations must be conducted in confined, poorly ventilated areas, and the absence

of conditions requiring Level A have not yet been determined

(29 CFR 1910.120 Appendix B, Part B.I). Select Level B when

the type and atmospheric concentration of substances have

been identified and require a high level of respiratory protection, but less skin protection (29 CFR 1910.120 Appendix B,

Part B.II.) www.osha.gov

[E] Workers engaged in emergency response and exposed to

hazardous substances presenting an inhalation hazard or

potential inhalation hazard shall wear positive pressure selfcontained breathing apparatus while engaged in emergency

response, until such time that the individual in charge of the

ICS determines through the use of air monitoring that a

decreased level of respiratory protection will not result in hazardous exposures to workers. In a chemical, biological, radiological, and nuclear (CBRN) environment, use only a respirator approved by NIOSH for use in a CBRN environment.

(1910.120(q)(3)(iv)) www.cdc.gov/niosh/npptl/topics/respirators/cbrnapproved/scba/default.html

[F] Based on the hazardous substances and/or conditions present, the individual in charge of the ICS shall implement

appropriate emergency operations, and assure that the PPE

worn is appropriate for the hazards to be encountered.

(1910.120(q)(3)(iii))

[G] “Standard emergency medical practice dictates that EMS personnel are to survey the accident scene and remain away

from the hazard area until it is safe to approach. ...the incident needs to be brought under control by more highly

skilled emergency responders before it would be permissible

for EMS personnel, including those certified at the Operations

Level, to enter to perform rescue or provide medical treatment.” (OSHA, 1995-Nechis).

[H] SIGNS OF A CHEMICAL, BIOLOGICAL, RADIOLOGICAL, AND

NUCLEAR (CBRN) OR HIGHLY TOXIC AGENT: suspicious circumstances, results from early detection equipment do not

O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 3 3

rule out CBRN, patients exhibiting symptoms. SIGNS OF AN

ONGOING RELEASE: Saturated clothing in an enclosed environment, visible spray/dust in air, flowing substance on surfaces, sound of possible substance release (e.g., gas or

spray), visible pooling, explosion at chemical plant – not yet

controlled; patients exhibiting symptoms of continuing exposure, unresponsive victims – cause uncertain.

[I] Information to Help Make the Decision that Respirator and

PPE Level Can Be Reduced: Rationale for reducing respiratory

protection levels should include one or more of the following:

(1) Air monitoring/screening tools to confirm potential inhalation hazard is of a level for which a decreased level of respiratory protection will not result in hazardous exposures to

employees (sensors, meters, direct reading instruments,

swab and wipe sample readers, dip indicators [pH paper],

battery operated detectors) indicates that the chemical class is

not one that is highly toxic or is one of low volatility, that bioagent is not of significant concern, that ionizing radiation

activity is not present in area, or that a secondary CBRN agent

is not present in area. (2) Clear evidence that the hazardous

substance is not highly toxic or volatile (e.g., credible placard

or label on leaking containers or tank). (3) Statement about

contents from person in control of the source of the release.

(4) Visible evidence strongly suggests agent of lower toxicity

(e.g., leaking from fuel tank of vehicle with a diesel

engine/fuel tank strongly suggests a diesel release; NFPA,

Hazardous Materials Information System (HMIS), or equivalent hazard rating scheme label on source container or tank

indicates low toxicity). In all cases, flammability and reactivity

may also produce hazards that should be taken into consideration when restricting access, or selecting equipment that

could be brought into the area, but minimal impact on PPE

and training decision in areas where EMS responders would

typically work. For the purposes of this document, OSHA

understands that other more highly skilled responders would

work in areas with high risk of flammability or reactivity.

[J] See Appendix I for summary information on respiratory protection. Consider NIOSH Respirator Selection Logic (2004)

(www.cdc.gov/niosh/docs/2005-100) for guidance on choosing

minimal acceptable respirator for the reasonably anticipated

worst-case scenario.

[K] EMS personnel are often first on the scene and, therefore,

should be given first responder awareness level training as a

minimum, even if they are not expected to handle contaminated patients. Furthermore, individuals trained at least to the

awareness level would identify poorly or incompletely

cleaned patients (when decontamination is done by others)

(OSHA, 1991-McNamara).

[L ] Some stakeholders providing input to this document recommend, and OSHA agrees, that as a best practice any employer that offers emergency response services should be prepared to decontaminate patients, even if the community

would normally assign that duty to a fire department or HAZMAT team. In particular, they believe EMS responders may be

called upon to decontaminate injured or ill patients, but not

necessarily ambulatory uninjured people who might be

assisted in decontamination by other emergency responders

(OSHA, 2006-EMS Stakeholder Comments).

[M] The Hazard Communication standard (29 CFR 1910.1200)

requires training of any workers who may potentially be

exposed to hazardous chemicals during their duties. This

training can incorporate an overview of the community’s ERP

to help clarify that this group of workers lacks any role in it

(OSHA, 2007-CPL-02-02-073).

Additional Note: See Appendix N for a general description and

discussion of the levels of protection and protective gear (e.g.,

Level A and Level B).
ZONE►

(EMS Responder

Assigned Role) ►

▼ Scenario

CBRNE agent or

substance generating IDLH environment at the site[B]

Unknown

substance -

could be a serious

hazard [H]

Partially characterized hazard, available information

suggests low or

moderate hazard

Known substance,

low or moderate

hazard

No emergency

response

HOT ZONE

(Rescue/Life support)

[A] [G]

When a skin hazard

is present...

Training: Operations

level[C]

Respirator: SCBA[E]

PPE: Level A[D]

No skin hazard...

Training: Operations

level[C]

Respirator: SCBA[E]

PPE: Level B[D]

Training: Operations

level[C]

Respirator: SCBA[E]

PPE: Level A[D,F]

Training: Operations

level[C]

Respirator: SCBA, or

as indicated by IC

based on site characterization.[E]

PPE: Level B, or as

indicated by Incident

Commander[F] based

on site characterization.[I]

Training: Operations

level[C]

Respirator & PPE:

As per Incident

Commander (IC)[E] [F, J]

Not applicable

WARM ZONE

(Decontamination/

treatment in warm

zone)

When a skin hazard

is present...

Training: Operations

level[C]

Respirator: SCBA[E]

PPE: Level A[D]

No skin hazard...

Training: Operations

level[C]

Respirator: SCBA[E]

PPE: Level B[D]

Training: Operations

level[C]

Respirator: SCBA[E]

PPE: Level A[D]

Training: Operations

level[C]

Respirator & PPE:

As per Incident

Commander[E, F I, J]

Training: Operations

level[C]

Respirator & PPE:

As per Incident

Commander (IC)[E] [F I, J]

Not applicable

COLD ZONE

(Treat

uncontaminated/

decontaminated

patients in clean area)

Training: Awareness

level strongly recommended[K] (Operations

level recommended).[L]

Respirator & PPE:

Only as needed for

preventing infection.

Training: Awareness

level strongly recommended[K] (operations

level recommended)[L].

Respirator & PPE:

Only as needed to

prevent infection.

Training: Awareness

level strongly recommended[K] (operations

level recommended).[L]

Respirator & PPE:

Only as needed to

prevent infection.

Training: Awareness

level strongly recommended[K] (operations

level recommended).[L]

Respirator & PPE:

Only as needed to

prevent infection.

Not applicable

EMERGENCYTRANSPORT FOR 911 CALLS

(Transport nominally

clean or cleaned

patients)[K]

Training: Awareness

level strongly recommended[K] (Operations

level recommended).[L]

Respirator & PPE:

Only as needed for

preventing infection.

Training: Awareness

level strongly recommended[K] (operations

level recommended).[L]

Respirator & PPE:

Only as needed to

prevent infection.

Training: HazCom[M]

(operations level recommended).[L]

Respirator & PPE:

Only as needed to

prevent infection.

Training: HazCom[M]

(operations level recommended).[L]

Respirator & PPE:

Only as needed to

prevent infection.

Not applicable

INTER-FACILITY

TRANSPORT ONLY

(Never respond to 911

calls. No mutual aid

agreements for emergency response)

Not applicable

Not applicable

Not applicable

Not applicable

Routine HazCom training.[M] PPE only as

needed to prevent

infection.

3 4

Occupational Safety and

Health Administration

Figure 1. How to Use Table 2

Step 2. Read

down the left

side of the

table to find

the anticipated

worst-case

hazardous

substance

release

scenario under

which the EMS

responder

could work.

Step 1. Read across the top rows to find the

anticipated zone where the EMS responder

could work and the responder’s role.

Step 3. Then find the EMS responder’s Training

and PPE needs at the point where the selected

Zone/Role column intersects with the selected

Scenario row.

Step 4. Look up

special notes and

the reference using

end notes that

appear after the

table.

Training: Awareness

Level[K]

(Operations Level

recommended)[C,L]

Respirator & PPE:

Only as needed

for preventing

infection
Best Practices for

Pre-Transport Patient

Decontamination

Patient decontamination is critical to patient safety,

to the protection of EMS personnel, and to continuing EMS operations. Many communities place

responsibility for decontamination activities on the

fire department or incident response personnel,

without directly involving EMS responders. Other

communities ask EMS responders to assist with the

process. Some stakeholders providing input to this

document recommended that any employer that

offers emergency response services should be prepared to decontaminate patients, even if the community would normally assign that duty to a fire

department or HAZMAT team. In particular, they

believe EMS responders may be called upon to

decontaminate injured or ill patients, but not necessarily ambulatory uninjured people who might be

assisted in decontamination by other emergency

responders (OSHA, 2006-EMS Stakeholder

Comments).20

Regardless of which responders will perform

decontamination, OSHA believes that EMS responders who might be sent to the scene of a release

will be better prepared to recognize an inadequately decontaminated patient if they understand the

basic decontamination process, even if these EMS

responders are not expected to be involved in

patient decontamination.

As a best practice, OSHA recommends that

employers provide information on decontamination

practices to all EMS responders who could be

assigned a role in a hazardous substance response.

Additional detailed training on performing decontamination is required for EMS responders whom the

employer has designated to perform decontamination.

Current accepted decontamination practices

focus on removing the patient’s clothing, cleansing

with soap and water, then rinsing. When these

steps are followed carefully, patient exposure is significantly decreased and patients pose less risk to

EMS personnel, transport vehicles and equipment.

Removing Contaminated Clothing

and Personal Effects

Studies estimate that removing contaminated clothing can reduce the quantity of contaminant associated with victims by an estimated 75 to 90 percent

(Macintyre et al., 2000; Vogt, 2002; USACHPPM,

2003a).21 Modeling studies that help quantify exposures during decontamination and patient handling

activities suggest that victims’ clothing can hold a

significant amount of contaminant. Removing contaminated clothing as soon as possible will reduce

both patient and responder exposure levels (Schultz

et al., 1995; Georgopoulos et al., 2004). The sooner

contaminated clothing and effects are removed the

less these potential sources will contribute to exposure levels.

Clothing and personal items that are contaminated should be sealed in double plastic bags to

eliminate them as a source of continuing exposure.

Many community plans provide for some

patient privacy and protection from harsh weather

during decontamination. The plans also often call

for the provision of tags to label bagged personal

belongings with the owners’ names. These provisions can help improve patients’ compliance with

decontamination procedures.

Cleansing with Soap and Water

Decontamination with soap and water remains the

best practice for most contaminants under most circumstances of mass decontamination. Initial rinsing

can often be started quickly and will help physically

remove water-soluble and particulate contaminants,

while a soap that dissolves grease will help remove

other substances.

Hurst (1997) notes that “the most important and

most effective decontamination after any chemical

or biological exposure is that decontamination

done within the first minute or two after exposure”

and that “after years of research world wide, simple

principles that consistently produce good results

are still recommended.” Specifically, timely physical removal of the contaminating substance is critical. However, “which decontamination method is

used is not as important as how and when it is

used.” (Hurst, 1997).

OSHA realizes that, although generally considered

a beneficial practice, 5 minutes of flushing with

O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 3 5

20 The stakeholders feel, however, that it makes less sense to suggest that EMS responders decontaminate ambulatory uninjured

people (OSHA EMS Stakeholder Comments, 2006).

21 The percentage of contaminant reduction depends on the type

of clothing the victim was wearing when exposed. The estimates

may be somewhat lower (down to 50 percent) for victims wearing short pants or skirts and higher (up to 94 percent) for victims

exposed to biological warfare agents while wearing protective

military uniforms (USACHPPM, 2003a).
rinse water may not always be practical in the field.

It serves primarily as a benchmark to guide decision making. USACHPPM recommends 1-minute

rinsing from head to toe with tepid water (slightly

warm, not hot) after removal of contaminated clothing, followed by a more thorough decontamination

by washing with a soap with good surfactant properties (e.g., a liquid soap such as hand dishwashing

detergent), tepid water and soft sponges. Avoid stiff

brushes and vigorous scrubbing, which can damage the skin and increase the chance that the contaminant would be absorbed by the patient’s skin.

USACHPPM recommends these procedures for

most classes of contaminants, except reactive

metal dusts, for which a soft dry brush should be

used to remove most of the material from the skin.

(USACHPPM, 2003a).

Assistance for Non-Ambulatory and

Ambulatory Patients

Non-ambulatory patients can require a substantial

proportion of the decontamination team’s time and

effort. EMS responders designated as decontamination team members are likely to experience the

greatest exposures while assisting these patients.22

The team members should take steps to identify

possible sources of contamination and limit their

exposure to those sources, as well as the exposure

of patients and any EMS responders who may

assist the patients later. For example, it is possible

to use specific procedures for removing patients’

clothing to minimize both decontamination team

and patient exposures. One such procedure is to

use blunt-nose scissors to cut away clothing, rather

than pulling it off. Practical exercises have shown

that seatbelt cutters also work well for removing

clothing and further reduce the chance of accidental

injury.23 In contrast, tugging on clothing can produce a wringing action that might distribute contaminant on the patient, decontamination team

members, and the surrounding area (in addition to

unnecessarily shifting a patient who may have

spinal injuries). As noted previously, once removed,

the clothing should be immediately placed into a

sealed container.

Some communities may ask ambulatory

patients to assist by performing some of the decontamination steps themselves. Specifically, minimal3 6

Occupational Safety and

Health Administration

ly exposed patients who are able can help by removing their own clothing and personal effects.

They may even begin wetting and cleansing themselves, although these and subsequent steps

should be supervised (if not performed) by a

responder trained in decontamination procedures.

When ambulatory patients assist with these initial

decontamination steps during large-scale incidents,

decontamination of all patients may be more expedient, and the risks to responders (e.g., from handling contaminated clothing) are reduced.

The methods decontamination team members

use to decontaminate themselves and remove

(doff) PPE also impact their own exposure. ATSDR

(2001) and Appendix M offer examples of procedures used by some teams.

EMS responders might find the following review

of basic decontamination steps helpful:

1) Activate the emergency decontamination

plan.

2) Learn as much as possible (as soon as possible) about the location of patients, the contaminant, its hazards, and associated symptoms. Previous arrangements with other first

responder agencies can improve how information flows to responders.

3) Arrange for decontamination equipment to

be delivered to a suitable location. Some systems are heavy and cumbersome – in addition to the need for an adequate area of relatively level ground, consider factors such as

vehicular access to deliver equipment and

also eventually to provide ambulance service

to patients who require it.

4) Activate the decontamination system and

assemble the decontamination team. These

individuals should be pre-designated by the

community plan so that they will be properly

trained and have drilled with the available

equipment prior to the emergency. Also in

advance, the community should consider the

need for staffing multiple decontamination

lines (for responders, ambulatory patients,

and non-ambulatory patients; or males and

females), which can increase patient compliance and/or process efficiency. Consider by

whom and where decontamination for critically ill/injured patients will be performed.

5) Perform any medical monitoring (e.g., vital

signs) of decontamination team members, if

specified by the community or EMS agency

plan.

6) Put on PPE.

22 OSHA understands that decontamination teams will consist of

firefighters, HAZMAT team members, and/or EMS personnel who

are FULLY qualified to do so and are wearing adequate protective

equipment.

23 Seatbelt cutters are not as useful for cutting through thick tape

around responder’s boots; shears work better for this type of material.
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 3 7

7) Triage patients to determine which individuals

require decontamination and provide critical

medical treatment to stabilize them before

decontamination.

8) Direct or assist patients (ambulatory and nonambulatory) in removing contaminated clothing and securing personal property as soon

as possible (within minutes of arrival).

9) Place clothing and other contaminated items

in a plastic bag that can be sealed (or when

available, place items in an approved hazardous waste container and cover). Ensure

that waste bags/containers are isolated and

remain outdoors so that the items are not a

continuing source of exposure.

10) Perform gross decontamination with water

(extensive amounts, if available), such as from

a hose. More time-consuming technical decontamination may be necessary to completely

remove contaminant. This more thorough

decontamination procedure involves washing

patients using soap, with good surface-active

properties (i.e., soaps that help oil dissolve in

water), and water (preferably tepid water to

improve patient compliance). Pay particular

attention to the back and hair on the head or

body. Make sure that hair wash water falls

away from the body, if possible. Remove all

obvious contamination on a patient with gentle

blotting or brushing, never rub or irritate the

skin. Avoid abrasive materials (such as “gritty”

soaps). This step should also include copious

rinsing, especially when dealing with acids or

bases. [See discussion, below.] Ambulatory

patients may be able to clean themselves

under direction of the decontamination team.

11) Inspect patients to evaluate the effectiveness

of decontamination. Guide decontaminated

patients to the medical treatment area (away

from any possible contamination). Return

inadequately decontaminated patients to the

shower area and repeat cleansing.

12) Decontaminate equipment and the decontamination system (if not disposable).

13) Decontamination team removes PPE and

decontaminates themselves. The order in

which PPE is removed during responder

decontamination can help minimize additional exposure. See Appendix M for an example

of a sequence for putting on (donning),

decontaminating, and removing (doffing) PPE.

14) Patient inspection provides a final check to

ensure that contaminant is not carried into

clean areas.

Decontamination procedures, like PPE use, can

be modified once the contaminant is identified;

decontamination team members who are cleansing

patients to remove known contaminants can tailor

procedures as appropriate. For example, a longer

rinse might be beneficial for contamination in the

eyes, or for contamination involving corrosive,

sticky, or oil-soluble substances. Organizations such

as the Centers for Disease Control and Prevention

(CDC) and the U.S. Department of Homeland

Security offer specific recommendations for decontaminating patients exposed to individual hazards, such as ionizing radiation (CDC, 2003; U.S.

Department of Homeland Security, 2003).24

Determining the adequacy of decontamination

efforts is a recurring issue in community preparedness discussions. If it was known that patients were

exposed to nerve agents and a decontamination

team had access to appropriate testing media (e.g.,

surface testing tapes), this confirmation could be

helpful. Although contaminant detection equipment

is available for certain other hazardous substances

(such as radiological hazards), in most cases confirmation that a patient has been carefully washed by

a trained decontamination team still offers the best

assurance of safety for EMS responders, vehicles

and equipment. As previously discussed, OSHA

strongly recommends that employers train to the

first responder awareness level all EMS responders

who could transport decontaminated patients from

a hazardous substance emergency site, and as a

best practice train them as first responders at the

operations level.

Decontamination in Low Water Situations

Decontamination with extensive amounts of water

remains the preferred method; however, for low

water situations, other methods can help physically

remove contaminant from patients. Several military

and civilian organizations are investigating decontamination aids for use in situations when little or no

water is available or when cold weather makes

water less practical. These methods include targeted application of available water, bulk absorbents

and reactive foams.

Once contaminated clothing is removed, spot

decontamination can be performed using little

water targeted to the skin that was originally

exposed (typically the hands and head/hair). Using

this method, it might be possible to perform gross

24 The International Commission on Radiological Protection

(ICRP) and the National Council on Radiation Protection and

Measurements (NCRP) also offer guidance for radiological incidents.
decontamination with a hand-pump sprayer and a

few gallons of water.

Hurst (1997) reviewed decades of literature on

decontamination methods and noted that an application of flour, followed by wet tissue wipes offers

some benefit in reducing the amount of chemical

substances left on the skin. Nevertheless, bulk dry

absorbents tend to be most useful (and have traditionally been used) for decontaminating large surface areas and points where contaminant has

pooled. The best absorbent for a job depends on

the contaminant, but any non-reactive substance

with a large porous surface area has potential to

serve as a sorbent. Materials considered by the U.S.

