United States Department of
Health & Human Services
Office of the Assistant Secretary for Preparedness and Response
Section 1: Introduction:
Mad Dogs and Englishmen
Go Out in the Noon Day’s Heat
Noel Coward,
although better remembered through Joe Cocker,
the Rotating Rocker
Joseph “Mad Dog” Cocciardi, PhD, MS, CIH, CSP, REHS/RS
Chief Safety Officer
CAPT Timothy “The Englishman” Davis, MD, MPH, USPHS
Deputy Chief Medical Officer
National Disaster Medical System (NDMS)
HHS / OS /ASPR / OPEO / NDMS
Section 1: Introduction
“Commanding Officers of volunteers
are very apt to err in this particular;
and the spirit of their men is such that they
shrink from complaint, and persevere in
efforts which may easily, under a burning
sun, become dangerous to life.”
The Lancet, 10 June 1865 (1)
Section 1: Introduction
Section 1: Introduction
Today’s Agenda:
1)
2)
3)
4)
5)
6)
7)
8)
Overview: Definition of the Problem.
Human Body’s Tolerance of Heat.
Environmental Measurements and Mechanisms.
Pre-Event Preparatory Activities: “The HARM” and
Acclimatization.
Self Application of Protective Measures: “Health
Monitoring and Heat Syndromes”.
Work Restrictions.
Work Regimen, Heat - NDMS.
“Lets Exercise”.
Section 1: Introduction
High-Risk Worker Population:
• Age 28 – 72 years, mean 54
• Part-time, shy to report risk factors (no pay)
• Mean Body Mass Index (BMI) “overweight”
• < 25 fit.
• 25-34 “heavy”, 25-50% >IBW
• 35-39 “obese”, <100% • > 40 “morbid obese”, >100%
• Chronic Health and on/off associated drugs
Section 1: Introduction
“The Problem”:
HHS-ESF #8-OPEO NDMS
Response and Deployment Activities
• 2005: Hurricane Katrina/Rita:
• Heat Stress Factors
• Co-Stressors
• Acclimatized Worker
Section 1: Introduction
“The Problem”:
• 2010: Haiti Earthquake Response:
•
•
•
•
Heat Stress Factors and Co-Stressors
Acclimatized and Medically Prepared Personnel
Availability of Clean Water
Availability of “Cooling
Areas”
• Lack of Environmental
Monitoring Equipment
Section 1: Introduction
“The Problem”:
• 2010: Gulf Oil Spill:
• Heat Stress Factors and Co-Factors
• Multiple Programs in Place
(Disaster Response v. OSHA Coverage)
Section 1: Introduction
“The Problem”:
• 2011: Joplin, MO (EF5 Tornado):
• Minot, ND Floods
• Events of Historical Significance:
– Manassas, VA Re-Enactment and Minority
– July 4th Mall Events (2009, 2010, 2011)
• Field Training Exercises:
– Emmitsburg, MD
• Extremely High Heat Index
• “Group Think” to Continue Activities
Section 2: Human Body’s
Tolerance of Heat
Section 2: Human Body’s
Tolerance of Heat
Section 2: Human Body’s
Tolerance of Heat
• The healthy human body is well-adapted to deal with
temperature extremes providing good judgment is used
• Any deviation from perfect health will impede the body
in dealing with heat stress.
– Very young (Î BSA:weight) or old (Cardiac Output <50%)
– Most health or skin conditions, most medications,
recent immunizations
– “Heavy” diet; ~ > 1000 cal meal, or 2k cal / day
– Lack of conditioning / acclimation
– Very low / high Body Mass Index (BMI), high muscle mass
– Impaired judgment (e.g., alcohol, drugs, mental illness)
– Restricted judgment / free choice (e.g., military, religious
pilgrimage, forced work, BSA, school outings, concerts,
NASCAR, sporting events, Raves)
Section 2: Human Body’s
Tolerance of Heat: Additive Heat Factors
Six (6) heat stress “agents” or factors
• air temperature
• wind velocity
• relative humidity
• mean radiant temperature (sun exposure)
• metabolic heat production (work)
• clothing insulation
Textbook of Military Medicine Ch 1 p .
