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HETA 99-0062-2804Newark Fire Department

Newark, New Jersey

Kevin C. Roegner, M.P.H.Joel E. McCullough, M.D., M.P.H., M.S.

This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved. Additional HHE reports are available at http://www.cdc.gov/niosh/hhe/reports



This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved.


applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved. Additional HHE reports are available at http://www.cdc.gov/niosh/hhe/reports

http://www.cdc.gov/niosh/hhe/reports



ii

PREFACEThe Hazard Evaluations and Technical Assistance Branch (HETAB) of the National Institute for OccupationalSafety and Health (NIOSH) conducts field investigations of possible health hazards in the workplace. Theseinvestigations are conducted under the authority of Section 20(a)(6) of the Occupational Safety and Health(OSHA) Act of 1970, 29 U.S.C. 669(a)(6) which authorizes the Secretary of Health and Human Services,following a written request from any employer or authorized representative of employees, to determinewhether any substance normally found in the place of employment has potentially toxic effects in suchconcentrations as used or found.

HETAB also provides, upon request, technical and consultative assistance to Federal, State, and localagencies; labor; industry; and other groups or individuals to control occupational health hazards and to preventrelated trauma and disease. Mention of company names or products does not constitute endorsement byNIOSH.

ACKNOWLEDGMENTS AND AVAILABILITY OF REPORTThis report was prepared by Kevin Roegner and Joel McCullough of HETAB, Division of Surveillance,Hazard Evaluations and Field Studies (DSHEFS). Field assistance was provided by Greg Kinnes, DSHEFS.Desktop publishing was performed by Denise Ratliff. Review and preparation for printing were performedby Penny Arthur.

Copies of this report have been sent to employee and management representatives at the Newark FireDepartment; the International Association of Fire Fighters (IAFF), Department of Occupational Health andSafety; IAFF Local 1860; and the New Jersey Public Employees Occupational Health and Safety Program.This report is not copyrighted and may be freely reproduced. Single copies of this report will be availablefor a period of three years from the date of this report. To expedite your request, include a self-addressedmailing label along with your written request to:

NIOSH Publications Office4676 Columbia ParkwayCincinnati, Ohio 45226

800-356-4674

After this time, copies may be purchased from the National Technical Information Service (NTIS) at5825 Port Royal Road, Springfield, Virginia 22161. Information regarding the NTIS stock number may beobtained from the NIOSH Publications Office at the Cincinnati address.

For the purpose of informing affected employees, copies of this report shall be postedby the employer in a prominent place accessible to the employees for a period of 30calendar days.

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Highlights of the NIOSH Health Hazard Evaluation

Evaluation of American Ref-fuel Incident

In December of 1998, 37 Newark Fire Department (NFD) fire fighters were exposed to irritant gasses duringa response to a fire at American Ref-fuel (AR). Following the incident, the IAFF asked NIOSH to investigatethe events leading to fire fighters’ exposures, and to review the medical care received by the fire fighters afterthe incident.

What NIOSH Did

# Interviewed fire fighters who responded to ARabout the response and their symptoms.

# Looked at medical records, radiocommunication logs, fire fighter incidentreports, and NFD procedures.

# Went to AR to see the area where the incidentoccurred.

What NIOSH Found

# Most fire fighters at the scene had some degreeof irritation to their eyes, throat, or lungs.

# Fire fighters were likely exposed to chlorine gasand nitrogen trichloride, and possibly very lowlevels of phosgene.

# Fire fighters were initially provided with wronginformation about the contents of the fire.

# The hazardous materials (HAZMAT) companywas committed to the incident in fire mode, sono HAZMAT response could be made.

# Not using self-contained breathing apparatus(SCBA) all the time, poor communications, andpoor building ventilation made exposuresworse.

# The treating physicians in the hospitalemergency rooms were aware of the fire fighterchemical exposure, but did not know thespecific substances.