Army for use in cold weather would also serve

under conditions where little water is available; suggested practices for conducting gross decontamination include blotting patients with sorbent substances such as paper towels, flour, sand, dirt, an oil

absorbent, or diatomaceous earth (Fuller’s earth)

with the intent of removing harmful material from

the patient as quickly as possible (SBCCOM, 2002).

As noted previously, patients’ clothing should be

removed as soon as possible to achieve the maximum benefit.

Gross decontamination with sorbent should be

followed up as soon as feasible with a warm water

wash. Various foams and creams may play a role in

the future, but at this time these products are not

approved for use on human skin (see Appendix L -

Decontamination Foam and Barrier Cream).

Vehicle and Equipment Decontamination

Prevention is the best policy for protecting vehicles

from contamination. Some industrial chemicals can

be neutralized,

but many will

be difficult to

remove from

porous materials and cracks/

crevices in the

interior. If contaminated, the

vehicle may need to be taken out of service.

Decontamination of non-porous equipment

materials follows a similar process to decontamination of skin (wash with extensive amounts of water

and soap, rinse thoroughly, inspect carefully),

although equipment can be scrubbed. Porous materials are more difficult to clean effectively and most

likely will need to be discarded with other waste

from the response and decontamination effort. An

OSHA letter of interpretation advises eliminating or

minimizing soft plush surfaces where they might

need to be decontaminated later (OSHA, 1994-

Bays).

Discovering that a Patient in the

Ambulance is Contaminated

EMS providers should make every effort to prevent

ambulances from becoming contaminated.

Contamination of an ambulance, and the EMS personnel associated with it, could cause them to be

removed from service and decrease the availability

of these critical resources. Representatives of the

EMS community requested guidance in addressing

this possible scenario.

OSHA believes that prevention is the first line

of defense for preserving emergency medical

resources. EMS responders should communicate

with other first responders and decontamination

teams regarding the extent of patient exposure and

the decontamination processes used to clean

patients. This information will help ambulance

operators ensure that only uncontaminated/clean

patients are loaded into the vehicle. EMS responders who suspect residual contamination on a

patient should not hesitate to suggest that the

patient be returned to the wash area for additional

cleaning.

In practice, however, it is possible that EMS personnel could discover evidence of contamination

associated with a patient who is already being

transported, although that patient was believed to

be clean.25 In this situation, efforts should focus on

minimizing further spread of the contaminant and

on (further) decontamination. Ambulance operators

should take the following steps:

En Route

• Notify the receiving hospital that the incoming

patient shows evidence of possible contamination so that decontamination procedures can be

activated.

• Verify that all clothing and personal effects are

completely removed and sealed in plastic bags

(double layer).

• Take available steps to contain the spread of contamination to vehicle and personnel (e.g., wrap

patient in disposable tarp or blanket if allowed

by patient care protocol).

3 8

Occupational Safety and

Health Administration

25 It is also possible that EMS responders might be instructed to

transport a contaminated patient. In this case, the responders

should confirm that the incident commander is aware that such

an action may cause the ambulance and crew to be taken out of

service.

Photo courtesy of Frank Califano
• Alert the incident site that a patient in transit

shows signs of contamination (describe the evidence) so that ongoing patient handling and

decontamination procedures at the site can be

modified appropriately.

Upon Arrival at the Receiving Hospital

• Treat EMS responders as victims, requiring

decontamination and/or treatment, until it is possible to confirm that they have not suffered ill

effects.

• Remove the ambulance from service and arrange

to have it surveyed immediately to determine

whether it can be placed back in service.

Certain ambulance designs can help reduce

exposure to airborne contaminants, but do not prevent exposure. For example, NIOSH investigators

researching tuberculosis (TB) exposure controls

evaluated the effectiveness of supplemental high

efficiency particulate air (HEPA) filtration systems in

ambulances (NIOSH, 1996).26 In tests conducted

under similar conditions, airborne particles were

cleared more rapidly from the air inside an ambulance equipped with supplemental HEPA filtration

than from an ambulance without HEPA filtration.

Furthermore, testing showed that “particle clearance

could be improved with the use of the rear vent fan”

(turned to the “high” setting) in combination with

fresh air provided through the ambulance’s main

heating and cooling system. Running the rear vent

fan provided some particle clearance even in an

ambulance that was not fitted with HEPA filters, in

part because running the vent fan increased air

exchange in the ambulance. With the main heating

and cooling system, HEPA filtration system, and rear

vent all running, the volume of air in the rear compartment of the ambulance was replaced at a rate of

almost once per minute (56 air changes per hour).

The investigators note that “while supplemental

engineering controls such as [HEPA filtration] can

improve particulate clearance in the ambulance, they

will not eliminate the potential for exposure....”

When HEPA filtration systems are used, consult the

manufacturer to determine the optimal testing and

maintenance schedule (NIOSH, 1996).

Detection Equipment

Detection Instruments

Numerous instruments allow EMS responders to

detect contaminant levels with varying degrees of

precision. Easy-to-use ionizing radiation meters perform well during emergency medical responses

and may be used to evaluate both contaminated

patients/equipment and the effectiveness of decontamination processes. EMS responders face a

greater challenge in identifying chemically or biologically contaminated individuals at the scene, both

before and after decontamination procedures.

The first indication of the need to activate the

decontamination team might come from first

responders who identify contaminated individuals

through an initial interview, by visual observation,

by the presence of indicative odors, and through

signs that a substance appears to be affecting

health. After a patient has been through the decontamination system, to confirm cleanliness, EMS

responders currently rely primarily on visual inspection and the extent to which the patient followed

prescribed showering procedures. Ionizing radiation

detectors effectively contribute valuable screening

information. In contrast, for most chemical substances the currently available simple, portable

chemical detection equipment can supplement

these methods, but do not replace them.

Ionizing Radiation Meters

Ionizing radiation occurs in three major forms –

alpha, beta, and gamma radiation.27 Most radiological substances emit one or more of these forms of

radiation. Of the three, alpha radiation, in general,

has the highest energy and is most hazardous if

ingested or inhaled, but presents minimal hazard

outside the body. Beta radiation (typically with less

energy) can cause skin burns at close range (i.e.,

skin contamination). Patients can become contaminated with alpha- or beta-emitting radioactive materials if these materials are released during a hazardous substance incident. Inhalation and ingestion

of these particles can be greatly reduced by removing contaminated clothing and washing thoroughly

(EPA RERT, 2007).

Two different exposure scenarios are possible for

photon/gamma radiation, which exists in the form

of energy that passes through the body, causing

damage to organs and tissues in its path. The

source of gamma radiation could be either (1)

gamma-emitting radioactive materials (contaminants released during a hazardous substance incident), or (2) a discrete gamma-emitting source of

radiation. In the first case, decontamination procedures will help remove the gamma-emitting materials from skin, which will reduce the radiation exposure, and subsequently the risk, to patients and

O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 3 9

26 HEPA filters are capable of removing 99.97 percent of the particles that are less than 0.3 microns in diameter (the most penetrating – or worst case – size).

27 Photon radiation types include gamma radiation, x-radiation,

and “bremsstrahlung” (a type of electromagnetic energy).
responders. In the second case, if only photon/

gamma radiation is released from a specific discrete

source and no gamma-emitting material contaminants (e.g., dusts) are involved, then gamma radiation will be emitted through the area exposing

patients (and responders) in the area until the

source is removed from the area or shielded with an

appropriate material such as lead. Exposure can be

controlled by moving the patient to a safe location.

When the source of gamma emission is removed or

shielded, the gamma radiation exposure will also

stop. Patients who were initially exposed by the

emitting source may have lingering health effects

from that initial exposure, but will not have additional exposure after the gamma-emitting source is

removed. These patients may not benefit from

decontamination procedures unless they are contaminated with other substances that need to be

removed. Likewise, EMS responders will not experience gamma radiation exposure if they arrive on

the scene after the discrete gamma-emitting source

is removed.

It is important that ionizing radiation meters (and

associated probes) used by EMS responders be

selected based on the types of radiological materials with which patients could be contaminated. If

radiation is suspected, a health physicist should be

consulted (EPA RERT, 2007).

Relatively reliable and easy-to-use instruments

are available for measuring beta and gamma forms

of ionizing radiation (e.g., survey meters fitted with

a Geiger-Mueller detector or “GM probe,” of which

a “pancake” probe is one common example). This

type of instrument typically functions as a rate

meter and provides a reading in the units of “counts

per minute” in analog or digital form. 28 For evaluating patient contamination, EMS responders might

find it helpful to have access to a rate meter with a

“scaler” feature. A scaler displays an integrated digital readout for a preset sample period, selected by

the operator, at a point of potential contamination

(e.g., a patient’s hair). The integrated digital readout

is easy to compare to readings from other parts of

the body or to background readings taken at a distance from the patient.

Because these probes are sensitive to gamma, x,

alpha, and beta radiations, they will always detect

the natural background radiation levels. Unless fully

shielded, they do not read zero, even in an environment that is not radiologically contaminated. For

this reason, GM probe values are more useful for

comparing contamination levels at different specific

positions (i.e., comparing a point of suspected contamination to a non-contaminated point) rather than

for checking radiation levels against specific fixed

criteria (EPA RERT, 2007).29 The U.S. Department of

Health and Human Services’ Radiological Event

Medical Management Web site contains detailed

information on the use of GM meters during patient

contamination evaluations and other helpful guidance for providing medical services during a radiological emergency (see http://remm.nlm.nih.gov/

index.html). Figure 2, at page 41, adapted from that

Web site, describes how to use a radiation meter to

conduct a survey for radioactive contamination on a

patient or an emergency responder.

These same GM meters will detect alpha radiation to a limited extent, but are less sensitive for

monitoring the presence of low-level alpha detection during decontamination procedures. When

alpha radiation is present, a survey meter with an

alpha scintillation probe is preferable for evaluating

the alpha radiation. Alpha detectors are best used

by an experienced operator under the direction of a

health physicist. These professionals will also be

better equipped to determine whether more than

one type of radiation is present (e.g., alpha and

beta, or beta and gamma).

Decontamination after a radiological materials

event involves mechanical removal of the radioactive particles from the individual. The process can

include washing, wiping, or irrigating the area. The

decontamination team should take care not to scrub

and abrade the skin. Once decontamination has

been performed, the area should be resurveyed

with a survey meter and appropriate probe. Decontamination efforts should continue until there is no

measurable decrease in the count rate.

Chemical and Biological Agent

Detection Equipment

There is no single ideal chemical or biological agent

meter (or even two or three meters) that will meet

all the needs of EMS responders. The requirements

of this group of responders are particularly high

because EMS responders have restricted space to

carry equipment, are generally not hazardous sub4 0

Occupational Safety and

Health Administration

28 GM meters, such as the popular Ludlum Model 12 rate meter

and equivalents are readily available from commercial sources

and may come equipped with a range of optional features. A

900-volt model will likely be most practical for EMS responders

(EPA RERT, 2007).

29 DOE has specific criteria for fixed and removable contamination values in 10 CFR 835 Appendix D, summarized on the

Lawrence Berkeley National Laboratory Web site at http://uclbl.

org/ehs/orps/pdf/radContamination.pdf. The Radiological Event

Medical Management Web site, http://remm.nlm.gov/remm_

RadPhysics.htm#pag, lists allowable limits of radiation for the

general public and radiation workers, and guidelines for radiation

response worker exposure.
stance technical experts, need rapid results, and

may be called upon to respond to the full spectrum

of hazardous substance emergencies that could

occur within their community (EPA ERT, 2007).

There are, however, many instruments that can contribute useful information under a variety of circumstances and may be available through local HAZMAT teams.

Promotional material, published selection criteria, and detection equipment recommendations list

an increasing number of instruments available to

detect and quantify hazardous substances (LSS,

2008; NIJ, 2000; IAB, 2007; HazTech, 2007;

DrägerSafety, 2007; Grainger, 2007). Recent advances

have lowered the detection limits of many instruments that assess airborne levels of specific chemical and biological substances. Reproducibility (of

results) is also improving and the value of monitoring equipment to emergency responders is generally on the rise. Although most equipment is still

more useful for evaluating an incident site and

determining the presence of a hazardous substance

in the environment than for declaring patients thoroughly clean after decontamination efforts, many

instruments offer at least some useful information

to EMS responders.

Photo-ionization detectors (PIDs) “are particularly

valued by emergency responders in general for

their relatively low cost, light weight, rapid detection

response, and ease of use” (ILN, 2006). These detectors play an important role in the earliest phase of a

response, but cannot be relied upon as the sole

source of analytical information. Investigators evaluated the benefits of PID for first responders interested in detecting chemical vapors. The investigators

obtained information from PID manufacturers, interviewed first responders who use these detectors,

and conducted independent laboratory evaluations.

The information showed that lab and user’s experiences were not “always consistent with the manufacturer’s stated capabilities of their equipment.” As

a general class of instruments, PID detectors are

useful for providing rapid, suggestive (but not definitive) “information about whether a site has been

compromised,” but false positive readings are difficult to avoid and appropriate calibration is critical to

PID effectiveness at a given site. This equipment is

most useful in the initial phases of site assessment

and if followed by other confirmatory test methods.

Some emergency responders use PIDs for site

worker health and safety support, when conditions

allow (i.e., when the PID can be accurately calibrated for the specific site circumstances, the hazard is

clearly identified, and in the absence of other comO S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 4 1

• Survey with Geiger-Mueller Detector.

Probe held about 1/2 inch from surface.

Move at a rate of 1 to 2 inches per second.

Follow a systematic pattern (see above).

Document readings in counts per minute (CPM)

on a body chart.

Compare radiation survey results before and

after decontamination procedure.

• Use nuclear medicine and radiation therapy technologists or others familiar with the use of radiation detection instruments.

• Goal is < 2 times background radiation reading.

• In general, areas that register more than twice the

previously determined background radiation level

are considered contaminated.

• For accidents involving alpha particle emitters, if

the reading is less than twice the background

radiation level, the person is not contaminated to

a medically significant degree. If the accident circumstances indicate that an alpha particle emitter

(such as plutonium) or low-energy beta emitter

could be a contaminant, a health physicist should

always be consulted.

• Specifics of the survey.

Have the person stand on a clean pad.

Instruct the person to stand straight, feet spread

slightly, arms extended with palms up and fingers straight out.

Monitor both hands and arms; then repeat with

hands and arms turned over.

Starting at the top of the head, cover the entire

body, monitoring carefully the forehead, nose,

mouth, neckline, torso, knees, and ankles.

Have the person turn around; repeat the survey

on the back of the body.

Monitor the soles of the feet.

Adapted from: USDHHS-REMM (2007) accessed

September 12, 2007 at http://remm.nlm.nih.gov/

howtosurvey.htm

Figure 2. How to Do a Survey for Radiation
peting substances that could cause false PID readings).

The formal report on the evaluation of PID use

for first responders...

...indicates that PIDs should always be part of

a decision-making context in which other qualitative and more definitive tests and instruments are used to confirm a finding.The performance of PIDs, as observed by users and

quantified by independent testing, may affect

the ability to make correct field decisions (ILN,

2006).

30

Other types of detectors are also available for

use with some constraints. Like PIDs, flame ionization detectors (FID) can be used primarily as a

screening tool, but with verification by other evaluation methods. This is because FIDs are subject to

interference by other substances and even humidity.

Bulky, but still portable, (shoulder-carried) atomic

absorption and gas chromatograph instruments can

provide more precise and accurate levels of detection and/or chemical specificity. Although these

instruments often require operators with more specialized training and need careful calibration to

obtain meaningful results, HAZMAT teams using

this equipment may be able to provide EMS responders with useful information on hazardous substance identification and concentration.

User-friendly equipment of adequate sensitivity

is available for certain specific agents typically used

as chemical weapons. HAZMAT teams in many

communities have acquired a selection of handheld

detection meters designed to detect parts per billion

(ppb) levels of specific chemical “nerve and blister

agents” used as chemical weapons (e.g., organophosphates and mustard agent) and other substances. Additionally, some of the current broadspectrum detection devices are capable of detecting

classes of agents (if not the individual agent) with

reasonable sensitivity and accuracy. In some cases,

other analyses of the basic properties of a substance may provide useful information about its

potential to be toxic, corrosive, volatile or flammable, even when the identity or airborne concentration remain unknown (OSHA, 2006-Stakeholder

Comments).

EMS stakeholders who advised OSHA on this

project note that the potentially small residual

contaminant on clothing and skin prior to

decontamination often cannot be detected

efficiently with current technology. It is even

more difficult to identify a handheld detection

method that will assure that decontamination

efforts have been adequate (except in cases

of radiation release).

“There is no foolproof chemical detector and

we are far from having a foolproof biological

agent detector.” False readings continue to be

a problem, with relatively harmless chemicals

triggering an alarm (OSHA Stakeholder

Comments, 2006). At this time, good supervision of the washing process remains a more

reliable indicator of good decontamination.

To the extent that they become available, EMS

responders might also find chemical detection tapes

and swabs useful for assessing the types of persistent, highly toxic, modestly volatile or non-volatile

CBRNE agents that could cling to a patient’s clothing, or to the patient’s body once contaminated

clothing has been removed (EPA ERT, 2007).

Employers of EMS responders should consider

meeting with HAZMAT teams to obtain an overview

of the strengths and weaknesses of the detection

equipment available to the teams with which they

would work in the event of an emergency release.

Together they should determine the utility of these

instruments to support EMS responder functions.

Keep in mind that EMS responder training and powers of observation to identify cases of contamination still remain a critical element of their defense.

Methamphetamine Detection Equipment

To assist law enforcement officials who go on site

during investigation or decontamination of illegal

methamphetamine laboratories, NIOSH researchers

have developed field methods to detect the presence of methamphetamine on surfaces, personnel

and PPE. These methods will help detect the presence of the drug in illicit laboratories and evaluate

the effectiveness of decontamination procedures.

NIOSH reports that:

“A prominent manufacturer of sampling technologies has commercialized two low-cost,

NIOSH-designed field methods to help first

responders, public health officials, and remediation workers quickly detect the presence of

methamphetamine on various environmental

surfaces.The sampling technique can be used

to detect trace levels of the illicit drug on sur4 2

Occupational Safety and

Health Administration

30 Appendix B of the source document contains interviews with

nine community incident commanders regarding the specific

detection equipment they take to sites and how they use the

information the detectors provide. See “Data for First Responder

Use of Photoionization Detectors for Vapor Chemical Constituents”

(ILN/EXT -05-00165 (Rev 1), Idaho National Laboratory

(November 2006). Accessed September 4, 2007 at:

www.inl.gov/technicalpublications/Documents/3589641.pdf.
faces, or used to evaluate decontamination

efforts or clearance” (NIOSH, 2006).

The first method involves a “colorimetric test

that detects the presence of methamphetamine

residue on surfaces from 15 to 5000 micrograms/100 cm2

. Results should not be used for

clearance purposes.” The second method is a set of

“semi-quantitative immunoassay tests that detect

low levels of methamphetamine residue on surfaces. They may be used to determine the need for

cleaning in a specific area or the need for further

cleaning onsite to reach state cleanup guidelines”

(SKC, 2006). The manufacturer notes that some

states and counties require lab results from quantitative wipe sampling before issuing a reentry certificate after cleanup efforts. In addition to screening

tests, laboratory analyses are also available.

O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 4 3
Conclusion

These best practices are intended to help EMS

responders’ employers investigate and identify in

advance of an incident the roles that their workers

can be expected to play during a hazardous substance release event in their community (including

under conditions of a mutual aid agreement).

Employers should use the information in this guide

when conducting hazard assessments to determine

worker PPE and training needs. The hazard assessments are based in part on worker roles and on the

types of hazardous substance releases for which the

community is preparing. The anticipated role of

workers and the related hazard assessments should

help guide the employers’ decisions about how to

prepare their EMS responders to work as safely as

is reasonably possible during treatment and transport of victims of hazardous substance releases.

In determining appropriate PPE and training for

their EMS responders, employers should refer to

the Summary of OSHA’s Recommendations for

Training and PPE section of this guide (at pg. 32).

4 4

Occupational Safety and

Health Administration
Appendix A

Glossary

Air-purifying respirator (APR): A respirator that uses

filters, cartridges, or canisters to cleanse the air.

Atmosphere supplying respirator (ASR): A respirator

that provides clean air from an uncontaminated

source to the facepiece. Examples include suppliedair (airline) respirators, SCBA, and combination supplied-air/SCBA.

Assigned protection factor (APF): A rating assigned

to a respirator style by OSHA. This rating indicates

the level of protection most workers can expect

from properly worn, maintained, and fitted respirators used under actual workplace conditions. An

APF of 1,000 indicates that the concentration of contaminant inside the facepiece would be 1,000 times

lower than the concentration in the surrounding air.