Section 2: Human Body’s
Tolerance of Heat: Individual Loss of
Decision-Making
• Persons in groups are less free to use personal
judgment to rest, seek shade, or drink appropriate
beverages in appropriate volume
– Military units, teams, pilgrimages, and outdoor mass
gatherings (beverage choice, cost, diet restrictions)
– Alcohol and controlled substances
• 7 weeks – life expectancy of an Irishman digging the
New Orleans canals
• 7 years – life expectancy of an African slave forced to
work the Mississippi delta (“down-river”)
– Even acclimated heat-tolerant Africans had high morbidity
because of the lack of free choice to seek shade and fluids,
or limit pace of work
(Note: The Cocciardi Correlary (2000)).
Section 2: Human Body’s
Tolerance of Heat: Acclimation/Adaption
• The human body can take as long as 2-6 weeks to
fully adapt to heat stress
• Adaptation can take as little as 2 days for those
conditioned with daily exercise
– Daily exercise enough to break a sweat
– If only every other day exercise the acclimation is
delayed for 2 weeks
– Adaptation is lost in less than one week of inactivity
(or vacation)
• Has resulted in death when heat exposure is resumed.
Bouchama 2002
Section 2: Human Body’s
Tolerance of Heat: Optimal Heat Regulation
• 70% of heat is lost over just 30% of body
surface where blood vessels resist collapse
– Head (especially scalp) & neck
– Axilla (arm pit area, brachial vein and artery)
– Groin area (femoral vascular complex)
• Heart must have near 100% Cardiac Output
for optimal heat loss using the skin as a
radiator (evaporation, convection, conduction)
– Immediate cardiac output increase from 5 -> 20
liter / min
Section 2: Human Body’s
Tolerance of Heat: Optimal Heat Regulation
The skin must be 100% unimpaired by
• Disease (rash, scaring), new or old burns, or heavy creams
• Restrictive clothing
• Vaso-constrictive chemicals (collapses blood vessels) such
as nicotine, caffeine, theo-bromides (chocolate)
• Over-the-counter (OTC) cold remedies, or drugs (e.g.,
cocaine, amphetamines), or
• Blocked from sweating by
–
–
–
–
–
–
–
anti-cholinergics - nausea
anti-histamines – allergy and cold
Tobacco products - nicotine
Tranquilizers – sleep medications
SSRIs – depression
Other psychiatric medications
Some Deodorant
Section 2: Human Body’s
Tolerance of Heat: Optimal Heat Regulation
• Any disease, medication, or immunization will impair
thermo-regulation to one degree or another
– affects base-temperature
– affects the cardiovascular, pulmonary, digestive, urinary,
nervous, endocrine, musculoskeletal, connective tissue,
metabolic, or dermatologic systems.
• Most common heart and hypertension medications
leave the worker more susceptible to heat illness
–
–
–
–
Adversely affect the pump (heart) & the radiator (skin)
vaso-active (affects blood vessels)
impacts cardiac output (efficient heart squeezing)
cause fluid and electrolyte loss (diuretic / water pills)
Section 2: Human Body’s
Tolerance of Heat: (H)Eat Stress
• Heavy eating dramatically affects heat tolerance
– ANY heavy meal (“eat-stress endotoxins”) immediately
prior to heat stress Bouchama 2002
• Alcohol even days before (electrolyte loss?)
– lower susceptibility to heat and impair thermoregulation.
• Endotoxins produced as blood is shunted to the skin
away from digestive track during digestive process
– Residual endotoxins cause ongoing heat-susceptibility
after apparent recovery if returned to duty too early
– Remember your mom’s warning about swimming and
stomach cramps after eating
• Every worker is vulnerable to “eat stress” in a hot,
humid, field environment with a full galley cafeteria
– Easy Safety professional intervention behind the scene
– Lighter (shorter) breakfast and lunch; substantial supper
Section 2: Human Body’s
Tolerance of Heat: Overheating in Humans & Automobiles
Humans, like automobiles, overheat faster when
1.