# The number of medical tests varied amonghospitals, but this difference did not appear tocause worse health outcomes.

What the Newark Fire DepartmentCan Do

# Better enforce SCBA use at the scene of a fire.

# Minimize gaps in HAZMAT coverage.

# Improve communication with local hospitals.

# Better educate fire fighters on decontaminationprocedures.

# Better integrate surveillance medical recordswith acute occupational health services.

What the Newark Fire DepartmentFire Fighters Can Do

# Use better judgement when removing SCBA atthe fire scene.

# Follow two-in, two-out rule.

CDCCENTERS FOR DISEASE CONTROL

AND PREVENTION

What To Do For More Information:We encourage you to read the full report. If you

would like a copy, either ask your health andsafety representative to make you a copy or call

1-513/841-4252 and ask for HETA Report # 99-0062-2804

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Health Hazard Evaluation Report 99-0062-2804Newark Fire Department

Newark, New JerseyFebruary 2000

Kevin C. Roegner, M.P.H.Joel E. McCullough, M.D., M.P.H., M.S.

SUMMARYOn December 22, 1998, the National Institute for Occupational Safety and Health (NIOSH) received a requestfor a health hazard evaluation (HHE) from the International Association of Fire Fighters (IAFF) on behalf offire fighters from the Newark Fire Department (NFD) to assess the incident response procedures followedduring a fire in a refuse waste-to-energy facility (American Ref-fuel) on December 17,1998, in Newark, NewJersey. The IAFF indicated that several of the fire fighters responding to the incident were subsequentlyhospitalized due to smoke and chlorine gas inhalation.

NIOSH investigators conducted a site visit to the NFD on April 12-13, 1999, and again on June 24, 1999.NIOSH personnel conducted private interviews with several NFD fire fighters who responded to the incidentand reviewed several incident-related records provided by the NFD, including the department’s standardoperating procedures (SOPs) and medical records. Self-administered questionnaires were distributed to firefighters who were not present on the days of the NIOSH investigation. In addition to the medical interviewsand questionnaires, medical records were reviewed from five hospitals where the fire fighters receivedmedical care, and from the occupational medicine provider for the NFD. NIOSH investigators also visitedAmerican Ref-fuel.

On December 17, 1998, the NFD received a report of a fire in the refuse pit of American Ref-fuel. The firewas declared a hazardous materials incident as information became known that the fire had involved chlorinebleach cleaner which, according to the product’s material safety data sheet, would liberate chlorine andphosgene as decomposition products. Fire fighters used the plant’s showering facilities for decontaminationpurposes before all of the 37 responding fire fighters were sent to area hospitals for evaluation. The medical survey showed that most fire fighters at the scene experienced some degree of acute upperrespiratory tract irritation, and many experienced lower respiratory tract irritation as well. Fifteen hadpersistent symptoms at 24 hours, and 13 had symptoms at the time of the NIOSH investigation. Based on thecombustion of chlorine-containing cleaner, the fire fighters’ exposures probably consisted primarily of irritantgases, such as chlorine and nitrogen trichloride.

Medical records revealed that the treating physicians were aware that the fire fighters were exposed tochemicals at a fire and were concerned about the inhalation of toxic fumes and smoke. However, neither firefighters nor treating physicians knew what specific toxins were present. The symptoms of the fire fighterswere consistent in the different hospitals, however the diagnostic tests performed differed. The university-based hospital performed the most diagnostic tests on the fire fighters. The other hospitals performed fewertests, but this did not appear to result in a greater rate of adverse health outcomes.

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The elements leading to fire fighter exposures at the waste-to-energy plant on December 17, 1998, arecomplex and multi-factorial in nature. Clearly, fire fighters did encounter exposures to irritant gasses atthe scene. The NFD approached the incident in fire mode, when in fact, a hazardous materials(HAZMAT) response approach would have been more appropriate.