A respirator with an APF of 1,000 will provide

greater protection than a respirator with an APF of

100. (Note:The APF should not be confused with a

similar measure, the “fit factor,” obtained during

quantitative fit testing. Fit factors, which tend to be

higher numbers, provide a relative indication of

how well a respirator fits an individual, but do not

represent the level of protection the respirator

would provide in the workplace.)

Awareness level: See first responder awareness

level.

CBRN: Chemical, biological, radiological, or nuclear

[agent or substance].

CBRNE: Chemical, biological, radiological, nuclear,

or explosive [agent or substance].

Cold zone: Area free of contamination. Equipment

and people leaving the hot zone should be decontaminated prior to arriving at the cold zone. If a hazardous substance from patients or equipment contaminates the cold zone, the area is redefined as a

warm zone.

Decontaminate (or decontamination): The process

of removing hazardous substance contamination

from a patient, equipment or other material. See

also Gross Decontamination and Technical

Decontamination.

Doff: To take off or remove (e.g., PPE).

Don: To put on, in order to wear (e.g., PPE).

EMS: Emergency medical services. The emergency

medical service system can encompass all levels of

patient emergency care, treatment or transport.

EMS responder: Individual trained to answer public

safety requests for emergency medical care. Includes all levels of emergency medical technicians

(EMTs) and paramedics. For the purposes of this

document, the term EMS responder also includes

individuals cross-trained or holding multiple qualifications (e.g., firefighter, hazardous materials team

member, police officer) only at the time that they

are performing the duties of an EMT or paramedic.

EMT: Emergency medical technicians of all levels

(EMT-Basic, EMT-Intermediate, EMT-Paramedic).

ERP: Emergency response plan.

First responder: Personnel who have responsibility

to initially respond to emergencies. Some examples

are firefighters, HAZMAT team members, law enforcement officers, lifeguards, forestry personnel,

EMTs, and other public service personnel. In the

case of hazardous materials incidents, these personnel typically respond at the site where the incident

occurred.

First responder awareness level: Individuals who

might reasonably be anticipated to witness or discover a hazardous substance release and who have

been trained to initiate an emergency response

sequence by notifying the proper authorities of the

release. They would take no further action beyond

notifying the authorities. [OSHA HAZWOPER

Standard, 29 CFR 1910.120(q)(6)(i)].

First responder operations level: Individuals who

respond to releases or potential releases of hazardous substances as part of the initial response to

the site for the purpose of protecting nearby persons, property, or the environment from the effects

of the release. These individuals shall have received

at least 8 hours of training or have sufficient experience to objectively demonstrate competency in specific critical areas. [OSHA HAZWOPER Standard, 29

CFR 1910.120(q)(6)(ii)].

Gross decontamination: The process of removing

clothing and/or a water rinsing of the naked body to

quickly remove the majority of hazardous substance

contamination from a patient. Also called primary,

or expedient decontamination.

HAZCOM: OSHA’s Hazard Communication standard

[29 CFR 1910.1200].

HAZMAT: Hazardous material.

HAZWOPER: OSHA’s Standard on Hazardous Waste

Operations and Emergency Response, 29 CFR

1910.120. In particular, paragraph (q) of this standard covers employers whose workers are engaged

in emergency response to hazardous substance

releases.

Hazard response zones: Any of the three areas designated to indicate the degree of hazard and locaO S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 4 5
tion of response activities. The three zones are hot

zone, warm zone, and cold zone. Consult the glossary entry for the individual zone for a more

detailed definition.

Hazard vulnerability analysis (HVA): The identification of potential emergencies and direct and indirect

effects these emergencies may have on the organization’s operations and the demand for its services.

Hazardous Substance: Any substance exposure to

which may result in adverse effects on the health or

safety of workers. This includes substances defined

under Section 101(14) of CERCLA; biological or disease-causing agents that may reasonably be anticipated to cause death, disease, or other health problems; any substance listed by the U.S. Department

of Transportation as hazardous material under 49

CFR 172.101 and appendices; and substances classified as hazardous waste.

Hazardous Substances Emergency Events

Surveillance System (HSEES): A state-based system

operated by the Agency for Toxic Substances and

Disease Registry (ATSDR) since 1989. The system is

intended to help characterize the public health consequences of hazardous substance releases.

Approximately one-third of the U.S. states currently

participate by collecting and submitting information.

The HSEES database stores information on events,

chemicals, victims, injuries and evacuations.

Hospital incident command system (HICS): An

example of an optional NIMS-based ICS tailored

specifically for use by hospitals and designed to

function in conjunction with other common ICSs

used by emergency response agencies (e.g., Fire

Service Incident Command System). See Appendix I

for additional information.

Hot zone: An area in and immediately surrounding

a hazardous substance release. It is assumed to

pose an immediate health risk to all persons, including EMS responders.

IDLH: Immediately dangerous to life or health

means an atmospheric concentration of any toxic,

corrosive or asphyxiant substance that poses an

immediate threat to life or would interfere with an

individual's ability to escape from a dangerous

atmosphere. NIOSH publishes a list of IDLH concentrations for various substances. NIOSH has set the

IDLH levels based on several toxicity criteria, which

give priority to 30-minute acute data that demonstrates the concentration that is lethal to 50 percent

of laboratory animals in 30 minutes.

Incident command system (ICS): A flexible organizational structure which provides a basic expandable system adapted by the Department of

Homeland Security as the common emergency

response organizational structure throughout the

nation.

Incident commander (IC): The individual who holds

overall responsibility for incident response and

management.

JCAHO: Joint Commission on Accreditation of

Healthcare Organizations.

LEPC: Local Emergency Planning Committee.

Mass casualty: “A combination of patient numbers

and patient care requirements that challenge or

exceed a community’s ability to provide adequate

patient care using day-to-day operations” (Barbera

and MacIntyre, 2003).

NFPA: National Fire Protection Association.

NHTSA: National Highway Traffic Safety

Administration, an organization under the U.S.

Department of Transportation (U.S. DOT).

NIMS: The National Incident Management System,

established by the U.S. Department of Homeland

Security as a standardized management approach

to incident response, including the NIMS-based ICS,

that all responders will use to coordinate and conduct response actions.

Paramedic: An Emergency Medical Technician –

Paramedic level. A person who is trained to give

emergency medical treatment or assist medical professionals in providing advanced life support.

Personal protective equipment (PPE): Examples

include protective suits, gloves, foot covering, respiratory protection, hoods, safety glasses, goggles

and face shields.

Powered air-purifying respirator (PAPR): A respirator

that uses a battery-powered blower to force air

through a filter or purifying cartridge before blowing

the cleaned air into the respirator facepiece.

Self-contained breathing apparatus (SCBA): A respirator that provides fresh air to the facepiece from a

compressed air tank (usually worn on the worker’s

back).

Skilled support personnel: Personnel, not necessarily an employer's own workers, who are skilled in

the operation of certain equipment, such as mechanized earthmoving or digging equipment or crane

and hoisting equipment, and who are needed temporarily to perform immediate emergency support

work that cannot reasonably be performed in a

timely fashion by an employer's own workers, and

who will be or may be exposed to the hazards at an

emergency response scene [from 1910.120(q)(4)].

Supplied-air respirator (SAR): A respirator that provides breathing air through an airline hose from an

uncontaminated compressed air source to the face4 6

Occupational Safety and

Health Administration
piece. The facepiece can be a hood, helmet, or tight

fitting facepiece.

Technical decontamination: The process of using a

cleansing agent to completely clean a patient. The

cleansing agent is typically soap and water, but

might include other solvents. Technical decontamination (also called secondary, or precautionary

decontamination) is more thorough, but also more

time-consuming than gross decontamination.

Triage: The process of screening and classifying

sick, wounded, or injured persons to determine priority needs in order to ensure the efficient use of

medical personnel, equipment and hospitals.

Warm zone: The area surrounding the hot zone,

where primary contamination is not expected but

where personnel must use protective clothing and

equipment to avoid hazardous substance exposure

from contaminated victims. People and items are

decontaminated in this zone as they return from the

hot zone and before being released to the cold zone.

The warm zone is located between the hot zone and

the cold zone, with consideration of environmental

factors such as wind direction and geographic conditions.

O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 4 7
Appendix B

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5 2

Occupational Safety and

Health Administration

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for EMTs Exposed to Hazardous Substances.

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O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 5 3

Command [RDECOM]) . (January). Accessed

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Prehosp Emerg Care 7:214-218. Apr-Jun.
5 4

Occupational Safety and

Health Administration

Appendix C

Additional Sources of Information

Inter Agency Board for Equipment Standardization

and Interoperability – general information and links

to related sites, such as the Responder Knowledge

Base, at www.iab.gov

• InterAgency Board – Standard Equipment List

(personal protective equipment)

www.iab.gov/Download/sel_section1_2006.pdf

• Radiological Event Medical Management Web

site, at www.remm.nlm.gov
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 5 5

Appendix D

Examples of Mutual Aid Agreements

and Templates

This Appendix provides three examples of mutual

aid agreements and templates for agreements

between service providers and communities. The

example from Westchester County, NY contains a

substantial amount of detail, while another example, from the Iowa Department of Public Health, is

brief and to the point. Many other formats and

arrangements exist and many are publicly available

on the Internet (For example, conduct an Internet

search using key words such as: Mutual Aid EMT; or

Mutual Aid memorandum of agreement EMT)

Emergency Management Assistance Compacts

(EMACs) serve a similar purpose for mutual aid

between states and can help fulfill the function of

mutual aid agreements. For information on intrastate

mutual aid and model intrastate legislative language,

see www.emacweb.org.

Westchester County, NY Mutual Aid agreement

[View at: www.westchestergov.com/emergserv/

EMS/PDF_files/mutualaidplandec03-v5.pdf]

Template for mutual aid agreement provided by the

Iowa Department of Public Health (IDPH)

[View at: www.idph.state.ia.us/ems/common/pdf/

mutual_aid_agreement.pdf]

Washington State Inter-county Mutual Aid omnibus

AgreementTemplate

[View at: http://emd.wa.gov/plans/documents/

MutualAidHandbook.pdf]
Appendix E

Using Hazardous Substances Emergency

Events Surveillance System (HSEES)

Information in Community Hazard

Evaluations – A Review

Case Study – How communities and industries

can use the HSEES system information to

reduce events (primary prevention) and inform

emergency responders as part of secondary

prevention (excerpt from Kaye et al. 2005).

Ammonia

Background

During 1996-2001, ammonia releases constituted 6.2% of all releases reported to HSEES. The

ammonia events were also 68% more likely to

result in more victims than expected based on

the percentage of all events in that category.

Because of the prevalence of victims during

these events, ammonia releases have been targeted for prevention in many states.

Primary prevention

As part of primary prevention efforts that targeted industry, Texas offered to provide frequent spillers with their own HSEES data. A

food processing company responded by

requesting their spill data. From the data they

discovered that two facilities they had just purchased had never reported any chemical releases to either HSEES or the Nuclear Regulatory

Commission (NRC). The two facilities apparently were lax in maintaining release records [a situation that could be easily corrected].

To reduce the risk of employee exposure and

minimize losses due to contaminated processed

foods, this company also implemented many

process safety measures in all 13 of its Texas

facilities. These measures included:

• Training on good workplace safety practices

for both new and veteran employees.

• Designing and implementing pollution prevention systems to capture released ammonia by way of a water recovery system, rather

than create fugitive plant emissions.

The company specifically used HSEES data to

evaluate the cyclic nature of ammonia (refrigerant) releases and found that there was a higher

frequency of releases during the summer, when

outside temperatures were greater than 100°F.

Engineering controls were added to the refrigeration systems to compensate for higher seasonal pressure, thereby reducing the frequency

of releases. A periodic inspection and maintenance schedule minimized component failures

before they occurred. By the end of 1999, an

automated early warning ammonia detection

system was installed in each company processing facility.

Secondary prevention

Because of the prevalence of ammonia-related

injuries, many of the states participating in the

HSEES system have chosen to target the producers, transporters, and handlers of ammonia

for secondary prevention of injuries. The farm

belt states particularly target their prevention

activities around ammonia because of the large

quantities of ammonia fertilizers used. One

such state is Minnesota, which analyzed its

ammonia release data and produced an article

aimed at health and safety personnel (Souther

et al., 2000) and first responders (Souther et al.,

2002). These articles contained additional information about ammonia and possible health

effects from exposure, how to respond to an

ammonia release safely, and first-aid tips if

exposure occurs. Calls from fire departments

for more information were received after the

articles were published. The articles were used

during training of fire department personnel,

and techniques described in the article are

actively used by fire department personnel

when responding to ammonia releases.

5 6

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Health Administration
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 5 7

In 1989, the Agency for Toxic Substances and

Disease Registry (ATSDR) implemented an active

state-based hazardous substances emergency

events surveillance system (HSEES) in an attempt

to adequately characterize the public health consequences of hazardous substance releases. A hazardous substance emergency event (herein called

“event”) is defined as uncontrolled or illegal releases or threatened releases of chemicals or their hazardous by-products. The HSEES collects information on events, chemicals, victims, injuries and

evacuations. Analysis of the HSEES data helps

identify risk factors associated with hazardous substances releases.

A knowledge of risk factors can be useful when

developing public safety interventions and can

impact the guidelines and policies aimed at reducing the number of events (primary prevention) and

the morbidity and mortality associated with such

events (secondary prevention) (Kaye et al., 2005).

Using the HSEES system, participating states

have been able to develop prevention outreach

activities such as awareness training of first responders, primary prevention of spills, and secondary

prevention of related injuries and deaths. One such

case, involving ammonia, has been excerpted from

Kaye et al. (2005) and is presented in the inset,

above.

Following are several additional studies that

have reviewed the HSEES system data and provide

valuable trend analysis information that might help

employers in planning for common incident types

in their areas. These examples also further illustrate

the type of information available from the HSEES

system.

Evaluation of Data from the Early 1990s

Hall et al. (1994, 1995, and 1996) studied the results

of events reported to the HSEES system from

January 1, 1990, through December 31, 1992.

General trends resulting from the reported hazardous releases are briefly summarized below.

Events

The majority (72%) of events occurred at fixed facilities (e.g., industrial sites, schools, farms, etc.) while

the remaining (28%) were transportation-related

(e.g., surface, air, or water transport). (Hall et al.

1994 & 1996). Spills (72%) and fires (10%) accounted for the majority of release types while the

remaining events resulted from explosions and

other types of releases (Hall et al., 1995). Over half

(55%) of the events occurred in areas with industrial

or commercial land use with an additional quarter

of events taking place in areas classified as rural

(Hall et al. 1994 & 1996). Even fewer events are

reported for residential areas. Most events occurred

on weekdays and typically took place between the

hours of 6 a.m. to 6 p.m. Fewer events occurred on

the weekends.

Chemicals

In the majority of events, only one chemical was

released. The most frequently released chemicals

were herbicides (19%), volatile organic compounds

(17%), acids (12%), and ammonias (13%) with the

remaining substance categories all below 10%.

(Hall et al. 1994 & 1996). In events with victims,

acids, volatile organic compounds, and ammonias

were most often released, while an increased number of herbicide releases occurred in transportation

events.

Victims

On the whole, workers (64%) were injured more frequently than the general public (22%) or first

responders (14%) (e.g., firefighters, police officers,

or hazardous materials or emergency response

teams) (Hall et al. 1994 &1996). Typically in transportation-related events, fewer (10%) of the victims

involved were from the general public (Hall et al.

1994 &1996). Most events were associated with a

limited number of injuries. For example, half of the

events resulted in just one injured person and one

quarter of the remaining events resulted in two

injured people. The majority of those injured tended to be male with a mean age in the mid-thirties

(Hall et al., 1994 & 1995).

Injuries

Some victims sustained more than one type of

injury from an event. The most frequently reported

injuries were respiratory irritation (40%) and eye

irritation (27%), followed by nausea (10%) (Hall et

al., 1994 &1996). In transportation events, victims

also commonly received trauma injuries and chemical burns. Injuries associated with death were trauma, chemical burns, thermal burns, heat stress, cardiac arrest and asphyxiation. Hall et al. (1994)

reported that 62% of the victims, including all the

victims from the general public, did not use any

type of personal protective equipment. Treatment

either occurred on-scene or at the hospital.

Evacuations

Evacuations were ordered for between 13-14% of

the events occurring between 1990 and 1992 with a

majority of the evacuations ordered by a public offi-
cial (e.g., police officer or firefighter). In-place sheltering was ordered for a few events. Hall et al.

(1994) reports that in more than half of the evacuations, the evacuation zone was a circle or radius

around the event, while in 21% of evacuations, no

criteria was used for the evacuation zone, in 18%

the zone was downwind and in 6%, the affected

building or part of the building was evacuated.

Rural/agricultural area compared to all

other non-rural areas

Berkowitz et al. (2004) examined data reported to

the HSEES system from 1993 to 2000. These data

were used to study factors associated with

death/multiple victims resulting from events involving the acute release of hazardous substances in

rural/agricultural areas compared to events in all

other non-rural/non-agricultural areas. In particular,

this analysis offers interesting insight into the

extent to which local environment and activities

influence the type of chemical events that occur.

Event parameters are shown in Table E-1.

Berkowitz et al. (2004) evaluated 43,133 events

(transportation and fixed facility) that were reported

to the HSEES from 1993-2000. There were a total of

579 death/multiple victim events of which 18% took

place in rural/agricultural areas while 81% took

place in other non-rural areas. Death/multiple-victim

events in rural/agricultural areas were more likely to

be associated with transportation incidents and

fires and/or explosions than in other situations. Of

the transportation events in the rural/agricultural

areas, 19 were associated with air transport (mainly

crop dusters) and resulted in 18 deaths.

Industries associated with rural/agricultural

areas included agriculture, forestry, fisheries, and

manufacturing. In addition to transportation, industries involved in the other non-rural area events

included manufacturing, and professional services

(e.g., schools, hospitals, and nursing/personal care

services).

5 8

Occupational Safety and

Health Administration

Parameters

Number of events

Total Death/multiple victim events

(transportation/fixed facility)

Number of total victims

Number of total deaths

Most common chemical releases

Injuries

Evacuations (transportation/fixed facility)

Berkowitz et al. (2004)

Rural/agricultural areas

6,661

107 (63/44)

632

91

The most frequently released chemicals in the rural/agricultural areas

were pesticides (14%), ammonia

(7.5%), and chlorine (6.5%). Multiple

chemicals were involved in 18% of

the total rural releases.

The majority of deaths resulted from

trauma (12.8%) or a combination of

traumatic and other injuries (3.6%).

Of those victims admitted to the

hospital in rural areas, the majority

presented with respiratory tract

symptoms (29.4%) often accompanied by gastrointestinal symptoms

(2.1%), eye irritation (0.8%),

headache (1.3%), shortness of

breath (<0.1%), or other symptoms.

39/107 events

All other non-rural areas

36,472

472 (68/404)

7,981

116

Events involving carbon monoxide

(27%) and 0-chlorobenzylidene malononitrile (19%) (a tearing agent)

were relatively common, although

ammonia, chlorine, and hydrochloric

acid accounted for a portion of the

releases (7 to 9 percent each).

Deaths resulted mainly from trauma

(2.9%), or a combination of traumatic and other injuries (0.9%), including

thermal burns (0.4%) and asphyxiation. Victims admitted to the hospital

in all other areas suffered from respiratory tract symptoms (26.6%),

similar to those in rural areas.

350/472 events

The findings presented in the studies above shed light on the trends in hazardous substance releases that occurred during the 1990s. It is important to keep in mind that these events were accidental releases, rather than intentional releases

related to terrorism. Nevertheless, unintentional releases continue to be the most common cause of events related to

hazardous substance releases and historical data such as from the HSEES system can be a valuable resource when

identifying and evaluating the reasonably anticipated worst-case scenarios nationwide (and in local communities) as

part of a hazard assessment for EMS responders. Accordingly, available relevant trends derived from such sources

should be considered when evaluating EMS responder preparation (i.e., training, PPE) for these events.

Table E-1. HSEES Reported Event Parameters During 1993-2000
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 5 9

Appendix F

Special Considerations for Responses

Involving Methamphetamine Laboratories

Public health officials increasingly recognize clandestine methamphetamine laboratories as a hazard

to first responders, including EMS personnel.