Air temperature is close to the radiator (skin)
temperature (98-99°F)
Fluid, trapped in the radiator (skin), is not circulating
Radiator (skin) is covered with dirt (clothing, creams)
Radiator fluid (blood volume) is low (dehydrated)
2.
3.
4.
•
5.
6.
7.
8.
> 3% volume loss before “thirsty”
Too little fluid returns to the pump (heart)
Pump is too small, too weak, or leaks (hearts > 50 yo)
Radiator (skin) is partially blocked (skin eruptions, burn)
Worker starts with warmer radiator (body) temperature
(illness, recent immunization)
Textbook of Military Medicine Vol 6
Section 2: Human Body’s
Tolerance of Heat: Overheating in Humans & Automobiles
Humans, unlike automobiles, also heat faster when
1. Clothing is impermeable, heavy, or both (e.g., most
uniforms, PPE, hats)
2. Environmental vapor pressure is near 44 mm Hg
(humidity > 85%)
3. Body’s control of blood flow or sweating is impaired
by drugs, disease, inoculations, or alcohol
4. Sweating is impaired by skin eruption
Textbook of Military Medicine Vol 6
Section 2: Human Body’s
Tolerance of Heat: Over-Riding Principle
• These principles follow Armed Forces safety doctrine
– “There is no peacetime mission that justifies the loss
of life or limb.”
The Battalion Commander’s Handbook, 1991
• Civilian adaptation: “No mission, unless clearly life or
death, justifies any risk to responder health and
safety.”
The Joetim’s Handbook, June 2012
Section 2: Human Body’s
Tolerance of Heat: Summary: Human Body’s Tolerance of Heat
1. Most over age 30 will have some increased
vulnerability.
2. Over age 50 particular are at-risk because of
natural decrease in Cardiac Output
•
Same distinction for burn survival
3. Diet is low-hanging intervention
4. Recognize that “malingering” may be an
individual using good judgment
Section 3: Environmental
Measurements and Mechanisms
Section 3: Environmental
Measurements and Mechanisms
Section 3: Environmental
Measurements and Mechanisms
• Heat Stress: The net load applied by
metabolic heat, air temperatures,
humidity, air movement and radiant
heat, as well as clothing
Section 3: Environmental
Measurements and Mechanisms
• Metabolic Rate: Human body heat
production
1 MET = 58 W/m2 (356 Btu/hr)
(Human body heat production)
(90,000 calories)
(Note: A food calorie (“from the labels”) is
a kilo calorie or 1,000 calorie energy
necessary to raise 1 kg of H20, 1 C)
Section 3: Environmental
Measurements and Mechanisms
Activity
W/m2
W1)
Btu/hr1)
Met
Reclining
46
83
282
0.8
Seated relaxed
58
104
356
1.0
Standing relaxed
70
126
430
1.2
Sedentary activity (office,
dwelling,
school, laboratory)
70
126
430
1.2
Teacher
95
171
583
1.6
Section 3: Environmental
Measurements and Mechanisms
Activity
W/m2
W1)
Btu/hr1)
Met
Walking on the level, 2 km/h
110
198
675
1.9
Standing, medium activity (shop
assistant,
domestic work)
116
209
712
2.0
Building industry - Brick laying
(Block of 15.3 kg)
125
225
768
2.2
Iron and steel - ramming the
mould with a
pneumatic hammer
175
315
1075
3.0
Building industry -forming the
mould
180
324
1105
3.1
Section 3: Environmental
Measurements and Mechanisms
Activity
W/m2
W1)
Btu/hr1)
Met
Iron and steel - ramming the
mould with a
pneumatic hammer
175
315
1075
3.0
Building industry -forming the
mould
180
324
1105
3.1
Walking on the level, 5 km/h
200
360
1228
3.4
Forestry -cutting across the grain
with a
one-man power saw
205
369
1259
3.5
Section 3: Environmental
Measurements and Mechanisms
Activity
W/m2
W1)
Btu/hr1)
Met
Building industry - loading a
wheelbarrow with stones and
mortar
275
495
1688
4.7
Bicycling
Golf
Softball
290
522
1780
5.0
Agriculture - digging with a spade
(24 lifts/min.)