Most fire fighters suffered irritant symptoms that were the result of exposures to irritant gases atAmerican Ref-fuel. For those fire fighters who had recovered at the time of the NIOSH investigation ordid not develop symptoms, it is unlikely that this exposure will result in further health problems. Thosewho developed more significant respiratory symptoms were being evaluated by health care providers.Several recommendations are offered for improving fire fighter health and safety, includingrecommendations for better integration of fire fighter medical surveillance information with acute careoccupational medicine providers, better personal protective equipment (PPE) usage, and filling gaps inHAZMAT coverage.

Keywords: SIC 9224 (Fire Protection), fire fighters, firefighters, incident command system, ICS,self–contained breathing apparatus, SCBA, hazardous materials

TABLE OF CONTENTS

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii

Acknowledgments and Availability of Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii

Highlights of the NIOSH Health Hazard Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Evaluation Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Smoke Inhalation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Chlorine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Phosgene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Nitrogen Trichloride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Incident Command System (ICS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Findings and Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Preplanning and Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Incident Command System (ICS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Hazardous Materials Response Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Safety Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Respiratory and Other Personal Protective Equipment (PPE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Medical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Glossary of Medical Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Health Hazard Evaluation Report No. 99-0062-2804 Page 1

INTRODUCTIONOn December 22, 1998, the National Institute forOccupational Safety and Health (NIOSH) receiveda request for a health hazard evaluation (HHE)from the International Association of Fire Fighters(IAFF). This HHE request was submitted onbehalf of fire fighters from the City of NewarkFire Department (NFD) to assess the incidentresponse procedures used during a fire in a refusewaste-to-energy facility (American Ref-fuel) onDecember 17, 1998, in Newark, New Jersey. TheIAFF reported that 37 fire fighters responded tothe incident, and that several of the responderswere subsequently hospitalized due to smoke andchlorine gas inhalation. The IAFF requested thatNIOSH review the response procedures usedduring this incident, investigate the potentialchemical exposures that may have occurred, anddetermine the health effects that fire fighters mayexperience from the exposure.

In response to this request, NIOSH investigatorsconducted a site visit to the NFD on April 12-13,and again on June 24, 1999. On April 12, anopening conference was held to discuss theincident and the nature of the request withrepresentatives of the NFD and IAFF Local 1860.During the remainder of the site visit, privateinterviews were held with NFD fire fighters andcommand staff who responded to the incident, andcopies of several NFD standard operatingprocedures (SOPs) and other pertinent recordswere obtained for review.

This report summarizes response procedures asthey affected the health and safety of the firefighters, including the Incident Command System(ICS) and safety management. This report alsodiscusses decontamination of fire fighters, assessesthe level of care received by fire fighters at areahospitals, and provides recommendations.

BACKGROUNDThe NFD employs 735 uniformed fire fighters, andserves a geographic area of 23 square miles. Thedepartment operates four shifts (tours), and isdivided into four battalions. Each tour works anaverage of 42-hours per week on a schedule oftwo, 10-hour shifts on duty followed by a day off,then two, 14-hour shifts, followed by three daysoff. Shift changes occur at 0800 hours (hrs) and1800 hrs. In 1992, the NFD initiated a policy ofrotating four apparatus companies (one from eachbattalion) out of service on each tour. Truck 8 wasretired from service in 1997, and the number ofcompanies rotating out of service was reduced tothree. In response to a working structural fire, theNFD will dispatch four engines, two trucks, aBattalion Chief (BC), a Deputy Chief (DC), aSafety Officer (SO), a rescue unit, and a rapidintervention team to the fire scene.

On December 17, 1998, the NFD responded to afire alarm at the eleven-story, American Ref-fuelplant located in an industrial area outside ofdowntown Newark. The facility was constructedin 1990, and is segmented into several areas, eachdesigned to play a role in converting non-hazardous waste into energy (Figure 1). At thewest end of the facility is a large, open tippinghall, where trucks enter to deposit loads into therefuse pit. The refuse pit measures 280 feet (ft.)across, by 90 ft. front to back, by 45 ft. deep. Theopen space above the refuse pit spans severalstories and is occupied by two 20-ton grapplingcranes. The cranes, which are remotely operatedfrom each of two control rooms that overlook thepit, homogenize the waste and move it from the pitand drop the waste into the waste charging hopper(7th story). Once in the hopper, refuse is fed intothe furnace. Heat generated by the combustingsolid waste produces steam in a waterwall boiler,the pressure from which is used to drive a turbinegenerator. The plant is licensed to accept non-hazardous waste.