Overall reports of injuries are substantially more

common for incidents involving these laboratories

than for hazardous substance release incidents in

general (MMWR, November 17, 2000).31 Furthermore, the incidence of methamphetamine use,

associated emergency room visits, lab seizures, and

related incidents have increased dramatically over

the past decade, both in the U.S. and internationally

(see Table F-1 and Figure F-1) (NIDC, 2006; Caldicott,

2005; DHHS, 2006). Due to the clandestine nature of

these scenes, occupants

are not usually forthcoming about the conditions when they report

an emergency. All too

often the labs are identified in the line of duty by

responders who are not

wearing any personal

protective equipment

(PPE) (Caldicott, 2005).

First responders may have no warning that a hazardous substance release has occurred or is in

progress when they arrive.

OSHA is preparing a

helpful guide addressing cleanup work at

clandestine methamphetamine laboratories.

Until the guide is available, this appendix

offers background information relevant to EMS

personnel responding

to this type of scene.

Year

1997

1998

1999

2000

2001

2002

2003

2004

2005***

Total Laboratories

2,806

3,802

6,750

7,021

8,542

9,282

10,199

9,895

5,249

Superlabs *

**

**

**

**

245

142

130

55

37

Adapted from NIDC, 2006. Data source: El Paso Intelligence Center National Clandestine Laboratory Seizure System.

*Large-scale production facilities that produce 10 pounds or more of drug per production cycle (NDIC, 2004), which

typically excludes small-scale “apartment” or “backpack” labs.

**Laboratory capacity data were not collected prior to 2001.

*** Data for 2005 are preliminary.

31 Injuries were associated with 52.7 percent of HSEES-reported

incidents involving clandestine methamphetamine laboratories.

By comparison, injuries were reported for 7.2 percent of all hazardous substance incidents entered in HSEES (MMWR,

November 17, 2000).

Table F-1. Reported Methamphetamine Laboratory Seizures, 1997-2005
EMS responders can be counted among the victims

of clandestine methamphetamine lab incidents.

MMWR (2000) reported an incident in April 1996,

where three Washington State EMTs and two police

officers experienced eye and respiratory irritation

after being exposed to emissions from a fire involving acetone, hydrochloric acid, and sodium hydroxide in an illicit methamphetamine lab in an apartment. Furthermore, EMS responders were among

the victims reported to the HSEES system by the

five states that contributed hazardous substance

release data specifically associated with methamphetamine laboratories between 1996 and 1999

(MMWR, 2000). These data included eight cases of

respiratory tract irritation among EMS responders

(47.1 percent of all symptoms reported by EMS

responders during methamphetamine laboratory

incidents), four cases of eye irritation (23.5 percent),

two cases of nausea and vomiting (11.8 percent),

and one report each of skin irritation, headache, and

shortness of breath (each 5.9 percent) (see Table F-2).

EMS responders sustained most injuries through

on-site exposure or direct contact with the clothing

or skin of contaminated persons. None of the

injured first responders were wearing PPE at the

time of injury (MMWR, November 17, 2000).

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Figure F-1. Distribution of U.S. Clandestine Methamphetamine Lab Incidents by State – 2004

Source: DHHS, 2006
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 6 1

Table F-2. Number and Percentages of First Responders Who Sustained Injuries during

Emergency Events Associated with Illicit Methamphetamine Laboratories byType of Injury

Trauma

Respiratory irritation

Eye irritation

Nausea/vomiting

Heat stress

Chemical burns

Skin irritation

Dizziness/CNS

Headache

Shortness of breath

Other

Total

1

3

0

0

0

3

0

0

0

0

1

8

Firefighters Police Officers EMTs Hospital Personnel Total

Injury* No. % No. % No. % No. % No. %

12.5

37.5

-

-

-

37.5

-

-

-

-

12.5

100

0

49

8

4

1

0

0

6

2

9

0

79

-

62.0

10.1

5.1

1.3

-

-

7.6

2.5

11.4

-

100

0

8

4

2

0

0

1

0

1

1

0

17

-

47.1

23.5

11.8

-

-

5.9

-

5.9

5.9

-

100

-

-

-

42.9

-

-

-

57.1

-

-

-

100

1

60

12

9

1

3

1

10

3

10

1

111

0.9

54.1

10.8

8.1

0.9

2.7

0.9

9.0

2.7

9.0

0.9

100

0

0

0

3

0

0

0

4

0

0

0

7

Source: MMWR, 2000 (based on HSEES system data 1996-1999 from five reporting states).

*Injuries include illnesses and other adverse health effects.

Methamphetamine laboratories can contain a wide

variety of flammable, toxic, and/or explosive chemicals (see Table F-3). Industrial hygiene advisors also

warn that clandestine laboratories can produce

more than one illicit substance (Umbrell, 2006). The

materials on hand might represent those needed for

a variety of drug “products.” Drug makers sometimes also stockpile quantities of ingredients, so

large amounts of these dangerous substances can

be present.
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These substances and additional compounds,

such as the phosphine gas and hydrogen chloride

emitted when they are mixed or heated, present

serious hazards to the skin, eyes, respiratory tract,

central nervous system (CNS), and various target

organs.

Neither medical surveillance nor occupational

exposure results are available for EMS responders

exposed to hazardous substances during clandestine drug lab response. Limited information, however, is available for other responders in related situations. Burgess et al. (2002) evaluated annual medical surveillance records for the period 1991 to 1998

for 40 California law enforcement drug laboratory

investigators (methamphetamine laboratories

account for most drug laboratory investigations.)

During the investigations, the officers understood

the hazards of the situation they would encounter

and sometimes took precautions such as wearing

respiratory protection, but also typically spent a

considerably longer period of time in the laboratoTable F-3. Chemical Hazards Encountered at Methamphetamine Laboratories

Chemical

Pseudoephedrine

Acetone/ethyl alcohol

Freon

Anhydrous ammonia

Red phosphorus

Hypophosphorous acid

Lithium metal

Hydriodic acid

Iodine crystals

Phenylpropanolamine

Hazards

Ingestion of doses greater than 240 mg causes hypertension, arrhythmia, anxiety, dizziness, and vomiting. Ingestion of doses greater than 600 mg can lead to renal failure and

seizures.

Extremely flammable, posing a fire risk in and around the laboratory. Inhalation or

ingestion of these solvents causes severe gastric irritation, narcosis, or coma.

Inhalation can cause sudden cardiac arrest or severe lung damage.

A colorless gas with pungent, suffocating odor. Inhalation causes edema of the respiratory tract and asphyxia. Contact with vapors damages eyes and mucous membranes.

May explode as a result of contact or friction. Ignites if heated above 260o

C. Vapor from

ignited phosphorus severely irritates the nose, throat, lungs, and eyes.

Extremely dangerous substitute for red phosphorus. If overheated, deadly phosphine

gas is released. Poses a serious fire and explosion hazard.

Extremely caustic to all body tissues. Reacts violently with water and poses a fire or

explosion hazard.

A corrosive acid with vapors that are irritating to the respiratory system, eyes, and skin.

If ingested, causes severe internal irritation and damage that may cause death.

Gives off vapor that is irritating to respiratory system and eyes. Solid form irritates the

eyes and may burn skin. If ingested, causes severe internal damage.

Ingestion of doses greater than 75 mg causes hypertension, arrhythmia, anxiety, and

dizziness. Quantities greater than 300 mg can lead to renal failure, seizures, stroke, and

death.

Source: DEA Office of Diversion Control (NDIC, 2004).

ries than would an EMS responder responding to an

emergency.

The study results found a median annual decline

of 40 milliliters (ml) per year in the officers’ lung

function (average 64 ±138 ml/year), measured as

forced expiratory volume in 1 second (FEV1). “For

34 subjects with valid exposure data, longer duration use of respiratory protection was associated

with a less rapid decline in FEV1, whereas lack of

respiratory protection during the processing phase

of laboratory investigation was associated with a

more rapid annual decline.” The authors recommended “more assiduous use of respiratory protection” (Burgess et al., 2002). Results of blood tests

administered as part of routine medical surveillance

suggest no significant longitudinal changes in

parameters, including serum alanine aminotransferase, serum aspartate aminotransferase, hemoglobin, and white cell count, “although platelets

declined slightly.”

Other investigators in Colorado noted a lack of
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 6 3

• Regardless of whether a cook is being conducted

at the time of entry, it is likely that most items

and individuals in the vicinity of the cook will be

contaminated with methamphetamine.

• If a methamphetamine cook has been conducted

within a building, chemicals from the cook will

have spread not only in the specific area of the

cook but throughout the building. This is especially true of hydrogen chloride and methamphetamine.

• If a methamphetamine cook has been conducted

within a building, all children within that building

are likely to have been exposed to methamphetamine and other chemicals and should be considered as exposed and contaminated.

• If any law enforcement or emergency services

personnel are to be entering a building suspected of being a clandestine methamphetamine laboratory, they should enter only with self-contained breathing apparatus and complete skin

protection unless it is known that the lab has not

been in recent operation and that all of the

chemicals are under control. In the opinion of the

authors, it is not likely that these conditions will

be known prior to entry in most cases. We therefore suggest that all initial entries be made with

the PPE previously mentioned.

• After the suspected laboratory is known to be

out of operation and the chemicals are in a stable condition, then investigators could reduce

the respiratory protection portion of the PPE to a

full-face air-purifying respirator with organic

vapor, acid gas, and P100 combination cartridges.

• All law enforcement officers and emergency

services personnel should be made aware of the

high potential for exposure to methamphetamine contamination and trained in the methods

to reduce the “take home” levels of methamphetamine. Testing at the scene on a periodic

basis should be used to verify that personnel are

not being contaminated on-scene.

• Decontamination of all items taken out of the

suspected laboratory should be conducted.

Efforts should be made to reduce contamination

transfer outside of the laboratory and periodic

testing should be conducted to assure that personnel and items are being adequately decontaminated.”

information about airborne concentrations of hazardous substances in active methamphetamine laboratories. This type of exposure information is necessary to ensure that first responders are adequately protected when they enter such an environment.

As a step toward characterizing the potential for

exposure, the researchers conducted extensive

industrial hygiene area and personal air monitoring

during controlled drug “cooking” experiments. For

this experiment, the two “cooks,” both forensic

chemists, used two different, but common, methamphetamine production methods. One cook used

hypophosphorous, while the other used flake phosphorous, both of which are substitutes for red phosphorus (typical of another common method). The

researchers also obtained wipe samples used to

evaluate the extent to which hazardous substances

were deposited on surfaces. These experiments

were conducted in realistic settings: the bathroom

and living area of condemned structures similar to

those often used as drug laboratories (Martyny et

al., 2005).

The results of these tests showed that short-term

exposure levels to hazardous substances in a functioning methamphetamine laboratory can be elevated to a level that can cause acute and chronic health

effects. Although personal exposure levels were not

typically in the IDLH range, short-term phosphine

levels as high as 62.3 ppm were recorded in the

immediate cooking area (on the table). This exceeds

the IDLH for phosphine of 50 ppm. Furthermore,

individuals who have been “cooking” methamphetamine can carry significant surface contamination.

The findings also indicate that surfaces throughout

the structure can be contaminated with methamphetamine even after a single cooking cycle

(Martyny et al., 2005).

Based on their sampling results, Martyny et al.

(2005) offered several conclusions relevant to EMS

responders responding to the scene involving a

methamphetamine laboratory. These are quoted

here:

• “If a methamphetamine cook is being conducted

and the hypophosphorous manufacturing

method is used, then exposure to levels of

hydrogen chloride that exceed current occupational levels are likely.

• During the cook, it is possible that exposures to

hydrogen chloride will exceed levels considered

by NIOSH to be immediately dangerous to life or

health (IDLH).
Appendix G

Clandestine Drug Labs – First Responder

Awareness Card

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O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 6 5
Appendix H

Training Curricula Options

Training Curricula for EMS Responders

Background

The National Highway Traffic Safety Administration

(NHTSA) curricula for EMS responders introduces

some topics relevant to HAZWOPER first responder

training. As noted in Appendix P, however, (see discussion of the roles of NHTSA and states in EMS

responder training), that curricula does not in itself

meet OSHA’s requirements because it lacks information on relevant local community conditions.

Furthermore, depending on how the NHTSA curriculum is offered, it might not meet the required 8-

hour HAZWOPER training duration for first responder operations level.

The National Fire Protection Association (NFPA)

offers an extensive list of competencies that supplement OSHA’s requirements for EMS responders’

HAZWOPER training at the first responder awareness and operations levels (as well as higher levels).

Specifically, the non-regulatory NFPA 472 provides

detailed recommendations for competencies NFPA

believes are important for all first responders (e.g.,

firefighters, police, EMS) who work at the awareness or operations levels (NFPA-742, 2008). A companion standard (also non-regulatory), NFPA 473,

suggests additional areas of competence specifically

tailored for EMS personnel (NFPA-473, 2008).

Two non-regulatory (optional) NFPA standards suggest training topics that can be

included in HAZWOPER training for EMS

responders. These two standards are:

• NFPA 472 Standard for Competence of

Responders to Hazardous Materials/

Weapons of Mass Destruction Incidents

(2008)

• NFPA 473 Standard for Competence for

EMS Personnel Responding to Hazardous

Materials/Weapons of Mass Destruction

Incidents (2008)

OSHA says of these and other NFPA standards

(such as NFPA 471 – Recommended Practice for

Responding to Hazardous Material Incidents):

In general, employers of emergency response

organizations who follow the NFPA standards

should be in compliance with 29 CFR

1910.120(q). It is important that the applicable

portions of all related standards be followed.

(OSHA, 2007-CPL-02-02-073).

As an example, OSHA notes that NFPA 471 no

longer addresses the position of “safety officer,”

although another NFPA standard (NFPA 1500 –

Standard on Fire Department Occupational Safety

and Health Program) does. A designated safety officer, however, is mandatory in the HAZWOPER standard. OSHA would consider the absence of a safety

officer as a failure to comply with the standard

(OSHA, 2007-CPL-02-02-073). Employers who use

NFPA standards are ultimately responsible for

ensuring that they are providing training or allowing

employees to demonstrate competence that meets

OSHA’s requirements.

The following sections provide an outline of

some of the competencies presented in NFPA 472

and NFPA 473 that are most relevant to EMS

responders. Each competency includes a brief summary of how responder competence is evaluated. In

general, although not precisely aligned with OSHA’s

competencies for first responders at the awareness

and operations levels, an EMS responder that

demonstrated competence in each of the areas listed by NFPA would likely also in the process demonstrate OSHA’s required competencies, as long as the

scenarios used for discussion are provided with the

HAZWOPER competencies in mind. Consult the

NFPA’s standards for complete listings of the individual competencies and specific details of NFPA’s

recommendations for demonstrating competence.

Select Examples of Core Competencies for

First Responder Awareness Level Personnel

Recommended in NFPA 472:

Detecting the presence of hazardous materials

(responder is requested to identify situations where

hazardous materials are present, provide numerous

examples of hazardous materials categories, identify specific types of container marking; perform exercises involving material safety data sheets (MSDSs)

and shipping papers, and identify indicators of possible criminal activity relating to various types of

hazardous substances or sites).

Surveying hazardous materials and collecting

related information (responder is requested to

name hazardous materials described in example

incidents, describe methods for determining substance names, and look up information in a standard reference book).

Initiating protective actions (responder is

requested to identify basic information from scenarios and plans, including the role of individuals at

first responder awareness level, appropriate precautions and PPE (from given lists), and security measures).

6 6

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O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 6 7

Initiating the notification process (responder is

requested to identify details related to notification in

provided scenarios).

Select Examples of Core Competencies for

First Responder Operations Level Personnel

Recommended in NFPA 472:

Competencies listed for first responder awareness level personnel.

Surveying hazardous material incidents (responder is requested to discuss hazardous materials

containers/packaging, possible materials release

and site conditions for example scenarios, and from

provided lists pick the correct answers to related

questions).

Describing response objectives and identifying

actions (responder is requested to describe exposures that could be avoided and risks to responders

under different scenarios or for different hazard

classes).

Determine suitability of PPE and decontamination issues (responder is requested to decide

whether available PPE is adequate for example situations, describe various SCBA and protective clothing configurations, and exhibit knowledge about

decontamination methods, equipment, and issues).

Scene control and preserving evidence (responder is requested to identify criteria and techniques

for establishing scene control, allowing personnel to

work, and preserving evidence under various incident site conditions).

Initiating the ICS (responder is requested to

demonstrate ICS initiation for a given scenario’s ERP

and identify various elements of an ICS).

Using PPE (responder is requested to identify or

discuss various factors that are critical to correctly

using PPE, such as when to use a buddy system,

control of thermal stress, and how to clean and

inspect PPE).

Select Examples of Competencies for Basic Life

Support and Advanced Life Support Personnel

Recommended in NFPA 473:

The non-regulatory NFPA 473 is intended for

“EMS personnel who respond to incidents involving

hazardous materials or weapons of mass destruction.” NFPA 473 also assumes that these EMS

responders “are trained to meet at least the core

competencies of the operations level responders”

as presented in NFPA 472 (NFPA-473, 2008). It is

understood that in any area of competence involving direct patient care, the EMS responder’s activities must be within the scope of practice and training of the individual responder.

NFPA 473 is aligned along EMS responder qualifications to provide basic life support (BLS) or

advanced life support (ALS), rather than along first

responder awareness or operations level training

requirements. Some employers might link BLS and

ALS qualifications to workers roles requiring first

responder operations level training and first responder awareness level training, respectively. Other

employers, however, might designate worker roles

along different lines, depending on conditions in the

community and the employers’ response plans.

Although most NFPA 473 competencies for both

BLS and ALS personnel are similar (or identical),

there are a few differences and these are indicated

by an asterisk (*) and notation summarizing the difference.

The following summary provides a number of

examples of the types of competencies included in

NFPA 473 specifically for EMS responders. Again,

consult the NFPA’s standards for complete listings

of the individual competencies and specific details

of NFPA’s recommendations for demonstrating

competence.

Surveying hazardous materials incidents

(responder is requested to describe details of identification, spread of contamination, effects or treatment for a range of physical, chemical and biological hazard types). [*ALS responder is also asked to

discuss how site and patients should be observed

for signs of exposure.] 32

Collecting and interpreting hazard and response

information (responder is requested to discuss

methods for gathering information about an incident and the health effects of any hazardous materials involved). [*ALS responder is also asked to identify ways to determine whether secondary devices

or other hazards might be present at the scene.]

Identifying high risk areas for potential exposures (responder is requested to assimilate given

information from a variety of sources and determine

areas where exposure is likely to occur.)

Incident communications (responder is requested to identify effective ways to communicate in support of the response plan).

Role of the BLS level responder [*or ALS level

responder] (responder is requested to describe the

ICS and how EMS responders function in performing specific duties within the system).

Determining the nature of the incident and providing medical care (responder is requested to discuss various modes and effects on patients of hazardous substance exposure during incidents). [*ALS

32 An asterisk (*) indicates a notable difference in this competency for BLS responders compared to what is expected of ALS

responders.
responder is expected to determine the physical and

toxicological/symptomatic characteristics of substances to which a patient could be exposed.]

Decontamination (responder is requested to

determine or identify specific aspects of decontamination procedures presented in a model plan and

associated standard operating procedures (SOPs).

[*ALS responder is expected to be able to execute

specific tasks that form major components of the

decontamination phase of a sample ERP and associated SOPs, for individual and mass decontamination scenarios.]

Preserving evidence (responder is requested to

determine whether criminal acts are involved in

example incidents and identify ways of safeguarding evidence while providing medical care).

Medical support for incidents (responder is

requested to describe or demonstrate how to create

and execute various aspects of a medical monitoring plan for responders wearing PPE). [*ALS

responder is asked to do the same for responders

wearing chemical protective suits.]

Tips for Successful EMS Responder

HAZWOPER Training Programs

Successful first responder training at the awareness

and operations levels depends on effective curricula

and on teaching methods that are compatible with

adult learners who are probably not accustomed to

spending time in a classroom.

One technique for drafting a successful training

program involves starting by outlining lectures and

exercises that will provide participants with the

tools they need to successfully “demonstrate competency” to perform the expected job functions

safely and effectively. Once the curricula addresses

those needs, details about laws, standards, and regulatory requirements can be incorporated into the

training program where they are most relevant.

Experienced trainers keep students engaged in

learning by organizing the curricula to alternate lecture periods and hands-on practical sessions.

Sometimes this means that some basic information

needs to be shifted later in the course to allow a

hands-on skill-development session (e.g., PPE use)

to be inserted between lecture sessions. Instructors

can help improve the learning experience by tailoring course material so it is related to participants’

work and life experience. The more interactive the

course, the more easily students will learn.