380
674
2333
6.5
Running 12 min/mile
Forestry - working with an axe
(weight 2 kg.
33 blows/min.)
500
900
3070
8.5
(Note: ACGIH identifies a metabolic rate of 300W for moderate work and 415W for heavy work)
Section 3: Environmental
Measurements and Mechanisms
• For NDMS Purposes:
– Light Work = (1 Mile walk under 15
minutes)
– Moderate Work = (Light pushing and
pulling) (e.g. 2 mile walk, under 30
minutes carrying a 25 lb. pack)
– Heavy Work = (Push/pull heavy loads)
(e.g. 3 mile walk under 45 minutes
carrying a 45 lb pack)
Section 3: Environmental
Measurements and Mechanisms
• Environmental Descriptors:
– Heat: Average kinetic energy of molecules in
an object, (typically squared for measurement
proportioned to the mean of kinetic energy)
– Humidity (Absolute): Water vapor in air
– Humidity (Relative): Absolute humidity
expressed as a percentage of the ability of air
to hold water at that temperature
– Humidity (Specific): Mass ratio of water vapor
content to the total content
Section 3: Environmental
Measurements and Mechanisms
• Temperature:
– Wet Bulb Temperature: Lowest temperature of an
object reached by the evaporation of water on the
object
– Dry Bulb Temperature: Air temperature shielded
from radiation and moisture (ambient
temperature)
– Black Bulb (Globe) Temperature: Mean radiant
temperature: Solar radiation
– WBGT: Composite temperature used to measure
effects of temperature, humidity, wind speed
(wind chill) and solar load on humans
Section 3: Environmental
Measurements and Mechanisms
• WBGT:
– Outdoors: = .7 Tw + 2 Tg + 1 Td
– Indoors: = .7 Tw + .3 Tg
Tw = Wet Bulb Temperature
Tg = Globe Temperature
Td = Dry Bulb Temperature
Section 3: Environmental
Measurements and Mechanisms
• Heat Index: (NWS,979): A combination of air
temperature (dry bulb), relative humidity,
and 9 constants/modifiers: (Body mass,
height, clothing, physical activity, thickness
of blood, sunlight, UV radiation exposure,
wind speed and physical activity)
(Note: Deviations from the constants result
in significantly different heat indices!)
Section 3: Environmental
Measurements and Mechanisms
Section 3: Environmental
Measurements and Mechanisms
• Psychrometer: (Wet/Dry Bulbs) provide rH
WBGT (Wet Bulb Temperature and Dry Bulb
Temperature)
(Note: Significant differences can be seen in
close geographic locations)
Section 3: Environmental
Measurements and Mechanisms
• We can measure/quantify heat stressors
in the field:
– Metabolic rate
– WBGT
– Heat index
Section 4: Pre-Event Preparatory
Activities
Section 4: Pre-Event Preparatory
Activities: Screening for
Vulnerable Workers
“The HARM”
and
“Acclimatization”
Section 4: Pre-Event Preparatory Activities:
Severe Weather-Based Heat Doctrine
• Conditions most likely to exacerbate Heat Stress
(consensus or evidence-base)
–
–
–
–
–
Body Mass Index (BMI) > 35
Absence of acclimation
Neurologic disorders (e.g., MS)
Endocrine disorders (e.g., thyroid)
Inherited disorders of muscle (e.g., Muscular dystrophy)
• Medications that affect metabolic rate, heat loss, or
cardiac activity (just about everything):
- Beta-blockers, vasoconstrictors, amphetamines (diet
meds), topical anesthetics (cocaine), laxatives,
antidepressants, antipsychotics, anticonvulsants,
diuretics
• “Very young” (< 15?) and “very old” (> 60?)