Health Hazard Evaluation Report No. 99-0062-2804

At 2008 hrs, December 17, 1998, the NFDreceived a 9-1-1 telephone call reporting a fire inthe refuse pit of the waste-to-energy facility. Afull assignment, consisting of four enginecompanies, two truck companies, a rescuecompany, a BC, a DC, and an SO was dispatchedto the scene. Engine Company 16 (EC16) was thefirst to arrive at 2012 hrs. In fire fighter interviewsit was reported that plant employees indicated toarriving fire fighters that there were two fires: afire on the seventh floor and a fire in the refuse pit.Truck one, the company which is also thehazardous materials (HAZMAT) unit company,was the second due truck for the response, and itarrived on site early in the incident. Severalcompanies ascended the stairs and elevators tosearch for the reported fire on the seventh floor.They were, however, unable to locate a fire on theseventh floor. The BC arrived at the scene at 2017hrs. The DC arrived at the scene at 2025 hrs, atwhich time he established a command post on thefirst floor. During most of the incident, it was un-clear what was burning in the pit. When the BCand DC inquired about what was burning, plantemployees indicated that it was garbage. Severalfire fighters reported that the incident wascomplicated by an intermittent heavy smokecondition, which limited visibility into the refusepit and across the upper floors. Fire fightersindicated that the smoke appeared white toyellowish-green, and would ebb and bank with theintermittent performance of ceiling exhaust fanslocated above the pit. The fire was declared undercontrol at 2238 hrs, at which time it was declareda hazardous materials incident as informationbecame known that the fire had involved chlorine-containing cleaner. The cleaner had been sent tothe facility for disposal. The product’s materialsafety data sheet, which reportedly was madeavailable late into the incident, indicated that thecleaner would liberate chlorine and phosgene asdecomposition products. Fire fighters used theplant’s showering facilities for decontaminationpurposes before all of the 37 responding firefighters were sent to area hospitals for evaluation.

METHODSNIOSH investigators visited the NFD on twooccasions, and the waste-to-energy plant to obtaininformation. During the first visit, NIOSH investi-gators held an opening conference with the localIAFF representative and representatives of theNFD. This meeting was arranged to discuss thestructure and staffing of the NFD, review theincident chronology and the procedures usedduring the response, and review actions of the firedepartment subsequent to fire fighters raisingconcerns about possible exposures to chlorine andphosgene. The NIOSH investigators spent addi-tional time during the two days interviewing firefighters and command personnel who responded tothe incident and reviewing incident-related recordsprovided by the NFD. These records included theincident chronology report, transcripts of radiocommunications during the incident, SOPsfollowed by the NFD, and various other recordspertaining to this incident. The NIOSHinvestigators also requested copies of thecommand reports submitted by each apparatuscaptain and others who assumed commandfunctions to the NFD. During the second visit,NIOSH investigators inventoried the hazardousmaterials response unit and spoke with the on-dutycaptain of that unit. This meeting was followed bya visit to American Ref-fuel where NIOSHinvestigators met with the plant manager andviewed the area where the incident occurred.Telephone interviews were conducted with NFDpersonnel not available during our site visit. Theincident response reports, transcripts from NIOSHinterviews with fire fighters, and other pertinentinformation were used to reconstruct events andprocedures used during the incident.