OSHA permits EMS responders who receive first

responder training (or demonstration of competence) at the awareness level to count it towards the

operations level training requirements. This means

that an employer may be able to offer just one

class, with the first responder awareness level students attending only the first portion of the class.

OSHA allows flexibility in how EMS responders

complete the initial and annual refresher training

requirements. Those who are able to satisfy part or

all of their HAZWOPER training requirement by

demonstrating competence may be offered opportunities to do so as part of organized training session, drills, and exercises. OSHA also allows workers who participate in critiques after incidents to

count that experience toward their training.

6 8

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O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 6 9

Appendix I

Hospital Incident Command System

Employers of EMS responders must work closely

with hospitals and other organizations during a hazardous substance release that affects patients. The

employers should be familiar with incident command system structures used in their communities,

including the Hospital Incident Command System

(HICS) updated from the earlier version (hospital

emergency incident command system – HEICS) in

2006. HICS is published by the California Emergency

Medical Services Authority (EMSA). The following

excerpt from the HICS Guidebook is provided as an

introduction to this 2006 version and is followed by

HICS Section 4.7.2 – Fire and Emergency Medical

Services.

Excerpt from Hospital Incident

Command System Guidebook:

Forward

Hospitals throughout the United States confront

a myriad of operational and fiscal challenges on

a daily basis. To effectively manage emergencies, whether external (e.g., fires, earthquakes) or

internal (e.g., child abductions, utility failure),

hospitals must invest the time and necessary

funds to ensure adequate preparations are in

place. Recent events such as the September 11,

2001 terrorism attacks, the Severe Acute

Respiratory Syndrome (SARS) outbreak in 2004,

and the Gulf Coast hurricanes of 2006 demonstrated the importance of hospital preplanning

and personnel training.

Since its inception in the late 1980s, the

Hospital Emergency Incident Command System

(HEICS) served as an important emergency management foundation for hospitals in the United

States. We recognized the value and importance

of using an incident management system, not

only in emergency situations but also in daily

operations, preplanned events, and non-emergent situations. Therefore, the HEICS IV Project,

sponsored by the California Emergency Medical

Services Authority, has evolved to become

HICS—the Hospital Incident Command System—

a comprehensive incident management system

intended for use in both emergent and nonemergent situations.

The HEICS IV project is not intended to be the

only answer to a hospital’s emergency preparedness needs. However, we believe this Guidebook

and the accompanying materials can play a

major role in advancing institutional preparedness while providing needed local, state, and

national standardization of hospital emergency

response and recovery.

We believe the new Hospital Incident

Command System has built upon the benefits

and successes of the original HEICS and provides hospitals of all sizes with tools needed to

advance their emergency preparedness and

response capability—both individually and as a

member of the broader response community.

Fire and Emergency Medical Services - Section

4.7.2

Fire departments, private ambulance providers,

air medical services, and a governing Emergency

Medical Services (EMS) entity all have significant

roles and interface with hospitals in the United

States.

Fire departments provide any or all of the following services: first responder basic life support

(BLS) and/or advance life support (ALS) medical

care; ambulance transport; hazmat response;

and search and rescue.

Private ambulance companies provide BLS

and/or ALS transport for 911 responses; interfacility transports; and standby for prescheduled

events, hazmat events, or search and rescue

events.

EMS governing entities (which may be fire

departments) provide medical direction to prehospital emergency medical technicians (EMTs)

and paramedics and system oversight for all

ambulance activities, to include licensure,

inspection, and approval or agreement for operating areas. The medical oversight often extends

to the interface between pre-hospital and hospital EMS, and in many communities this entity

acts as the disaster coordinator/manager in a

large-scale emergency.

Hospitals should also be familiar with air

medical services that may be used and have an

individual or community plan for how best to

coordinate multiple requests for assistance.

Planning consideration should be given to how

helicopters or fixed wing aircraft can assist with

personnel, patient, and equipment/supply transport if necessary.

During an emergency, EMS (which we define

as the combination of any of the services

described above) can be expected to bring a sig-
nificant segment of the involved population to

the hospital for medical care. For this reason,

information-sharing procedures must be well

known by both parties, and dependable and

redundant communication systems and technology must be in place and properly used.

Hospitals should also be familiar with their

community multiple/mass casualty plan, including appropriate response codes and terminology,

as well as the triage, treatment, and transportation practices to be employed. EMS personnel

should have a fundamental understanding of

how the hospital will respond, including what

information is needed to declare a disaster, alternative travel routes into the facility, and where

triage and decontamination will be conducted.

Preplanning should also address issues such as

what personnel supplementation can be provided by either party, including trained decontamination team supplementation, and how response

information will be shared. In addition to patient

transport and possible staff and equipment augmentation, EMS responds when the hospital

itself is the scene of an incident; plans for such

response should also be mutually developed.

More Information:

More information on the Hospital Incident

Command System can be found at www.emsa.

ca.gov/HICS/default.asp (accessed July 10,

2009).

7 0

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O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 7 1

Appendix J

Summary of Respirator Types and

Selection Information

Summary of Respirator Types

and Characteristics

Table J-1. Summary of Respirator Types and Characteristics

Inlet covering - Every respirator has an inlet covering the part of the respirator between the user’s respiratory

tract and the air-purifying device or breathing air source. Inlet covering types and examples include:

Tight-fitting

• Quarter mask

• Half facepiece

• Full facepiece

• Mouthbit/nose clamp

Loose-fitting

• Hood

• Helmet

• Loose-fitting facepiece

Respirator types

Air Purifying

Filtering facepieces

Air purifying

respirators (APR)

Powered air purifying

respirators (PAPR)

Air-supplied

Atmosphere supplying

respirators (ASR)

Escape

Can be either negative

or positive pressure

and either APR or ASR

Typical inlet

covering

Tight-fitting

Tight-fitting

Tight or loosefitting

Tight or loosefitting

Tight or loosefitting

Details

As user inhales, air passes through a

facepiece made of filter material.

As user inhales, air passes through aircleaning filters, cartridges, or canisters.

A fan passes air through air-cleaning

filters or cartridges.

Supplies air from a source independent

of the ambient atmosphere (e.g., via an

airline or using a compressed gas tank

containing an acceptable quality of

breathing air (Grade D). A regulator controls the rate at which air flows to the

inlet covering.

• May use an air cleaning device or

provide air from a small compressed

gas tank (bottle).

• Usually single use.

• Any respirator intended to be used

only for emergency exit.

Example(s)

• Dust masks

• Half or full facepiece

respirator with

particulate filters

(non-powered)

• Full facepiece PAPR

• Supplied air respirator

(SAR), also called an

airline respirator

• Self-contained breathing apparatus (SCBA)

• Emergency life support apparatus (ELSA)

• Mouthbit
Advantages and Disadvantages of Various

Types of Respiratory Protection

7 2

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Table J-2. Advantages and Disadvantages of Various Types of Respiratory Protection

Type of Respirator

Air Purifying

Air-purifying respirator

(including powered airpurifying respirators

(PAPR))

Atmosphere-Supplying

Self-contained breathing

apparatus (SCBA)

Positive pressure suppliedair respirator (SAR)

(also called airline

respirator)

Advantages

• Enhanced mobility

• Lighter in weight than

SCBA; generally weights 2

pounds or less (except for

PAPRs)

• Provides the highest

available level of protection

against airborne

contaminants and oxygen

deficiency.

• Provides the highest

available level of protection.

• Enables longer work periods

than an SCBA

• Less bulky and heavy than

an SCBA; SAR equipment

weigh less than 5 pounds

(or 15 pounds, if escape

SCBA protection is included)

• Protects against most airborne contaminants

Disadvantages

• Cannot be used in IDLH or oxygen-deficient

atmospheres (less than 19.5 percent oxygen

at sea level).

• Limited duration of protection; may be hard to

gauge safe operating time in field conditions.

• Only protects against specific chemicals and

up to specific concentrations (see later section on Assigned Protection Factors).

• Use requires monitoring of contaminant and

oxygen levels.

• Can only be used for specific gases or

vapors provided that a cartridge change

schedule is identified and a safety factor is

applied, or if the unit has an ESLI (end-ofservice-life-indicator).

• Bulky, heavy (up to 35 pounds).

• Finite air supply limits work duration.

• May impair movement in confined spaces.

• Not approved for use in IDLH or oxygendeficient atmospheres (less than 19.5 percent

oxygen) unless equipped with an auxiliary

self-contained air supply.

• Impairs mobility.

• NIOSH certification limits hose length to 300

feet.

• As the length of the hose is increased, the

airflow must be increased to ensure that the

minimum approved airflow is delivered at

the faceplate.

• Air line is vulnerable to damage, chemical

contamination, and degradation. Decontamination of hoses may be difficult.

• Employee must retrace steps to leave work

area.

• Requires supervision/monitoring of the air

supply line.

Adapted from: Managing Hazardous Materials Incidents (Volume 1) – Emergency Medical Services: A Planning

Guide for the Management of Contaminated Patients, Appendix B (ATSDR, 2001 -

www.atsdr.cdc.gov/mhmi/#bookmark05).
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 7 3

Advantages and Disadvantages of Various

Respirator Facepiece Styles

Table J-3. Advantages and Disadvantages of Various Respirator Facepiece Styles

Facepiece style

Half facepiece

Full facepiece

Loose fitting

helmet/hood

Advantages

• Employee may wear any appropriate

eyewear that does not interfere with

the respirator seal.

• When used with a powered air-purifying respirator (PAPR), a tight fitting

facepiece might allow an employee

to pull filtered air into the facepiece if

the battery fails.

• Provides eye protection.

• Better assigned protection factor,

when fit is tested with quantitative

methods.

• Provides eye protection from splashes.

• Provides skin protection for the head

and (certain models) neck.

• Fit testing is not required.

• Some employees find loose fitting

respirators more comfortable than

tight fitting models.

• Can be worn by employees with

facial hair and facial scars/deformities.

• Employees may wear their own

glasses under the helmet/hood.

Disadvantages

• If there is a break in the seal between the

mask and the face, contaminated air can

enter. Fit testing must be performed prior to

use and user seal checks must be done by

the user every time the respirator is used.

• Lower assigned protection factor than other

facepieces.

• Does not provide eye protection.

• If there is a break in the seal between the

mask and the face, contaminated air can

enter. Fit testing must be performed prior to

use and user seal checks must be done by

the user every time the respirator is used.

• Employees who wear glasses may require

spectacle kits to be used inside the facepiece.

• When used with a PAPR, provides little or no

protection if the battery fails.

Adapted from Personal Protective Equipment Guide for Military MedicalTreatment Facility Personnel Handling

Casualties from Weapons of Mass Destruction andTerrorism Events (Technical Guide 275). U.S. Army Center

for Health Promotion and Preventive Medicine (USACHPPM), August 2003.
OSHA Assigned Protection Factors for

Respiratory Protective Devices

Definition - Assigned protection factor (APF)

(1910.134(b))

Assigned protection factor means the workplace

level of respiratory protection that a respirator or

class of respirators is expected to provide to employees when the employer implements a continuing, effective respiratory protection program as

specified by this section.

Use of Assigned Protection Factors (APFs)

(1910.134(d)(3)(i)(A))

Employers must use the assigned protection factors

listed in [Table J-4] to select a respirator that meets

or exceeds the required level of employee protection. When using a combination respirator (e.g., airline respirators with an air-purifying filter), workers

must ensure that the assigned protection factor is

appropriate to the mode of operation in which the

respirator is being used.

7 4

Occupational Safety and

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Table J-4. Assigned Protection Factors

Type of respirator 1, 2, 5

1. Air-Purifying Respirator

2. Powered Air-Purifying Respirator (PAPR)

3. Supplied-Air Respirator (SAR) or Airline

Respirator

• Demand mode

• Continuous flow mode

• Pressure-demand or other positivepressure mode

4. Self-Contained Breathing Apparatus

(SCBA)

• Demand mode

• Pressure-demand or other positivepressure mode (e.g., open/closed circuit)

Quarter

mask

5

..............

..............

..............

..............

..............

..............

Loose-fitting

facepiece

..............

25

..............

25

..............

..............

..............

Notes:

1 Employers may select respirators assigned for use in higher workplace concentrations of a hazardous substance for use at lower concentrations of that substance, or when required respirator use is independent of

concentration.

2 The assigned protection factors in this table are only effective when the employer implements a continuing,

effective respirator program as required by this section (29 CFR 1910.134), including training, fit testing, maintenance, and use requirements.

3 This APF category includes filtering facepieces, and half masks with elastomeric facepieces.

4 The employer must have evidence provided by the respirator manufacturer that testing of these respirators

demonstrates performance at a level of protection of 1,000 or greater to receive an APF of 1,000. This level of

performance can best be demonstrated by performing a workplace protection factor (WPF) or simulated WPF

(SWPF) study or equivalent testing. Absent such testing, all other PAPRs and SARs with helmets/hoods are to

be treated as loose-fitting facepiece respirators, and receive an APF of 25.

5 These APFs do not apply to respirators used solely for escape. For escape respirators used in association with

specific substances covered by 29 CFR 1910 subpart Z, employers must refer to the appropriate substancespecific standards in that subpart. Escape respirators for other IDLH atmospheres are specified by 29 CFR

1910.134 (d)(2)(ii).

Half

mask

103

50

10

50

50

10

.............

Full

facepiece

50

1,000

50

1,000

1,000

50

10,000

Helmet/

hood

..............

25/1,0004

..............

25/1,0004

..............

50

10,000
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 7 5

Respirators for IDLH Atmospheres

Selected Excerpts from 29 CFR 1910.134 – OSHA’s

standard on Respiratory Protection

Hazard Evaluation (1910.134(d)(1)(iii))

The employer shall identify and evaluate the respiratory hazard(s) in the workplace; this evaluation shall include a reasonable estimate of

employee exposures to respiratory hazard(s)

and an identification of the contaminant's chemical state and physical form. Where the employer

cannot identify or reasonably estimate the

employee exposure, the employer shall consider

the atmosphere to be IDLH.

The employer shall select respirators from a sufficient number of respirator models and sizes so

that the respirator is acceptable to, and correctly

fits, the user. (1910.134(d)(1)(iv))

Respirators for IDLH atmospheres (1910.134(d)(2))

The employer shall provide the following respirators for employee use in IDLH atmospheres:

A full facepiece pressure demand SCBA certified

by NIOSH for a minimum service life of thirty

minutes, or

A combination full facepiece pressure demand

supplied-air respirator (SAR) with auxiliary selfcontained air supply.

Respirators provided only for escape from IDLH

atmospheres shall be NIOSH-certified for escape

from the atmosphere in which they will be used.

All oxygen-deficient atmospheres shall be considered IDLH. Exception: If the employer demonstrates that, under all foreseeable conditions, the

oxygen concentration can be maintained within

the ranges specified [inTable II of the standard],

then any atmosphere-supplying respirator may

be used.

Respirators for Atmospheres that are

Not IDLH

Respirators for atmospheres that are not IDLH

(1910.134(d)(2)).

The employer shall provide a respirator that is

adequate to protect the health of the employee

and ensure compliance with all other OSHA

statutory and regulatory requirements, under

routine and reasonably foreseeable emergency

situations.

Choosing APR Cartridges that Offer Protection

Against a Wide Range of Contaminants

The combination of high efficiency (P-100) particulate filters plus organic vapor (OV) cartridges in

what has come to be known as “stacked cartridges” will protect against many of the airborne hazards that EMTs might encounter (e.g.,

toxic dusts, biological agents, radioactive particulates, organophosphates and other pesticides,

and solvents).33 Acid gas and amine cartridges

add an additional level of protection from gases

which have been implicated in at least one case

of healthcare worker injury.34

33 For PAPRs the equivalent to a P-100 filter is the high efficiency

(HE) filter.

34 Despite the number of carbon monoxide victims treated at hospitals, it is not anticipated that EMS responders would benefit

from specialty cartridges that remove carbon monoxide from air.

There are no reported cases of healthcare workers being injured

through secondary contamination from victims of carbon

monoxide poisoning (Horton et al., 2003; Hick et al., 2003; Walter

et al., 2003). If the source of carbon monoxide is producing an

ongoing release, appropriately trained responders equipped with

SCBA will need to control the release and evacuate victims.
Appendix K

Thermal Stress: Working in Hot or Cold

Environments

Heat Stress and Strain

EMS responders must work in a wide variety of hot

or hot and humid environments. Comfort is not the

only issue in working in such environments. Workers

who are suddenly exposed to working in a hot environment face additional and generally avoidable

hazards to their safety and health. Chemical protective clothing can add an extra burden by reducing

air circulation on the skin and limiting the body’s

natural ability to cool itself as sweat evaporates.

Extended use of respiratory protection can also hinder a worker’s ability to replenish fluids by drinking,

putting the worker at greater risk. The employer

should provide detailed instructions on preventive

measures and adequate protection necessary to

prevent heat stress. Detailed guidance on preventive measures can be found in the following documents.

NIOSH Publication No. 86-112 – Working in Hot

Environments provides basic general information

for employers and employees on thermal stress

from working in hot environments. Access this publication at www.cdc.gov/niosh/hotenvt.html#

protective

The problems of thermal stress and chemical protective clothing are outlined in paragraph X of

OSHA’s Technical Manual, Section VII, Chapter 1 –

Chemical Protective Clothing

www.osha.gov/dts/osta/otm/otm_viii/otm_viii_1.html

Cold Stress and Hypothermia

Dust EMS responders who assist patients during

incidents involving cold weather may be subject to

cold exposure, which can affect performance and

ultimately lead to hyperthermia. Wet conditions

(including sweat) and wind can exacerbate the situation. Decontamination procedures often mean

greater exposure to water and removal of clothes

resulting in greater exposure to cold and wind.

Effective alternate decontamination methods should

be considered in extremely cold climates.

The U.S. Army Technical Bulletin TB-MED 508 –

Prevention and Management of Cold-weather

Injuries offers details on cold stress management.

Section 3-2 provides guidance on avoiding

hypothermia, while Section 3-6 offers suggestions

for PPE use and decontamination in very cold

weather. Although intended for military troops, the

advice (e.g., straps on the respirator mask must not

be too tight, as this will reduce blood flow to the

skin of the face and can cause frostbite) applies to

any worker wearing protective gear at extremely

low temperatures. www.usariem.army.mil/

download/tbmed508.pdf

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O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 7 7

Appendix L

Decontamination Foam and Barrier Cream

Decontamination foams have been the subject of

research by Sandia National Laboratories. These

foams are effective for use on equipment against

certain biological and chemical contaminants.

These products have been licensed for commercial

production (EnviroFoam, 2008; Modec, 2008). The

foams have not been approved for use on human

skin.

For certain weapons of chemical, biological, radiological, nuclear, or explosive (CBRNE) contaminants (nerve and blister agents, specifically),

Reactive Skin Decontamination Lotion (RSDL) offers

some benefit but has some inherent risk. The FDA

has approved this lotion for use on human skin.

According to the product distributor, the U.S. military is conducting efficacy testing and recently

began permitting local police, fire departments,

emergency medical teams, and the other organizations to use the lotion (E-Z-EM, 2006).

Another product under development by the military, Skin Exposure Reduction Paste Against

Chemical Warfare Agents (SERPACWA), is also

intended for use on human skin (Ellen, 2003). This

product functions as a barrier cream when applied

before any opportunity for exposure occurs. The

cream is intended to protect military personnel from

adverse effects if a small amount of contaminant

penetrates through “hastily donned full-body protective gear.” It is hoped that a related product

(active topical skin protectant), also under development, will offer greater protection. Neither of these

products is FDA approved.
Appendix M

Examples of PPE Donning and

Doffing Sequences

7 8

Occupational Safety and

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PPE Donning Sequence

(NOTE: The following sequence outlines the order in which some EMS personnel find it efficient to put

on their specific PPE. This sequence was developed for personnel who would wear a hooded PAPR respirator, chemical protective suit, gloves and boots. The sequence may be adapted for other types of respirators and protective equipment. The list is not intended to provide detailed step-by-step instructions

for putting on the PPE.)

1. Test PAPR flow rate to be sure it meets rate specified by the manufacturer.

2. Remove jewelry & clothing.

3. Put on inner nitrile gloves.

4. In COLD WEATHER: Put on inner suit. Tape gloves at wrist & zipper at neck.

5. In WARM WEATHER: Put on scrubs.

6. Put on outer chemical protective suit to waist. Put on boots & outer chemical protective gloves.

7. Connect PAPR to hood with hose; turn airflow on. Put on butyl hood (position the inside shroud

between suits). Pull chemical protective suit up and on.