Section 4: Pre-Event Preparatory Activities:
Severe Weather-Based Heat Doctrine
• Common Conditions plausible to exacerbate Heat
Stress (reported or case-base)
– Dermatologic disorders / any skin condition affecting >10%
body surface (5%=hand)
– Medications that affect metabolic rate, heat dissipation,
cardiac activity:
- Beta-blockers, vasoconstrictors, amphetamines (diet
meds), topical anesthetics (cocaine), laxatives,
antidepressants, antipsychotics, anticonvulsants, diuretics
– Recent Immunizations (< 3 days)
– “Low” BMI (undefined, suggest BMI < 20)
– Heavy muscle-massed, balanced by likely conditioned
• Large meals (think swimming cramps after eating)
Section 4: Pre-Event Preparatory Activities:
Severe Weather-Based Heat Doctrine
• Positive modifiers
– Pre-acclimatized. Home environment similar to
deployed conditions.
– Enough exercise to break a sweat every day.
– Active life-style. Daily outdoor physical activity 20
hours per week or initialed heat-tolerance program >
1 week)
– Completion of a medical-sanctioned acclimation
period
• Absence of alcohol, caffeinated drinks, and heavy
meals (> 1 week?)
Section 4: Pre-Event Preparatory Activities:
Severe Weather-Based Heat Doctrine
• Negative modifiers
– Requirement for any daily medication that affects
heat gain or loss (most medications)
– Lack of a sustained physical activity program
– Personal physician’s warning
• Alcohol, caffeinated drinks, and heavy meals
current or recent (within 1 week?)
Section 4: Pre-Event Preparatory
Activities: Heat Clearance
Levels:
1. Voluntary self-screening
2. Medical oversight / review
3. Medical Physical exams
Section 4: Pre-Event Preparatory Activities:
Voluntary Self-Screening
• Develop a Job Hazard Analysis:
– Hazard Exposure Risk Assessment (HERA) is a two
page Physician-Safety Professional prepared
document given to each worker
– Hazards identified
– Vulnerable health issues identified – chronic
conditions, medications, conditioning / acclimation
• Distribute well in advance the Job Hazard Analysis
for worker self-screen on honor system. Options:
1. I’m perfect. No problems, so accepts assignment
2. Issues, begins exercise program for rapid acclimation
3. Issues, so self-disqualifies and does not go
Section 4: Pre-Event Preparatory Activities:
Voluntary Self-Screening
Distribute US Forest Service (USFS) Standards:
• Not evidence-based, but a credible standard
• Requires all job positions to be classified
(official, or self-identified)
– Light – administrative, non-field supervisors,
HQ VIP visitors
– Moderate – most deployed ASPR staff
– Arduous – heavy manual labor (fire-jumpers)
Section 4: Pre-Event Preparatory Activities:
Voluntary Self-Screening
(or can be a monitored test)
US Forest Service Standards:
• Light – Walk Test – walk 1 mile under 15
minutes and be capable of duty unimpaired
• Moderate – Field Test – walk 2 mile under 30
minutes with a 25 pound backpack and be
capable of unimpaired duty
• Arduous – Pack Test – walk 3 miles under 45
minutes with a 45 pound sack and be fit for
duty
Section 4: Pre-Event Preparatory Activities:
Medical Oversight/Review
• Distribute Responder Health Statement (RHS):
– Paper-version successfully used by California DMATs
for over a decade.