On April 12-13, confidential interviews wereconducted with fire fighters who were present atthe scene of the incident. The fire fighters whoresponded to the incident and were at work on thedays of the NIOSH investigation were interviewedby NIOSH investigators. Also, self-administeredquestionnaires (accompanied with NIOSH-


addressed and postage-paid envelopes) weredistributed by a union representative to firefighters who were not present on the days of theNIOSH investigation. The fire fighters were askedabout their job activities at the scene, their use ofpersonal protective equipment (PPE),decontamination procedures, the amount of time atthe scene spent with and without PPE, healthsymptoms that began at the scene, persistent healthsymptoms, and the medical care they received. Inaddition to the medical interviews andquestionnaires, medical records from the fivehospitals where the fire fighters received medicalcare, and from the occupational medicine providerfor the department, were reviewed.

EVALUATION CRITERIAFire fighters work in varied and complex environ-ments that increase their risk of on–the–job deathand injury. Every day, fire fighters in the UnitedStates are injured in the line of duty.1 Accordingto the IAFF, 45 professional fire fighters died inthe line of duty in 1998, and an additional 39professional fire fighters died as a result ofoccupational diseases directly related to firefighting.2 When compared to data compiled forprivate industry by the Bureau of Labor Statistics(BLS), the incidence of fire fighter job-relatedinjury is nearly 4.5 times that of workers in privateindustry; 32.4 percent (%) of fire fighters wereinjured in 1998 compared to only 7.1% of privateindustry workers.2 In terms of severity, fire fighterinjuries caused 4,342 lost work hours per 100workers.2 Fire fighters face many health hazards,including: inhalation of a wide variety of toxiccombustion products; chemical exposures bydirect skin and eye contact; physical hazards,including heat, cold, noise, and falling objects; andexposure to carcinogenic chemicals or combustionproducts. The hazardous exposures most relevantto the American Ref-fuel incident are discussed infurther detail below.

Smoke InhalationSmoke is the volatilized product of combustion. Itvaries according to temperature, oxygen availa-bility, and composition of the material beingburned.3 The inhalational toxins in smoke arechemicals in the form of gases, vapors, aerosols,particulate, and fumes.4 Upon combustion,synthetic and natural polymers may producerespiratory irritants (nitrogen and sulfur oxides,aldehydes, halogenated compounds, and organicacids), simple asphyxiants (carbon dioxide,oxygen-deficient atmospheres), and cellularasphyxiants (carbon monoxide, hydrogencyanide).5

Each component of smoke may contribute torespiratory damage in different ways. Althoughsmoke inhalation is often referred to as apulmonary burn, true thermal injury to the lowerrespiratory tract appears to be unusual. The upperairway is very effective in protecting against injuryby heat below the tongue (the trachea andbronchial tubes). Even in the absence ofrecognizable symptoms or disease, fire fightersoften have subclinical effects that may persist forweeks or months, as evidenced by both restrictiveand obstructive lung changes on spirometrytesting.6

The irritant gases and asphyxiants generatedduring combustion account for virtually all of theclinically recognized respiratory effects of smokeinhalation. Most of the irritant gases that causedirect pulmonary injury are highly reactive acidsor bases which, upon inhalation and hydrationwithin the lung, result in the denaturation oroxidation of cellular components.5, 6 Highly water-soluble agents, such as ammonia, sulfur dioxide,hydrogen fluoride, or acrolein, cause injury to theproximal airway and mucosa, and their noxiousnature is more likely to be recognized by exposedpersons. By contrast, agents with intermediate orlower water solubilities (e.g., phosgene or nitrogenoxides) are more likely to result in subtlepresentations, with delayed onset of respiratorydamage. In this instance, fewer warning symptoms


may result in prolonged exposures and damage todistal airways and alveolar membranes.5, 6

The vast majority of inhalation victims (90% to95%) acutely complain of shortness of breath,cough, or hoarseness. Symptoms such as cough,sore throat, or hoarseness suggest upper airwayinjury and the potential for life-threatening airwayobstruction. Shortness of breath and wheezingsuggest lower respiratory tract damage. Headache,nausea, vomiting, dizziness, confusion, chest pain,palpitations, and loss of consciousness maysuggest systemic poisoning or simple asphyxianteffects. The age of the victim and past medicalhistory are important risk factors for thedevelopment of inhalation injury. Those withasthma or chronic respiratory diseases may bemore susceptible to the effects of irritant gasinhalation.3