8. Ensure zipper is covered & secured, put tape on top.

9. Belt PAPR to waist.

10. Put outer butyl hood shroud over suit.

11. Stretch arms, pull suit sleeves OVER gloves, tape in place.

12. Pull suit cuff over boot top, tape in place.

13. Place a piece of tape on the hood exterior and label with the employee’s name & time that

employee is entering the warm zone.

PPE Decontamination & Doffing Sequence

(NOTE: The following sequence outlines the order in which some EMS personnel find it effective to

decontaminate themselves and their PPE as one procedure, to minimize the chance of contaminating

their skin while removing their PPE. This sequence was developed for personnel who would wear a

hooded PAPR respirator, chemical protective suit, gloves and boots. The sequence may be adapted for

other types of respirators and protective equipment. The list is not intended to provide detailed step-bystep instructions.)

1. Wash hands thoroughly.

2. Still wearing PPE, wash self, starting at the top of the head and working down to the bottom of the

boots. Have a partner wash your back.

3. Untape boots and gloves, but do not remove them.

4. Unlock PAPR and place it on chair/gurney/floor, etc.

5. Remove the outer suit—roll the suit away from you, inside out (with help from a partner).

6. Remove outer gloves along with the outer suit.

7. Remove PAPR hood, place in waste.

8. Step out of boots and suit into final rinse area (keep inner gloves and clothing on). Wash and rinse

thoroughly (with partner’s help).

9. In COLD WEATHER: Remove (inner) suit, place in waste.

10. Remove nitrile gloves: first pinch one glove and roll it down partially, then place thumb in other

glove & remove both gloves simultaneously.

11. Wash again, removing inner clothing, then step out of decontamination shower and into

towels/blankets.

Source: Adapted from Managing Hazardous Materials Incidents (Volume II). Hospital Emergency Departments: A

Planning Guide for the Management of Contaminated Patients. U.S. Department of Health and Human Services.

Public Health Service. Agency for Toxic Substances and Disease Registry (Revised 2000). www.atsdr.cdc.gov
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 7 9

Appendix N

General Description and Discussion of the

Levels of Protection and Protective Gear

This appendix, taken from Appendix B of OSHA’s

HAZWOPER standard (29 CFR 1910.120) and adapted with additional information from Appendix C of

ATSDR (2001), sets forth information about personal

protective equipment (PPE) protection levels that

may be used to assist employers in complying with

the PPE requirements of the HAZWOPER standard.

As required by the HAZWOPER standard, PPE

must be selected which will protect employees

from the specific hazards which they are likely to

encounter during their work.

Selection of the appropriate PPE is a complex

process which should take into consideration a variety of factors. Key factors involved in this process

are identification of the hazards, or suspected hazards; the routes by which employees could be

exposed to the potential hazard (inhalation, skin

absorption, ingestion, and eye or skin contact); and

the performance of the PPE materials (and seams)

in providing a barrier to these hazards. The amount

of protection provided by PPE is material- and hazard-specific. That is, protective equipment materials

will protect well against some hazardous substances and poorly, or not at all, against others. In

many instances, protective equipment materials

cannot be found which will provide continuous protection from the particular hazardous substance. In

these cases, the PPE must be changed or work must

stop before breakthrough time is reached (55 FR

14074, Apr. 13, 1990).

Other factors in this selection process to be considered are matching the PPE to the employee's

work requirements and task-specific conditions. The

durability of PPE materials, such as tear strength

and seam strength, should be considered in relation

to the employee's tasks. The effects of PPE in relation to heat stress and task duration are a factor in

selecting and using PPE. In some cases layers of

PPE may be necessary to provide sufficient protection, or to protect expensive PPE inner garments,

suits, or equipment.

The more that is known about the hazards at the

site, the easier the job of PPE selection becomes. As

more information about the hazards and conditions

at the site becomes available, the site supervisor

can make decisions to upgrade or downgrade the

level of PPE to match the tasks at hand.

The following are guidelines which an employer

can use to begin the selection of the appropriate

PPE. As noted above, the site information may suggest the use of combinations of PPE selected from

the different protection levels (i.e., A, B, C, or D) as

being more suitable to the hazards of the work. It

should be cautioned that the listing below does not

fully address the performance of the specific PPE

material in relation to the specific hazards at the job

site, and that PPE selection, evaluation and reselection is an ongoing process as sufficient information

about the hazards and PPE performance is obtained.

Personal protective equipment is divided into

four categories based on the degree of protection

afforded. Table N-1 presents the recommended

equipment, suggestions for when it should be used,

and limiting criteria associated with this level of

PPE.
8 0

Occupational Safety and

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Table N-1. PPE Levels of Protection

Level of Protection

Level A

Offers the highest available

level of respiratory, skin,

and eye protection.

Equipment

• Positive pressure, full

facepiece self-contained

breathing apparatus

(SCBA), or positive

pressure supplied air

respirator with escape

SCBA, approved by the

National Institute for

Occupational Safety

and Health (NIOSH).

• Totally-encapsulating

chemical-protective suit.

• Coveralls.*

• Long underwear.*

• Gloves, outer, chemicalresistant.

• Gloves, inner, chemicalresistant.

• Boots, chemical-resistant, steel toe and

shank.

• Hard hat (under suit).*

• Disposable protective

suit, gloves and boots

(depending on suit

construction, may be

worn over totallyencapsulating suit).

Should be Used When

• The hazardous

substance has been

identified and requires

the highest level of

protection for skin, eyes,

and the respiratory

system based on either

the measured (or

potential for) high

concentration of

atmospheric vapors,

gases, or particulates; or

the site operations and

work functions involve a

high potential for splash,

immersion, or exposure

to unexpected vapors,

gases, or particulates of

materials that are harmful to skin or capable of

being absorbed through

the skin.

• Substances with a high

degree of hazard to the

skin are known or suspected to be present,

and skin contact is

possible, or

• Operations must be

conducted in confined,

poorly ventilated areas,

and the absence of

conditions requiring

Level A have not yet

been determined.

Limiting Criteria

Fully encapsulated suit;

material must be

compatible with the

substances involved.
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 8 1

Level of Protection

Level B

Offers the same level of

respiratory protection, but

less skin protection than

Level A.

It is the minimum level

recommended for initial

site entries until the

hazards have been further

identified.

Equipment

• Positive pressure,

full-facepiece selfcontained breathing

apparatus (SCBA), or

positive pressure

supplied air respirator

with escape SCBA

(NIOSH approved).

• Hooded chemicalresistant clothing

(overalls and longsleeved jacket; coveralls; one or two-piece

chemical-splash suit;

disposable chemicalresistant overalls).

• Coveralls.*

• Gloves, outer, chemical-resistant.

• Gloves, inner, chemicalresistant.

• Boots, outer, chemicalresistant steel toe and

shank.

• Boot-covers, outer,

chemical-resistant (disposable).*

• Hard hat.*

• Face shield.*

Should be Used When

• The type and atmospheric concentration of

substances have been

identified and require a

high level of respiratory

protection, but less skin

protection.

• The atmosphere

contains less than 19.5

percent oxygen; or

• The presence of incompletely identified vapors

or gases is indicated by

a direct-reading organic

vapor detection instrument, but vapors and

gases are not suspected

of containing high

levels of chemicals

harmful to skin or

capable of being

absorbed through the

skin.

• Note: This involves

atmospheres with IDLH

concentrations of specific substances that

present severe inhalation hazards and that

do not represent a

severe skin hazard; or

that do not meet the

criteria for use of airpurifying respirators.

Limiting Criteria

Use only when the vapor

or gases present are not

suspected of containing

high concentrations of

chemicals that are harmful

to skin or capable of being

absorbed through intact

skin.

Use only when it is highly

unlikely that the work

being done will generate

either high concentrations

of vapors, gases, or particulates or splashes of material that will affect exposed

skin.
8 2

Occupational Safety and

Health Administration

Level of Protection

Level C

The level of air purifying

respiratory protection

depends on the type of

facepiece and fit testing

performed. Offers limited

skin protection.

Level D

No respiratory protection;

minimal skin protection.

Equipment

• Full-face or half-mask,

air purifying respirators

(NIOSH approved).

• Hooded chemical-resistant clothing (overalls;

two-piece chemicalsplash suit; disposable

chemical-resistant overalls).

• Coveralls.*

• Gloves, outer, chemicalresistant.

• Gloves, inner, chemicalresistant.

• Boots (outer), chemicalresistant steel toe and

shank.*

• Boot-covers, outer,

chemical-resistant (disposable).*

• Hard hat.*

• Escape mask.*

• Face shield.*

• Coveralls.

• Gloves.*

• Boots/shoes, chemicalresistant steel toe and

shank.

• Boots, outer, chemicalresistant (disposable).*

• Safety glasses or

chemical splash

goggles.*

• Hard hat.*

• Escape mask.*

• Face shield.*

Should be Used When

• The atmospheric

contaminants, liquid

splashes, or other direct

contact will not adversely affect or be absorbed

through any exposed

skin;

• The types of air

contaminants have been

identified, concentrations measured, and an

air-purifying respirator

is available that can

remove the contaminants; and

• All criteria for the use of

air-purifying respirators

are met.

• The atmosphere

contains no known

hazard; and

• Work functions preclude

splashes, immersion, or

the potential for unexpected inhalation of or

contact with hazardous

levels of any chemicals.

Limiting Criteria

This level should not be

worn in the hot zone.

The atmosphere must contain at least 19.5 percent

oxygen.

This level should not be

worn in the hot zone.

The atmosphere must contain at least 19.5 percent

oxygen.

NOTES:

*=Optional, as applicable.

As stated before, combinations of personal protective equipment other than those described for Levels A, B, C,

and D protection may be more appropriate and may be used to provide the proper level of protection.

Source: 29 CFR 1910.120, Appendix B – General description and discussion of the levels of protection and

protective gear.
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 8 3

Appendix O

Occupational Health Hazard Experience

of EMS Responders

Background/Overview

Employers’ decisions regarding worker protection

must begin with an evaluation of the hazards to

which workers might be exposed. A review of the

literature shows that EMS responders are subject to

many of the same occupational safety and health

hazards as are workers in other transportation,

medical, and public service occupations. EMS

responders are subject to hazardous substance

exposures as well as numerous other hazards,

including back injuries, automobile crashes, assault,

stress, bloodborne pathogens, and injuries to the

extremities, eyes, and ears.

Review of the Literature on Risks to

EMS Responders

Experience of EMS Responders Exposed to

Hazardous Substances

EMS responders routinely respond to sites where

hazardous substance releases have occurred. The

responders can become exposed to hazardous substances when they provide medical treatment at

these sites or at locations where contaminated persons, equipment, or vehicles have been moved after

the release. Although most studies of hazardous

substance exposure only looked at the broader

group of emergency service providers (including

various combinations of firefighters, police, EMTs,

HAZMAT teams, and in some cases emergency

room personnel), several reports provided detailed

information specific to EMS responders.35 OSHA has

summarized those reports in the following section.

EMTs at theTokyo Subway Sarin Gas Attacks

The experience of EMTs was specifically documented for the Tokyo subway sarin gas attacks of 1995.

In that disaster, officials dispatched 1,364 EMTs and

131 ambulances (plus some minivans) to 15 affected subway stations, from which they transported

688 of the 4,000 victims who eventually were seen

at area hospitals. A review of incident records indicated that 135 (9.9%) of the EMTs showed acute

symptoms and received medical treatment at hospitals.36 The authors did not indicate whether EMTs

entered the contaminated subway areas, but indicated that they did assist contaminated victims.

Most of the affected EMTs “started having symptoms during transportation, and it is suspected that

they were exposed in ambulances to the vaporized

sarin from victims’ clothes.” (Okumura et al., 1998).

The EMTs “wore standard work clothing without respiratory protection” and “ventilation in ambulances

and minivans at first was poor” because windows

were closed, although these were later opened to

improve the ventilation in transport vehicles.37

Okumura et al. (1998) note that it is important to

consider several additional factors when evaluating

the experience of EMTs during this disaster, including the lack of proper patient decontamination, the

duties performed by EMTs in Japan, and the ratio of

victims that arrived at the hospital via ambulance

compared to other forms of transportation. These

additional factors are described in more detail here:

• Lack of decontamination: Little or no effort was

made to decontaminate victims before transporting them (Okumura et al., 1998). If performed,

these types of decontamination activities might

have significantly reduced victim exposure levels, particularly because many victims experienced continued exposure while they waited in

crowded, enclosed rooms before being treated at

hospitals. While earlier efforts to decontaminate

the victims would likely have reduced EMT exposures during victim transport, the act of decontamination might have contributed to the exposure

of EMTs who assisted victims with washing and

undressing. Sarin off-gassing from abandoned

contaminated clothing could also have continued

to present a source of exposure to EMTs in the

area. EMTs would have required additional precautions to operate safely.

• EMT duties: Okumura et al. (2004) point out

that “Under Japanese law, only physicians are

allowed to perform endotracheal intubation and

administer medications to victims of a chemical

attack at the site of the incident.” In Japan, emergency response physicians can be dispatched for

this purpose (in contrast, EMS personnel in the

U.S. are often authorized to perform intubation).

Hick et al. (2003) also reviewed the literature

describing this incident and noted that the healthcare employees most affected were several 35 Historically, “general-population sources [of injury and illness

data] contain information on police and firefighters, but EMS personnel are not typically broken out.” (Houser et al., 2004).

36 The authors did not elaborate on the symptoms, but imply that

the acute symptoms were considered possible effects of sarin

exposure.

37 An important consideration for those planning EMS responder

protection is that “even in the absence of risk, the perceived risk

without PPE can lead to symptoms and compromise workflow.”

Hick (2007).
8 4

Occupational Safety and

Health Administration

physicians who spent up to 40 minutes attempting to resuscitate the initial victims of the incident. As might be expected, the medical personnel most affected provided treatment involving

extended close contact with the most critically ill

victims – who were also likely to have been the

most highly exposed and perhaps the most highly contaminated.

• Victim transportation to the hospital: Records

from one Tokyo hospital indicate that, while the

greatest number of victims arrived by foot, the

percentage who arrived by taxi (24 percent of all

victims arriving at that hospital) was more than

three times the number transported by ambulance (7 percent). Another 13 percent arrived by

private vehicles (Okumura et al., 1998). Although

it might be assumed that the most severely exposed and affected victims were transported by

ambulance, two of the three reported cardiac

arrest cases were transported by private vehicles

that happened to be passing the subway station

shortly after the incident (Okumura et al., 1998).

Although victims were triaged at the subway stations, some victims worsened during transport,

suggesting greater or continuing exposures. This

suggests that if more victims had been transported by ambulance, more EMTs might have experienced the effects of exposure. A follow-up evaluation of rescue team members and police officers,

made 2 to 3 years after they had been exposed to

sarin in the Tokyo incident, suggested a decline in

memory function independent of traumatic stress

symptoms. The authors were not able to determine whether the effect was due to direct neurotoxicity of sarin (Nishiwaki et al., 2001).

Hazardous Substances Emergency Events

Surveillance (HSEES) Data for EMS Responders

Horton et al. (2003 and 2008) and ATSDR (2004 and

2007) reported on the experience of EMTs responding to events recorded in the Hazardous Substances

Emergency Events Surveillance (HSEES) system.38

For the purposes of this database, a hazardous substance was any substance (i.e., chemical, biological,

or radiological) that could reasonably be expected

to cause an adverse health effect. Events involving

only petroleum are excluded by HSEES. Hazardous

substance emergency events were defined as “actual, uncontrolled, or illegal releases of a hazardous

substance(s) that had to be removed, cleaned up, or

neutralized according to federal, state, or local law.”

Victims of such events were defined as “persons

sustaining at least one injury or symptom (i.e., respiratory irritation) or death as a result of the event.”

The HSEES data for seven years from 1995

through 2001 show that EMTs constituted one-half

of one percent (0.5 percent) of all reported victims

of hazardous substance emergency events (13,173

total victims from more than 44,000 events) recorded during this period. Altogether, 72 EMT injuries

were reported.39 The 13,173 total victims also included 190 volunteer firefighters, 273 career firefighters,

437 police officers, and 32 hospital personnel, indicating that first responders (of all types) accounted

for a notable number victims injured during reported events of this period (Horton et al., 2003).

A subsequent report reviewed the frequency

with which medical treatment and decontamination

were provided during HSEES events. These HSEES

data indicate that medical treatment (first aid) was

provided (presumably by EMS responders in most

cases) for 262 injuries sustained by individuals at

hazardous substance release sites in the year 2004

(ATSDR, 2004). Figure O-1, reprinted from ATSDR

(2004), contrasts this value to the 1,039 hazardous

substance release site injuries treated in hospitals.

These figures suggest that EMS responders are

being called to some scenes to treat patients, but

that the vast majority of victims injured in hazardous substance release events are being transported or otherwise finding their way to hospitals

for treatment (in some cases, possibly in addition to

treatment at the scene).

Decontamination is performed infrequently, but

is somewhat more likely to occur at the scene of the

release than at medical facilities. “Of the 1,766

(96.0%) victims [in 2004 for whom decontamination

status was reported to HSEES], 1,483 (84.0%) were

not decontaminated, 157 (8.9%) were decontaminated at the scenes, 101 (5.7%) were decontaminated

at medical facilities, and 25 (1.4%) were decontaminated at both the scenes and medical facilities.”

(ATSDR, 2004).

Victims who were decontaminated in 2004 were

not necessarily injured. “For events in which uninjured persons were decontaminated, the median

number of uninjured decontaminated individuals

38 The HSEES system data were collected by the Agency for Toxic

Substances and Disease Registry (ATSDR). The 16 reporting

states included (grouped by geographical area): Alabama,

Mississippi, Texas, Iowa, Missouri, Minnesota, Wisconsin, New

York, New Jersey, Rhode Island, New Hampshire, North Carolina,

Colorado, Oregon, Washington, and Utah (Horton et al., 2003;

Berkowitz et al., 2004). Two additional states, Florida and

Michigan, began reporting in 2006 (Horton et al., 2008). Not all

states participated for the full period.

39 Horton et al. (2003) reported that 3,453 of these approximately

44,000 events involved injured victims; however, the total number of EMTs responding to these events is not known.
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 8 5

was 3 persons per event (range: 1–

100 persons). Decontamination was

done at the scene for 144 uninjured

employees, 451 uninjured responders, 140 uninjured members of the

general public, and 72 uninjured

students.” Decontamination was

done at medical facilities for 4 uninjured employees, 3 uninjured

responders, and 20 uninjured members of the general public (ATSDR

2004). Information is not available

on the class of responders performing decontamination at the scene.

An evaluation of more recent

HSEES data looked specifically at

secondary contamination of medical personnel, equipment, and

facilities that resulted from hazardous materials events during the

four years from the beginning of

2003 through 2006 (Horton et al.,

2008). The authors evaluated secondary exposure during three

phases of the events: The Hazmat

phase (at the site of the hazardous

substance release), the transport

phase (during transit to a medical

treatment facility), and the hospital

phase. EMTs are likely to have

been the personnel primarily

involved in providing medical

treatment during the Hazmat and

transport phases.

During the four-year period,

33,157 events were reported, 15

(0.05 percent) of which resulted in

secondary contamination of 17

medical personnel (12 EMTs and

five hospital employees) and 15

ambulances. Nearly three-quarters

of these 15 events occurred at fixed

facilities, while approximately onequarter were transportation-related

incidents. The authors reported

that during the Hazmat phase of

these events, 47 non-medical personnel were also injured (primarily

respiratory irritation) and 42 people

were decontaminated at the scene

of release.

Figure O-1. HSEES Injury Disposition — for Hazardous Substances

Emergency Events Surveillance in 2004

Substances Involved in HSEES

Events that Resulted in

Secondary Contamination of

Medical Personnel, Equipment

or Facilities 2003-2006:

Sulfuric acid*

Mace/pepper spray*

Solvent waste*

Chlorine and chloramine gas*

“Meth” chemicals*

Mercury

1,3,5 trinitrobenzene

Hydrochloric acid

Malathion

Acetic acid

Anhydrous ammonia* (2 events)

___

* Indicates that secondary

contamination caused injury to

medical personnel. Other

substances contaminated

equipment and/or facilities only.

The quantities of substances

released ranged from less than

one ounce to 600 gallons.