• Online version beta-tested, await execution
• Online physician review and Tier-level assigned:
– Tier 1 – no limitations to any plausible location:
• Can be off-meds for period (14 days) w/o harm
– Tier 2 – limits possible based on location:
• Plausible harm if off meds x 2 weeks
– Tier 3 – do not deploy; pregnancy, post-/pre-op:
• Can self-declare without explanation
Section 4: Pre-Event Preparatory Activities:
Medical Oversight
US Forest Service Standards for Tier 1 and 2:
- Co-worker validated self-reported
- Company-monitored group, EMS on standby
• Light – Walk Test – walk 1 mile under 15 minutes
and be capable of duty unimpaired
• Moderate – Field Test – walk 2 mile under 30
minutes with a 25 pound backpack and be
capable of unimpaired duty
• Arduous – Pack Test – walk 3 miles under 45
minutes with a 45 pound sack and be fit for duty
Section 4: Pre-Event Preparatory Activities:
Medical Oversight/Review
U.S. Peace Corps Accommodation List*
Arrhythmia
Epilepsy
Asthma
Diabetes, T-1
Diabetes, T-2
Gluten Intolerance
Intrauterine
Device (IUD)
Lactose
Intolerance
Migraines
Pacemaker
Disorderly
Conduct
Dermatologist
ADD/ADHD
Blindness
Bipolar
glaucoma
Polycystic Ovarian
Bee Allergy
Syndrome
Mammogram Req Mental Health
Seafood Allergy Tattoos
Age (Seniors)
Auditory
Ulcerative Colitis
*Possible
Section 4: Pre-Event Preparatory Activities:
Peace Corps Unable to Accommodate
Asthma-severe
Steroid use < 2 yr
COPD / Emphysema
Cancer (recent
treatment)
Cardiac Arrhythmias
– symptomatic
Cystic Fibrosis
Complex medical
health conditions
Complex mental
health conditions
Conditions-requiring Conditions-requiring Connective Tissue
blood thinner
steroids
Disorders
Coronary Artery
Disease
Celiac Sprue
w/i 6 months
Crohn’s Disease
Esophageal Varices
Diabetes - with any
complications
Diverticulitis
Glomerulonephritis- Heart Conditionschronic
chronic
Hematological
Hemophilia
Disorder – chronic
Inflammatory Bowel Kidney Stones –
Disease
recurrent
Hepatitis – chronic
Iritis – chronic
Endocarditis
Heart Failure
Immuno-suppressed
HIV / AIDS
Section 4: Pre-Event Preparatory Activities:
Peace Corps Unable to Accommodate
Addison’s Disease
Allergic Reactionlife threatening
Lou Gehrig’s
Disease (ALS)
Aneurysminoperable
Major Depression –
Multiple Sclerosis –
Muscular Dystrophy
Myasthenia Gravis
recurrent
no exacerbation x 3y
Narcolepsy – poorly Obstructive Sleep
controlled
Apnea - +/- CPAP
Pancreatitis –
chronic
Pyelonephritis –
chronic
Schizophrenia
Optic Neuritis –
recurrent
Parkinson’s Disease Psychosis
Osteoporosis w/ high
risk for stress fractur
Hosp Psychiatric
within past 1 year
Reiter’s Syndrome –
Rheumatoid Arthritis Sarcoidosis
chronic
Thrombophlebitis –
recurrent
Ulcerative Colitis
Uveitis – chronic
Major Depression –
Ventricular Shunt for
Muscular Dystrophy
Myasthenia Gravis
recurrent
hydrocephalus
Section 4: Pre-Event Preparatory Activities:
Peace Corps Experience
• Not evidence-based, but a credible standard
• Published annually, available online:
– Health of the Volunteer (non-injuries)
– Safety of the Volunteer (injuries)
Section 4: Pre-Event Preparatory Activities:
Physical Exams
• High expense, degree of complexity, and liability
• Consider for remote long-term, overseas
assignments
• Little is found on occupational physical exam that
is not identified on valid health statement (RHS) :
– If they lie on the health statement, little is picked up
on routine physical
• Weight, Blood Pressure, Blood Sugar can be
obtained by paramedic screening at lower cost:
– baseline prior to work environment
– Find egregiously out of control conditions
Section 4: Pre-Event Preparatory Activities:
Guidance and Instructions
1. Workers should avoid high-risk duty if their BMI > 35,
pregnancy beyond 1st trimester (first 3 months), have < 10
hours per week of outdoor activity, or have had repeated
difficulty with hot, humid, or sunny conditions (more than
one).