From Horton et al. (2008).
8 6

Occupational Safety and

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The data suggest that EMS responder injuries

were more likely to occur when the substance

release involved a vapor or aerosol compared to

spilled liquids or solids. Causal information was

only available for 14 of the 15 events and indicated

an equal number of the events (7 events) were

caused by accidents due to human error as were

caused by intentional or illegal acts (also 7 events).

Three of the events were associated with clandestine methamphetamine labs (Horton et al., 2008).

During the transportation phase, at least one

ambulance was contaminated in each of the 13

events during which patients were transported by

ambulance. Respiratory irritation was the most frequent injury among the 12 reported EMT injuries

due to secondary contamination during the transport phase. Two of the 12 EMTs (17 percent) wore

exam gloves (not chemical-resistant), while the

other 10 EMTs were wearing no PPE when they

were injured. None of the EMTs had received HAZWOPER training (Horton et al., 2008).

The HSEES data from an overlapping period,

including the years 2002 through 2006, were

reviewed in a separate analysis that specifically

assessed EMT/EMS involvement in hazardous substance release events (ATSDR, 2007). In those five

years, 54,729 incidents were reported with EMTs

responding to 4,138 (8 percent). Of 11,293 total

injuries reported during this period, 38 (0.3 percent)

were associated with EMT/EMS who responded and

then were injured at the scene of the hazardous

substance release. The 38 EMT/EMS injuries averaged over the 4,138 scenes to which EMT/EMS

responded, suggest that on average an EMS

responder experiences injury at a rate of slightly

less than 1 injury per 100 HSEES events to which

EMTs responded (0.9 percent). The data also show

that during this same period, 894 victims (9 percent)

were decontaminated at the scene.

Figures O-2 through O-4 present additional information on the HSEES events at which EMT/EMS

injuries occurred. Figure O-2 illustrates that these

EMS responder injuries were more often associated

with an aerosol or vapor release (two-thirds of the

injuries), compared to a solid or liquid spill (ATSDR,

2007). Figure O-3 compares the relative frequency

with which specific symptoms were reported in

EMT/EMS personnel injured at the scene. Note that

multiple injuries reported for the same victim are

recorded individually in HSEES; as a result, the total

number of reported injuries is greater than the number of injured EMT/EMS personnel. Respiratory irritation accounted for 39 percent of the EMT/EMS

injuries and was reported nearly twice as often as

the next most frequent symptom, dizziness/central

nervous system (CNS) effects (17 percent). A wide

variety of chemical substances were released at

sites where EMT/EMT injuries occurred, as indicated

by Figure O-4 (ATSDR, 2007).

Figure O-2. ReleaseType for Incidents at Which EMS Responders Were Injured (HSEES 2002-2007)
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 8 7

Figure O-3. Frequency of Specific Symptoms Among EMT/EMS Injured at Scenes with

Hazardous Substance Release (HSEES 2002-2006)

Figure O-4. Chemical Categories Associated with Hazardous Substance Release –

Scenes at Which EMT/EMS Were Injured (HSEES 2002-2006)

39

2

9

2 3

9 9
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Occupational Safety and

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Other Reports of EMS Responder Injury during

Hazardous Substance Releases

The published literature contains several other reports

of hazardous substance effects on EMS personnel

responding to clandestine drug laboratories, acts of

terrorism, and transportation incidents in the U.S.

Response to clandestine methamphetamine laboratories presents an increasing source of hazardous substance exposure, injuries, and illnesses

to EMS responders in jurisdictions where these labs

are prevalent. “Substances used in the methamphetamine laboratories are often corrosive, explosive, flammable, and toxic and can cause fires,

explosions, and other uncontrolled reactions.”

(MMWR, November 17, 2000). The results are

devastating to laboratory occupants, emergency

responders, and the local public.

Berkowitz et al. (2004) analyzed HSEES data

between 1993 and 2000 and found that the nine

reports of EMS responders injured during hazardous substance release events all occurred in

non-rural areas. This trend is in contrast to the finding that emergency responders in general (and volunteer firefighters in particular) were three times

more likely to be injured in rural/agricultural areas

than in other areas. The report continues:

“Of note was the large proportion of victims

who were responders, mainly police officers

and EMTs, in the events involving drug laboratories. More than half of these events involved

fire and/or explosion, and almost all injured

police officers and EMTs did not wear personal

protective clothes.These circumstances indicate that responders typically are very vulnerable to hazardous exposures.They often enter

the event area with little knowledge of the

chemicals involved, and they do not have the

proper protection that may prevent contact

with these chemicals.” (Berkowitz et al., 2004)

Although injuries resulted from only 7.2 percent

of all the hazardous substance incidents reported by

five states to the HSEES system during 1996 to

1999, injuries resulted from a much higher portion

(52.7 percent) of incidents when methamphetamine

processing was a factor at the incident scene

(MMWR, November 17, 2000).40 In one incident in

April 1996, three Washington State EMTs and two

police officers experienced eye and respiratory irritation after being exposed in an apartment to emissions from a fire involving acetone, hydrochloric

acid, and sodium hydroxide in an illicit methamphetamine lab. Overall, symptoms reported by EMS

responders across all five states included eight

cases of respiratory tract irritation (47.1 percent of

EMS responders reported symptoms), four cases of

eye irritation (23.5 percent), two cases of nausea

and vomiting (11.8 percent), and one report each of

skin irritation, headache, and shortness of breath

(each 5.9 percent). “EMTs sustained most injuries

through onsite exposure or direct contact with the

clothing or skin of contaminated persons.... None of

the injured first responders was wearing personal

protective equipment at the time of injury.”

(MMWR, November 17, 2000). The associated

MMWR editorial noted that “standard uniforms

worn by police officers, EMTs, and hospital personnel provided little or no chemical/respiratory protection.” See Appendix G for additional discussion of

response to clandestine methamphetamine laboratories.

EMS personnel who responded to the World

Trade Center rescue effort in 2001 visited healthcare

facilities 183 times. The most common complaints

were musculoskeletal injuries (38 cases), headache

(21 cases), respiratory effects other than acute infection (18 cases), eye irritation or injury (17 cases),

and skin problems (11 cases) (Berrios-Torres et al.,

2003). Most of the affected EMS responders were

treated and released; there were no fatalities among

this group and only one EMS responder was admitted to a hospital. The authors could not determine

incident rates for these injuries and illnesses because the total number of individuals working in the

capacity of EMS responder during the response was

not recorded. This study evaluated injuries and illnesses for which various groups of first responders

were treated and results do not reflect the number

of firefighters who died in the World Trade Center

disaster.

Other studies shed light on exposure patterns of

emergency response personnel in general (not specific to EMS responders). One review of injuries

caused by hazardous materials accidents in

Massachusetts between 1990 and 1996 found that

“when injuries did occur, they were more frequently

among civilians (25 percent of the incidents) than

public service personnel (7 percent of the incidents).

Inhalation exposure was more common [among the

public] than dermal exposure, while injury to public

service personnel involved only minor musculoskeletal injuries.” (Kales et al., 1997).

Six first responders were among 44 people

injured in Texas when a tanker car was punctured

during a train derailment in 2004. “At least 60,000

pounds of chlorine (as released gas) reacted with

sodium hydroxide to form sodium hypochlorite,

40 The five states were Iowa, Minnesota, Missouri, Oregon, and

Washington.
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 8 9

killing two people. [EMS] personnel were among

the first responders at the scene.” (MMWR, 2005).

Eighty first responders were decontaminated after

responding to the event.

Compared to the amount of information available for firefighters and police, relatively few reports

provide injury and illness statistics specifically for

EMS responders. The more general emergency

responder information, however, has some inferential value. A Rand report (Houser et al., 2004) rates

the applicability of available emergency services

casualty data (for firefighters, police, etc.) to EMS

responders.41 The report classifies the relevance of

general emergency services data to the experience

of EMS responders as “medium” for fatal and nonfatal injury and illness. On the other hand, for HAZMAT incidents, the applicability of general emergency services data to the experience of EMS

responders is rated as “high,” suggesting that the

author considered many of the determinants of hazardous materials exposure similar for responders in

various specialties (e.g., fire, HAZMAT, medical, and

police).

Risk to EMS Responders of Injury and Illness from

Causes Other than Hazardous Substance Exposure

As shown in the previous section, hazardous substance exposure is a real concern for EMS responders, but is far from the only concern. For comparison, this section describes other causes of injury

and illnesses in EMS responders (i.e., not related to

hazardous substances).

Injury and illness statistics support the need for

safer work practices. In a survey of registered EMTs

in New England, Schwartz et al. (1993) described

self-reported injury rates (for back, stress, assault,

hearing loss, eye injury, ambulance collision, etc.).42

The average prevalence rates, standardized to the

number of occurrences per 100 full-time equivalent

(FTE) EMTs per year, were highest for stress that

interfered with the job (prevalence rate of 27.1),

back injury (25.4), and injuries to extremities (23.7).

Over half the back injuries resulted in lost workdays,

the average being 25 days, and the range from 2 to

180 days. EMTs reported being assaulted at a rate of

20.3 occurrences per 100 FTE EMTs/year and being

involved in an ambulance collision at a prevalence

rate of 9.9 occurrences per 100 FTE EMTs/year. Eye

injury (due to foreign objects or chemicals) and

hearing loss were reported less frequently, with

prevalence rates of 3.4 and 6.0, respectively; however, even these values potentially represent a large

number of affected individuals, considering that

there were over 38,000 registered EMTs at the time

that this survey was conducted.43

Gershon et al. (1995) also investigated accidents

and injuries among EMS responders in the early

1990s. In this case, the research evaluated medical

charts for EMS responders employed by a county

fire department, which conducted approximately

32,000 emergency responses in 1992. EMS employees filed 226 injury reports: 23 percent related to

sprains, 20 percent to strains, and 15 percent in

response to exposure to body fluids. The back (20

percent) and respiratory tract (15 percent) were the

sites most frequently injured. “Most incidents were

caused by stretcher mishaps, especially during

transport of heavy patients.”

In a more recent retrospective review, Maguire et

al. (2005) studied on-duty injury reports recorded

between 1998 and 2002 for two EMS agencies that

were the sole 9-1-1 EMS providers in large urban

areas (civilian, non-firefighting). Agency employees

logged over 2.8 million hours and experienced 489

reported injuries over the period studied (227 of

these involved lost work time). The overall injury

rate was 34.6 per 100 FTEs/year, with sprains,

strains, and tears the most frequent category of

injury, and the back the most frequently injured site.

The authors conclude, “Our findings have shown

that the rate of injuries among EMS workers was

higher than the rate for any private industry published by the [Department of Labor] in 2000.”

Other investigators also found that transportation-related crashes and assaults contributed substantially to EMS responder injury rates, with EMS

responders accounting for 33 percent of fatalities

41 For example, the authors analyzed how closely study findings

based on data covering the combined experience of firefighters,

police, and other types of emergency responders (defined as

“general emergency services data”) would track the actual experience of EMS responders. The authors rated EMS personnel’s

risk of fatal injury or illness (e.g., due to collapse of a burning

structure or gunfire) as lower than that of firefighters and police,

while the hazardous materials exposure of EMS personnel was

rated as more similar (but not necessarily identical) to that of firefighters and police.

42 Questionnaires were mailed to a random sample (2 percent) of

all registered EMTs in Vermont, New Hampshire, Rhode Island,

Maine, Connecticut, and Massachusetts. Fifty-six percent of the

786 surveys were successfully returned. The average responder

was 35 years old with 8 years on the job (ranging from less than

1 year to 36 years of EMT experience) (Schwartz et al., 1993).

Note that the low return rate is a possible source of bias in the

study, which could have lead to an over-representation of injury

rates as EMTs who had been injured might be more likely to

return the survey.

43 The authors were not able to determine the proportion of all

registered EMTs that were full-time, part-time, or not actively

working in the field. The survey respondents, however, worked

an average of 33 hours per week.
9 0

Occupational Safety and

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associated with ambulance occupants in crashes.

The authors cited inconsistent seatbelt/restraint use

as a weak point in EMS responder vehicular safety

(MMWR, February 28, 2003). Kahn et al. (2001)

reviewed fatal ambulance crash records from 1987

to 1997, confirming that the most serious or fatal

injuries occurred in the rear (compared to the front

driver compartment) and were associated with

improperly restrained occupants. The authors also

found that 41 percent of ambulance drivers had

poor driving records and 16 percent had been cited

for traffic violations.

EMS responders also experience elevated occupational mortality and ground transportation-related

fatalities that are a significant factor in the estimated

fatality rate for EMS personnel. For this group, the

fatality rate from all causes was 12.7 deaths per

100,000, more than twice the national average of 5.0

deaths per 100,000 for the same period (Maguire et

al., 2002; MMWR, February 28, 2003). The authors

reviewed three independent fatality databases from

approximately 1992 to 1997 and estimated there

were 114 EMS employee fatalities during those 6

years, including at least 67 ground transportationrelated fatalities, 19 air ambulance crash fatalities,

13 deaths resulting from cardiovascular incidents,

10 homicides, and 5 deaths due to other causes

(Maguire et al., 2002). Citing more recent data from

the National EMS Memorial Service, Houser et al.

(2004) reported that causes of EMS employee lineof-duty fatalities from 1998 to 2001 were due to aircraft accidents (57 percent, primarily from rescue

helicopter crashes), motor vehicle accidents (26 percent), heart attacks/stress (7 percent), and other (11

percent).

Injuries and fatalities are not limited to employees. Students and trainees are similarly affected.

Cone and McNamara (1997) surveyed emergency

medicine residency programs and concluded,

“Injuries sustained by [emergency medical residents

in the field] during EMS rotations are uncommon

but nontrivial, with several serious injuries and one

fatality reported.”

The problem of assaults on EMS responders has

been receiving increasing attention. Mechem et al.

(2002) analyzed an occupational injury database at

the Philadelphia Fire Department (PFD) and found

that 4 percent of occupational injuries were due to

assaults. Among 1,100 employee injury reports

from 1996 to 1998, the authors identified 35 involving assaults on paramedics and an additional nine

involving assaults on firefighters. Forty-one percent

of the assaults occurred during patient care activities, and in 82 percent of the cases, the employee

sought medical treatment. Twenty-six (59 percent)

of the assaults were classified as intentional and 17

(38 percent) were considered unintentional (defined

as “patient in an altered mental status”). “The finding that far more paramedics than firefighters were

assaulted is noteworthy, given that at the time the

PFD employed almost ten times as many firefighters as paramedics.” The same authors reviewed

several other studies, which suggested similar

trends: 61 to 90 percent of EMS providers had been

the victim of abuse or a violent act, or been assaulted on the job, usually by a patient, a patient’s family

member, or a bystander.

Despite the levels of assault, when Mock et al.

(1999) studied the effects of violence and shift

schedules on EMS providers, results suggested that

the providers were no more anxious than the general working public. Cydulka et al. (1997), however,

found that stress levels were “very high” among

Promoting Ambulance Safety

Ambulance safety advocates recommend a

multi-tiered approach to addressing the high

EMS responder vehicle-related injury and death

rates. The following are some examples:

One specialist advocates an interdisciplinary

approach including better access to EMS accident and injury statistics, increased application

of automotive safety principles to ambulance

design, wearing helmets in the back of an

ambulance (until other safety features are

implemented), driver feedback with “black box”

technology, incorporating Intelligent Transportation System technology into ambulances, consideration of ergonomics in crashworthiness

research, improvements in fleet management/

policy, and relevant standards to guide these

processes (Levick, 2006; EMS Insider, 2006).

Green, et al. (2005) conducted computer modeling and crash testing to identify potential solutions to the high EMS employee injury rate and

found opportunities for improvements in ambulance restraints, seat design, cabin geometry,

and padding.

Ambulance safety is advanced by recent publications, such as the U.S. Fire Administration’s

Policies and Procedures for Emergency Vehicle

Safety, which includes a customizable model

policy (USFA/IAFC, 2006) and the American

National Standards Institute’s ANSI/ASSE Z15.1

standard on Safe Practices for Motor Vehicle

Operators (ANSI/ASSE, 2006).
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 9 1

the 22 percent of the National Association of

Emergency Medical Technicians (NAEMT) membership who returned a survey, which had been sent to

all members. These authors cited a number of reasons ranging from job dissatisfaction to personnel

shortages.

EMS responders are also subject to bloodborne

pathogen exposures. Needlesticks and other percutaneous injuries resulting in exposure to blood or

other potentially infectious materials are a concern

due to the high frequency of their occurrence and

the potential severity of the health effects associated

with exposure. When these injuries involve exposure to infectious agents, affected EMS responders

are at risk of contracting disease. Exposed individuals may also suffer from adverse side effects of

drugs used for post-exposure prophylaxis and from

psychological stress due to the threat of infection

following an exposure incident (OSHA, 2001-BBP

Preamble). Surprisingly, there is some evidence that

EMS responders’ rate of zero-conversion for the

hepatitis C virus (HCV), due to needlesticks, is similar to that of the general population. The authors

hypothesize that this is a combination of the

“healthy worker syndrome” (i.e., unhealthy employees leaving the profession), plus some level of

increased risk due to activities associated with the

EMS responder profession (compared to the general population), resulting in a neutral risk ratio (Boal

et al., 2004). A separate study reported that needlestick rates were lower for EMS personnel using selfretracting lancets than other types (Peate, 2001).

These studies show the breadth of risks that

EMS responders face in the line of duty. These personnel are exposed to substantial hazards from

motor vehicle crashes, sprains and strains, on-thejob violence, and other significant sources of injury

and illness. Comprehensive efforts to improve the

occupational health and safety of EMS responders

must address these factors, but should also promote adequate preparation for hazardous substance

scenarios.
9 2

Occupational Safety and

Health Administration

Appendix P

Industry Characteristics that Affect How

Employers Train and Protect their

Employees

A multitude of EMS industry characteristics affect

how employers make decisions about training and

protecting EMS responders.

Characteristics of the EMS Industry

• The array of regulatory organizations with

jurisdiction over EMS responders and the

agencies for which they work.

• The diversity of state-specific certification,

training, and regulatory requirements and the

applicability of OSHA’s HAZWOPER standard

(or the equivalent in State plan states) to EMS

agencies.

• The overlap between career and volunteer

EMS providers.

• The overlap between public and private

ambulance agencies.

• The overlap between inter-facility transporting

ambulance services and emergency response

services.

• The mechanism and sources used to fund

EMS and the extent of such funding.

• The unique paradigms under which EMS

agencies operate in order to accomplish their

important public health and emergency medicine missions.

• The mutual aid agreements between EMS

agencies and other organizations/jurisdictions.

• The influence of ad hoc in-the-field decisions

on EMS responder health and safety.

• The employer’s and contracting municipality’s

diligence in complying with OSHA or state

health and safety regulations.

• The close relationship between this industry

and hospital-based emergency services, fire

departments, and hazardous materials response teams.

• The role EMS agencies play in 9-1-1 response.

• The local community’s expectations regarding

EMS.

• The diverse conditions under which EMS

responders could work.

• The “terms of art” unique to this and closely

related industries.

• The need to make informed decisions quickly

based on initial information that may be

incomplete.

• The limited equipment/storage space available on an ambulance.

• The challenges of treating patients while

ensuring personal safety and health.

This appendix examines three specific strengths

and challenges faced by the EMS industry including its relationship with the U.S. Department of

Transportation’s (DOT) National Highway Traffic

Safety Administration (NHTSA); the applicability of

federal and state OSHA HAZWOPER standards and

other regulations; and the complexity created by

overlapping organizational demographics of EMS

responders has on the industry. Although state and

federal government organizations play a large role,

local EMS provider demographics also can affect

the way employers implement EMS responder

health and safety programs.

The Roles of NHTSA and States

NHTSA develops the National Standard Curriculum

(NSC), which is voluntarily adopted by the states to

meet their individual needs. States then license

EMS responders and provide oversight of initial and

ongoing training requirements. Typically, an EMS

responder who is properly trained to the NSC, is

evaluated to be competent, and meets other state

requirements, is then eligible to be licensed by the

state to practice.

NHTSA’s NSC provides the framework for a

nationally recommended minimum standard for

EMS responder education. The curricula may be

supplemented by additional resources and education, some of which are also available as training

course outlines from NHTSA. NHTSA does not,

however, dictate the amount of time trainers in

a state will spend instructing on a given topic.

Although objective and didactic material in the NSC

contain most of the elements of OSHA’s standard

on Hazardous Waste Operations and Emergency

Response (HAZWOPER) training, the material does

not meet the requirements for HAZWOPER training.