2. Workers with one or more of the above conditions (#1) need
close observation, limited duties, enforced work-rest cycles,
and ideally are reviewed by Healthcare Providers (HCP) prior
to working in high-risk environments.
3. In general Safety Professionals can allow workers with heat
Risk Factors into high risk heat environments if the worker
has at least one Positive Modifier for every Risk Factor. If
any doubt, Healthcare Providers (HCP) can clear most who
have Common Conditions and Positive Modifiers.
Section 4: Pre-Event Preparatory Activities:
General Guidance and Instructions
4. Safety Professionals should refer to an Occupational HCP
prior to allowing anyone with one of the above evidence- or
consensus-based Conditions (1.a-g), or Common Conditions
(2.a-e) with one or more Negative Modifiers
5. Workers with Common Conditions and both Positive and
Negative Modifiers will need to be reviewed based on other
criteria such as planned activity (supervisory versus
strenuous labor), environment (HVAC), and access to
definitive care.
6. All at-risk workers should avoid caffeinated drinks, heavy
meals, and adhere to strict enforcement of “dry”
deployments.
Section 5: Self Application of
Protective Measures and Heat Syndromes
Section 5: Self Application of
Protective Measures Health
Monitoring and Heat Syndromes
Section 5: Self Application of
Protective Measures and Heat Syndromes:
Health Monitoring at the Event
• If available, review Tier status or equivalent
• With Tier stratification, concentrate on
acclimation for minimum of 2-6 weeks
• Without Tier, eye-ball screen:
– BMI > 35 high-risk
– BMI 25-35 can be a marker for poor conditioning
Section 5: Self Application of
Protective Measures and Heat Syndromes:
Self Monitoring
• Operational Medicine and civilian Safety
Professionals have found resting tachycardia to
be an invaluable screening tool (Pulse > 110
requires rehab).
• Monitoring pulse up to hourly proved successful
for the ASPR-supervised Deepwater Horizon Oil
Spill safety program involving 48,000 workers,
and repeated during field exercises conducted
with temperatures exceeding 100 F.
Section 5: Self Application of
Protective Measures and Heat Syndromes:
Calculate Work-Site Medical Requirements
Activity
Office based
Construction / Demobilization / Field work
On Scene response either on or off shore
Number of personnel
Fewer than 20
20 to 99
100 to 499
500 to 1999
2000+
Score
1
3
4
Score
1
2
3
4
5
Section 5: Self Application of
Protective Measures and Heat Syndromes:
Work-Site Medical Requirements
Time to a “definitive care center”
Less than 30 minutes
Less than 60 , greater than 30 minutes
1 to 6 hours
More than 6 hours
Add one number from each category for
the total score.
Recommended medical staffing
Level 1 - First Aid
Level 2 - Pre-hospital Paramedic Care
Level 3 – Emergency Provider-based Care
Score
1
2
3
4
5
6 to 9
>10+
Emergency provider = someone approved for hospital-based interventions
such as ATLS, heart resuscitation, stabilization and transport. Typically a physician,
but can be a PA, NP, or Special Forces medic depending on local laws and customs
Section 5: Self Application of
Protective Measures and Heat Syndromes:
Heat Injury Syndromes
•
•
•
•
Heat rash – itchy, sweat gland dysfunction
Heat cramps – assumed salt imbalance
Heat syncope – multiple possibilities
Heat Exhaustion – lethargic, appropriate,
and <100°F
• Heat Stroke – altered mental status,
confusion, irrational, >102°F or 40°C:
– Classic – hot, dry, mental health or dependent
– Exertion – hot, sweaty, athletic, pseudo-athletic
Section 5: Self Application of
Protective Measures and Heat Syndromes:
Treatment is Not Rocket Science but can be Life Saving
• Rash – ice, hydrocortisone cream
• Cramps – rest, hydration, +/- e-lyte drinks
• Syncope – hydrate, cool rest, small meals, no
alcohol
• Exhaustion – same, rest x 1-2 days
• Stroke – ice, rapid cool-down, cautious IV
hydration, hospitalization:
– IV = ER transport / evacuation at all road races
Section 6: Work Restrictions
Section 6: Work Restrictions
Section 6: Work Restrictions
• Assist Work Protocols:
– Reduction of heat stresses on deployed
personnel where action limits have been
exceeded
(Note: When assist work protocols are provided
onsite, medical screening and a trained workforce
are assumed)
Section 6: Work Restrictions
• Assist Work Protocols (Reduction of Heat
Stress):
– Adjustment of Work Schedules:
• Schedule Changes
• Work/Rest Regimen
– Provision of Shade/Cooling Shelters:
• 50% staff holding capacity
• Information supplied by Safety Officers
– Provision of 1 liter of potable fluids per work hour,
with 150 ounces minimum per worker per day
provided
– Provision of cooling devices in special situations
(field showers, misting devices, cooling vests)
Section 6: Work Restrictions
• Work Acclimatization: 2 hours of work
activities per day, performed 5 of 7 days
(10 of last 14 days prior to work),
performing work similar to that to be
performed at temperatures.
(Note: Noticeable loss of acclimatization
occurs after 4 days)
Section 6: Work Restrictions:
Environments
Section 6: Work Restrictions:
Personal
• Workforce Monitoring:
– Physiological Monitoring:
• Pulse Rates
• Needs for other types of monitoring???
Section 6: Work Restrictions:
Physiological Monitoring
Section 6: Work Restrictions
• Restrict (Stop) Work Protocols:
– Pulse > 110, with restriction until resting pulse
returns, reduction in future work cycles
– Request of responder for shade or cooling (5
minute mandatory rest)
– Heat illness identification
– Cancellation (rescheduling) of work
Section 6: Work Restrictions
• State of Washington: Standards for Heat
Illness Prevention (Effective May 1 –
September 30, annually):
– 89oF for workers in all clothing*
– 77oF for workers in double layer woven
clothing*
– 52oF for non-breathable (vapor barrier)
clothing*
*Outdoors, for 15 minutes in any 60 minute
period
Section 6: Work Restrictions
– Required written Heat Exposure Safety
Program
– Annual Supervisor and Worker Training
– Monitoring personnel work and medical
treatment required for workers who show
signs or symptoms of heat illnesses
Section 6: Work Restrictions
• CAL-OSHA: Heat Illness Prevention
Requirements:
– Shielded dry bulb temperature triggers
– Drinking water (1 qt/employee/hr)
– Shade:
• 25% adjacent areas at 85oF
• or if requested by employee
• Access to shade area permitted at all times/5
minute minimum
• Equivalent means permitted (except agriculture)
Section 6: Work Restrictions
– High Heat Procedures (95oF):
• Communication capabilities
• Observation of employees/encourage hydration
• Supervision of non-acclimatized employees for 14 days,
(unless employee has been performing similarly for 10
of the last 30 days, 4 hours/day
– Required Employee and Supervisor Training
– Written Protocol for these Illness Prevention
Requirements
(in place since 2005 (emergency standard), updated in 2006 and 2010)
Section 7: Work Regimen, Heat
Section 7: Work Regimen, Heat
Section 7: Work Regimen, Heat
Section 7: Work Regimen, Heat
Section 8: “Lets Exercise”
Section 8: “Lets Exercise”
Section 8: “Lets Exercise”
Section 8: “Lets Exercise”
Exercise #1:
• Using the HHS Model (and note any deviations/with
rationale) identify your program for the protection of a
100 member Disaster Response Work Team – Identify
your actions within the 5 areas of:
1)
2)
3)
4)
5)
Medical Screening and Workforce Training
Site Environmental Monitoring
Workforce Monitoring
Assist Work Protocols
Restrict Work Protocols
• Identify any potential costs or barriers to your program
implementation – What does your heat safety program
look like (Safety Officer/Medical
Officer/Equipment/Controls)
??