Specifically, to meet HAZWOPER requirements, the

standard curricula would need to be customized to

(1) include information relevant to local community

conditions and (2) provide students with adequate

training time to meet the HAZWOPER training

requirements (e.g., 8 hours for operations level

training). As a national program the NSC does not

include information on specific local community

conditions, nor does it specify training time requirements for those elements that could serve as the

basis for meeting the general HAZWOPER training

requirements.

The current EMS education system has limitations. According to an advisory panel, a more formal national EMS training program could provide
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 9 3

greater consistency across the U.S. (NHTSA, 2000).

The advisory panel listed hazardous materials incidents as one of 22 core content categories, although

compatibility with HAZWOPER training requirements is not specifically listed as an objective. A

revised system, called the National EMS Education

Standards is currently under development. The new

system is expected to offer a more structured core

content and credentialing process that will also be

easier to adapt as the need arises.

The U.S. is not alone in updating EMS training

standards and considering competency of EMS personnel who could respond to a hazardous material

release. An EMS training system in Canada, implemented by the Minister of Health and Long-term

Care in the Province of Ontario, Canada, is already

incorporating a high degree of standardization into

the province-wide standards for EMS training, vehicles, and equipment. While this structure might not

be practical in the U.S., certain aspects may serve

as illustrative examples when EMS decision makers

review local, regional, state, and federal standards.

In particular, since the events of September 11,

2001, policies dictate that “when an incident involves the response to hazardous materials... the

expectation is that all municipal and community

response agencies (fire, police, and emergency

medical services) throughout the province have the

capacity to respond... in keeping with the awareness level as defined by the National Fire Protection

Association Standard 472 (NFPA 472): Standard

for Professional Competence of Responders to

Hazardous Materials Incidents (2002, Edition). This

means that all responders should be able to recognize the presence of hazardous materials and take

appropriate safety precautions, secure the scene of

the incident, and call the appropriate authorities for

assistance.” (Barg, 2004).

Applicability of Federal and State OSHA HAZWOPER Standards and Other Regulations

Emergency responders at the site of a hazardous

substance release are covered under OSHA’s HAZWOPER standard, or the parallel OSHA-approved

State Plan standard.44 Emergency responders,

including firefighters, law enforcement, and EMS

personnel, are often employees of local, municipal,

or state governments or effectively acting in that

capacity under a contract or other agreement.

Although Federal OSHA's standards and enforcement authority do not extend to such state and local

governments, these employers and employees are

covered by the 26 states that operate OSHA-approved State Plans and, in states without State Plans, by

the U.S. Environmental Protection Agency (EPA)

with regard to HAZWOPER (29 CFR 1910.120).45

State Plan programs set and enforce standards,

such as those for HAZWOPER and Respiratory

Protection, which are identical to or “at least as

effective as” Federal OSHA standards, and, therefore, may have more stringent or supplemental

requirements. State Plan standards apply to state

and local government employees and, in some

cases, to volunteers. EPA's HAZWOPER parallel

standard was adopted to cover public sector

employees in states without OSHA-approved State

Plans who otherwise would not be covered by the

Federal OSHA standard, including volunteers who

work for a government agency engaged in emergency response, such as firefighters. For consistency, OSHA interprets the HAZWOPER standard for

EPA. Federal OSHA administers the safety and

health program for the private sector in the remaining states and territories, and also retains authority

with regard to safety and health conditions for

Federal employees throughout the nation (OSHA,

1991-Borwegen).

Employers of EMS responders are also regulated

under numerous and diverse local programs. Narad

(1998) conducted an inventory of ambulance service

regulatory programs in California and noted that

“California has a variety of regulatory programs for

ambulance services; these are shared among the

state, county, and city governments, as well as

multi-county agencies. The types of regulatory programs and the standards used vary widely around

the state.” This pattern is duplicated to some degree

in each of the 50 states across the U.S. Although it

is beyond the scope of this document to discuss

individual local programs, employers need to be

aware of them and communicate with local program administrators to address any conflicts

between local programs and state or federal

requirements.

The Influence of Overlapping Organizational

Demographics of EMS Responders

One method of describing EMS responder activities

is to divide them according to functional roles

44 (those who respond to emergencies and those who In a letter of interpretation OSHA explained that public employee EMTs in State Plan programs must be covered by approved

state OSHA standards. The extent to which volunteers are covered in State Plan programs depends on state law and policy

(OSHA, 1996 – Grassley).

45 In states without OSHA-approved State Plans, state and local

government employees are covered with regards to HAZWOPER

under EPA’s 40 CFR Part 311.
9 4

Occupational Safety and

Health Administration

do not). Other divisions can be made according to

the type of organization the EMS responder works

for, how many hours per week the responder works,

or whether the responder is a volunteer.

Many EMS responders are considered “interfacility transporting EMS responders” and primarily

transfer patients to and from medical facilities under

non-emergency conditions. Many of these EMS

responders do not respond to 9-1-1 calls as a regular part of their jobs. In contrast, most of the

remaining EMS responders do work in an emergency-response capacity at least some of the time.

These two EMS responder groups have substantially different risk of encountering a hazardous substance during their normal duties.

EMS responders can be further subdivided into

(1) EMS personnel for whom providing medical care

before the patient arrives at a healthcare facility is

the primary duty and (2) EMS responders who are

cross-trained as firefighters, hazardous materials

team members, or law enforcement officers.46 In the

latter case, the EMS responders’ medical duties

supplement the other related profession. EMS

responders in both groups might experience similar

ranges of hazards while performing medical care

(regardless of what hazards they might encounter

when filling the other role(s) for which they are

cross-trained). Among fire-based EMS responders,

“the integration with firefighters and associated

emphasis on safety and access to quality equipment

may lead to fire-based EMS systems experiencing

fewer shortcomings in their [PPE] options”

(LaTourrette et al., 2003).

The cross-trained EMS responders may have

additional training and qualifications (e.g., to wear a

higher level of respiratory protection) than EMS

responders who perform only medical response

activities. Those additional qualifications are related

to requirements of the EMS responders’ other occupational expectations and are not a traditional standard requirement for medical emergency response

activities.

EMS responders may work for public, private, or

contract agencies, fire departments, hospitals, or

other types of organizations. This makes it difficult

to fully characterize the EMS industry and has implications for how OSHA and EPA regulations are

applied.

Finally, EMS responders may work full-time or

part-time, or they may work on a strictly voluntary

basis. An undefined number of EMS responders

maintain their certification, but do not actually practice (i.e., they work in a different field).

In summary, EMS responders are a diverse

group. Their risks vary with their primary and secondary roles. OSHA recognizes that this diversity of

roles and risks must be taken into consideration

when identifying best practices and recommendations. Additionally, state and local jurisdictions have

a good deal of freedom to tailor programs to local

needs; however, the number and variability of local

influences affecting an individual EMS responder

agency can lead to numerous requirements which

are sometimes confusing.

46 Approximately “40 percent of EMS response is provided by fire

departments (after Karter, 2001), with independent agencies and,

to a smaller extent, hospitals, private firms, and law enforcement

agencies making up the remaining 60 percent.” (LaTourrette et

al., 2003).
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 9 5

Appendix Q

Sources of Help in Addressing Biological

Agent Issues

Hazardous substance release events could include

the immediately identified (or announced) release of

biological agents. When the hazard assessment

suggests that hazardous substance releases in the

region could involve biological agents, employers of

EMS responders should plan to protect their workers from these agents.

Biological agents generally occur in the form of

viruses, bacteria, and substances produced by biological agents (e.g., ricin). Some are infectious

agents, while others cause health effects through

other processes, such as toxicity. In the event that

the biological agent is a viral variant with a high

patient mortality rate (e.g., a pandemic influenza),

EMS responders should assume (until confirmed

otherwise) that the virus is spread by airborne

transmission (i.e., as an aerosol) as well as by

droplets. EMS responders will require respiratory

protection (minimum N95).46 This level of respiratory protection is also appropriate for bacteriological

agents such as tuberculosis (TB), commonly spread

by infectious process.

OSHA’s standard on bloodborne pathogens (29

CFR 1910.1030) sets forth requirements for protecting workers, including EMS responders, from this

type of biological agent (e.g., Hepatitis B).

More detailed information on addressing the

issues surrounding biological agent exposures and

disease spread by infectious processes are available

at the following sources:

• Pandemic flu: www.pandemicflu.gov

• Preparing for a Bioterrorist Attack: Legal and

Administrative Strategies: www.cdc.gov/ncidod/

eid/vol9no2/02-0538.htm

• CDC Disease Listings (look up general and technical information on disease agents [infectious

and otherwise] from anthrax to yersiniosis):

www.cdc.gov/ncidod/dbmd/diseaseinfo/default.

htm

• OSHA’s Pandemic Influenza Preparedness and

Response Guidance for Healthcare Workers and

Healthcare Employers: www.osha.gov/

Publications/OSHA_pandemic_health.pdf

• OSHA Regulations: Bloodborne Pathogens standard (29 CFR 1910.1030): www.osha.gov/pls/

oshaweb/owadisp.show_document?p_table=

STANDARDS&p_id=10051

• NIOSH page on Eye Protection for Infection

Control: www.cdc.gov/niosh/topics/eye/eyeinfectious.html

• CDC Infection Control Guidelines: www.cdc.gov/

ncidod/dhqp/guidelines.html

• OSHA Safety and Health Topics page on possible

hazards and solutions for healthcare workers at

healthcare facilities and elsewhere (includes

information relevant to EMS responders):

www.osha.gov/SLTC/healthcarefacilities/

recognition.html

• OSHA Safety and Health Topics page for

Emergency Responders: www.osha.gov/SLTC/

emergencypreparedness/responder.html#First

• NIOSH guidelines for healthcare workers and

healthcare facilities: www.cdc.gov/niosh/

hcwold0.html

• CDC Emergency Response and Preparedness

page on ricin: http://www.bt.cdc.gov/agent/ricin

Concern about Needlesticks and

Biological Agents

Needlesticks are one of the greatest sources of concern for EMS responders under normal conditions

and the need for concern is potentially even greater

during incidents involving biological agents. In the

course of their job duties, EMS responders are

potentially subject to exposure to blood and other

potentially infectious material (OPIM). This increases

their risk of exposure to bloodborne diseases, such

as hepatitis B and C and human immunodeficiency

virus (HIV) (Adams & Elliot, 2006; Boal et al., 2005;

Peate, 2001; Rischitelli et al., 2001). EMS responders

are also exposed to airborne infectious diseases,

like meningococcal meningitis and tuberculosis

which have serious health effects (Miller et al.,

2005). Exposed individuals may also suffer from

adverse side effects of drugs used for post-exposure

prophylaxis and from psychological stress due to

the threat of infection following an exposure incident (OSHA, 2001-BBP Preamble). Because EMS

46 Airborne transmission, as occurs in tuberculosis, is spread

through small infectious particles such as droplet nuclei. Unlike

the larger droplets, these very small airborne droplet nuclei can

be readily disseminated by air currents to susceptible individuals.

They can travel significant distances and can penetrate deep into

the lung to the alveoli where they can establish an infection. The

presence of significant airborne transmission would indicate the

need for ventilation procedures and respiratory protection

greater than that afforded by a surgical mask, e.g., a NIOSHcertified N95 or higher respirator.
9 6

Occupational Safety and

Health Administration

responder work is performed in uncontrolled, emergency environments, usually dealing with trauma or

sudden onset of illness, there is a greater potential

for needlesticks or blood exposure to occur (Boal et

al., 2005; Peate, 2001).

Preliminary results of a national study to prevent

blood exposure in paramedics by the Pennsylvania

Department of Health determined that blood exposures occurred through (1) needle or lancet stick, (2)

cuts from sharp objects, (3) blood in eyes, nose or

mouth, (4) uncooperative or combative patient bites

(skin break) and (5) blood on non-intact skin

(Pennsylvania Department of Health, 2007). Twentytwo percent of the paramedics reported at least one

exposure to blood and an additional seven percent

reported more than one blood exposure in the last

twelve months of service (Pennsylvania Department

of Health, 2007).

EMS responders do not always report the exposure. The Pennsylvania study cited reasons for nonreport as:

• The paramedic did not consider the exposure

significant or forgot about the exposure.

• The paramedic determined that he/she was too

busy and reporting involved too much paperwork.

• The paramedic did not want to be reprimanded.

• The paramedic was worried that somebody

would find out about the exposure.

• The paramedic thought that the company rarely

took action when a worker is exposed.

The critical concept in this kind of responder

work is the need to focus on prevention of exposure

to blood and OPIM (Boal et al., 2005). A review of

literature determined that combinations of strategies reduced needlestick injuries for healthcare

employees. Enhanced training on sharps education,

safe needle choice, a uniform approach to exposure

plans with concise treatment protocol, and limiting

long work hours have been cited as actions that

decrease needlestick injuries (Adams & Elliot, 2006;

Ilhan et al., 2006; Miller et al., 2005; Peate, 2001).
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 9 7

OSHA Assistance

OSHA can provide extensive help through a variety of

programs, including technical assistance about effective safety and health programs, state plans, workplace consultations, and training and education.

Safety and Health Management

System Guidelines

Effective management of worker safety and health

protection is a decisive factor in reducing the extent

and severity of work-related injuries and illnesses and

their related costs. In fact, an effective safety and

health management system forms the basis of good

worker protection, can save time and money, increase

productivity and reduce employee injuries, illnesses

and related workers’ compensation costs.

To assist employers and workers in developing

effective safety and health management systems,

OSHA published recommended Safety and Health

Program Management Guidelines (54 Federal Register

(16): 3904-3916, January 26, 1989). These voluntary

guidelines can be applied to all places of employment

covered by OSHA.

The guidelines identify four general elements critical to the development of a successful safety and

health management system:

• Management leadership and worker involvement,

• Worksite analysis,

• Hazard prevention and control, and

• Safety and health training.

The guidelines recommend specific actions, under

each of these general elements, to achieve an effective

safety and health management system. The Federal

Register notice is available online at www.osha.gov.

State Programs

The Occupational Safety and Health Act of 1970 (OSH

Act) encourages states to develop and operate their

own job safety and health plans. OSHA approves and

monitors these plans. Twenty-five states, Puerto Rico

and the Virgin Islands currently operate approved

state plans: 22 cover both private and public (state and

local government) employment; Connecticut, Illinois,

New Jersey, New York and the Virgin Islands cover the

public sector only. States and territories with their own

OSHA-approved occupational safety and health plans

must adopt standards identical to, or at least as effective as, the Federal OSHA standards.

Consultation Services

Consultation assistance is available on request to

employers who want help in establishing and maintaining a safe and healthful workplace. Largely funded

by OSHA, the service is provided at no cost to the

employer. Primarily developed for smaller employers

with more hazardous operations, the consultation

service is delivered by state governments employing

professional safety and health consultants. Comprehensive assistance includes an appraisal of all mechanical

systems, work practices and occupational safety and

health hazards of the workplace and all aspects of the

employer’s present job safety and health program. In

addition, the service offers assistance to employers in

developing and implementing an effective safety and

health program. No penalties are proposed or citations issued for hazards identified by the consultant.

OSHA provides consultation assistance to the employer with the assurance that his or her name and firm

and any information about the workplace will not be

routinely reported to OSHA enforcement staff. For

more information concerning consultation assistance,

see OSHA’s website at www.osha.gov.

Strategic Partnership Program

OSHA’s Strategic Partnership Program helps encourage, assist and recognize the efforts of partners to

eliminate serious workplace hazards and achieve a

high level of worker safety and health. Most strategic

partnerships seek to have a broad impact by building

cooperative relationships with groups of employers

and workers. These partnerships are voluntary relationships between OSHA, employers, worker representatives, and others (e.g., trade unions, trade and

professional associations, universities, and other government agencies).

For more information on this and other agency

programs, contact your nearest OSHA office, or visit

OSHA’s website at www.osha.gov.

OSHATraining and Education

OSHA area offices offer a variety of information services, such as technical advice, publications, audiovisual aids and speakers for special engagements. OSHA’s

Training Institute in Arlington Heights, IL, provides

basic and advanced courses in safety and health for

Federal and state compliance officers, state consultants, Federal agency personnel, and private sector

employers, workers and their representatives.

The OSHA Training Institute also has established

OSHA Training Institute Education Centers to address

the increased demand for its courses from the private

sector and from other federal agencies. These centers

are colleges, universities and nonprofit organizations

that have been selected after a competition for participation in the program.

OSHA also provides funds to nonprofit organizations, through grants, to conduct workplace training

and education in subjects where OSHA believes there
9 8

Occupational Safety and

Health Administration

is a lack of workplace training. Grants are awarded

annually.

For more information on grants, training and education, contact the OSHA Training Institute, Directorate

of Training and Education, 2020 South Arlington

Heights Road, Arlington Heights, IL 60005, (847) 297-

4810, or see Training on OSHA’s website at

www.osha.gov. For further information on any OSHA

program, contact your nearest OSHA regional office

listed at the end of this publication.

Information Available Electronically

OSHA has a variety of materials and tools available on

its website at www.osha.gov. These include electronic

tools, such as Safety and HealthTopics, eTools, Expert

Advisors; regulations, directives and publications;

videos and other information for employers and workers. OSHA’s software programs and eTools walk you

through challenging safety and health issues and

common problems to find the best solutions for your

workplace.

OSHA Publications

OSHA has an extensive publications program. For

a listing of free items, visit OSHA’s website at

www.osha.gov or contact the OSHA Publications

Office, U.S. Department of Labor, 200 Constitution

Avenue, NW, N-3101, Washington, DC 20210; telephone (202) 693-1888 or fax to (202) 693-2498.

Contacting OSHA

To report an emergency, file a complaint, or seek

OSHA advice, assistance, or products, call (800) 321-

OSHA or contact your nearest OSHA Regional or Area

office listed at the end of this publication. The teletypewriter (TTY) number is (877) 889-5627.

Written correspondence can be mailed to the nearest OSHA Regional or Area Office listed at the end of

this publication or to OSHA’s national office at: U.S.

Department of Labor, Occupational Safety and Health

Administration, 200 Constitution Avenue, N.W.,

Washington, DC 20210.

By visiting OSHA’s website at www.osha.gov, you

can also:

• File a complaint online,

• Submit general inquiries about workplace safety

and health electronically, and

• Find more information about OSHA and occupational safety and health.
O S H A B E S T P R A C T I C E S F O R P R O T E C T I N G E M S R E S P O N D E R S 9 9

OSHA Regional Offices

Region I

(CT*, ME, MA, NH, RI, VT*)

JFK Federal Building, Room E340

Boston, MA 02203

(617) 565-9860

Region II

(NJ*, NY*, PR*, VI*)

201 Varick Street, Room 670

New York, NY 10014

(212) 337-2378

Region III

(DE, DC, MD*, PA, VA*, WV)

The Curtis Center

170 S. Independence Mall West

Suite 740 West

Philadelphia, PA 19106-3309

(215) 861-4900

Region IV

(AL, FL, GA, KY*, MS, NC*, SC*, TN*)

61 Forsyth Street, SW, Room 6T50

Atlanta, GA 30303

(404) 562-2300

Region V

(IL*, IN*, MI*, MN*, OH, WI)

230 South Dearborn Street

Room 3244

Chicago, IL 60604

(312) 353-2220

Region VI

(AR, LA, NM*, OK, TX)

525 Griffin Street, Room 602

Dallas, TX 75202

(972) 850-4145

Region VII

(IA*, KS, MO, NE)

Two Pershing Square

2300 Main Street, Suite 1010

Kansas City, MO 64108-2416

(816) 283-8745

Region VIII

(CO, MT, ND, SD, UT*, WY*)

1999 Broadway, Suite 1690

PO Box 46550

Denver, CO 80202-5716

(720) 264-6550

Region IX

(AZ*, CA*, HI*, NV*, and American Samoa,

Guam and the Northern Mariana Islands)

90 7th Street, Suite 18-100

San Francisco, CA 94103

(415) 625-2547

Region X

(AK*, ID, OR*, WA*)

1111 Third Avenue, Suite 715

Seattle, WA 98101-3212

(206) 553-5930

* These states and territories operate their own

OSHA-approved job safety and health programs

and cover state and local government employees

as well as private sector employees. The

Connecticut, Illinois, New Jersey, New York and

Virgin Islands plans cover public employees only.

States with approved programs must have standards that are identical to, or at least as effective

as, the Federal OSHA standards.

Note: To get contact information for OSHA Area

Offices, OSHA-approved State Plans and OSHA

Consultation Projects, please visit us online at

www.osha.gov or call us at 1-800-321-OSHA.