All victims of smoke inhalation should begintreatment with supplemental oxygen, which shouldbe adjusted based on arterial blood gases andclinical history. The observation period forasymptomatic patients without significant riskfactors for chronic obstructive pulmonary diseaseor coronary artery disease is 4 to 6 hours. Thosewho remain asymptomatic during the observationperiod can be discharged from the health carefacility with appropriate follow-up instructions.7

If initial clinical findings are minimal, but there isa history of smoke inhalation, arterial blood gases(ABGs) should be obtained. ABGs, which usuallyinclude carboxyhemoglobin levels, are an essentialearly part of nearly every evaluation of a firefighter with smoke inhalation.8 Although pulseoximetry is a convenient way to continuouslymonitor oxygenation in patients, it is unreliable orfalsely normal in patients who haved y s h e m o g l o b i n e m i a s ( e . g . ,carboxyhemoglobinemia or methemoglobinemia)because it measures only oxygen dissolved in theblood and not the status of tissue oxygenation. Inpatients who have altered hemoglobin, the pulseoximetry does not reflect the impaired oxygencarrying or delivery capacity of the red cells.

Pulse oximetry does not distinguish betweencarboxyhemoglobin (COHb) and oxyhemoglobin(O2Hb). In these situations, a Co-oximeter shouldbe used to measure specific levels of hemoglobinsthat are unable to transport oxygen efficiently.9

A thorough eye exam in the emergency departmentis indicated for those suspected of having smokeinhalation injury or exposure to corrosivesubstances. Eyes contaminated by smoke,aerosols, and particulates should be treatedsimilarly to splash injuries and liberally irrigatedwith plain water or normal saline. A thorough eyeexam should be performed following irrigation.Ophthalmologic consultation is indicated in thosepresenting with more than minor complaints orphysical findings.8

ChlorineChlorine is a yellow-green gas with a sharp orpungent odor at room temperature. Chorine isonly slightly soluble in water, but on contact withmoisture it forms hypochlorous acid (HClO) andhydrochloric acid (HCl). The unstable HClOreadily decomposes, forming oxygen-free radicals.Because of these reactions, water substantiallyenhances chlorine’s oxidizing and corrosiveeffects.10

Chlorine’s odor and irritant properties generallyprovide adequate warning of hazardous concen-trations. However, prolonged, low-level exposurescan lead to olfactory fatigue and tolerance ofchlorine’s irritant effects. Mucous membraneirritation may occur at 0.2 to 16 parts per million(ppm); eye irritation occurs at 7 to 8 ppm, throatirritation at 15 ppm, and cough at 30 ppm.11

Inhalation of high concentrations of the gas causesnecrosis of the lining of the trachea and bronchi aswell as pulmonary edema, emphysema, anddamage to the pulmonary blood vessels. Exposureto 500 ppm can be lethal over 30 minutes, while1000 ppm can be lethal within a few minutes.12

The severity of the damage to the respiratory tractis determined by the concentration and duration of


exposure. With high exposures, laryngeal edemawith signs of obstruction of the breathingpassages, acute tracheobronchitis, and chemicalpneumonitis have been described. Followingacute exposure to chlorine gas, both obstructiveand restrictive lung disease may occur.11 Moderateto severe exposure often results in residualpulmonary dysfunction, most notablyhyperreactive airways and low residual volumes.The pulmonary function usually returns towardbaseline within 7 to 14 days. Although completerecovery generally occurs, symptoms andprolonged pulmonary impairment may persist,especially after massive chlorine exposures.13,14

Reactive airways dysfunction syndrome (RADS)may occur. Chronic exposure may cause moderatereduction in pulmonary function and corrosion ofthe teeth.14

Chlorine may irritate the skin and can causeburning pain, inflammation, and blisters. Directcontact with liquid chlorine or concentrated vaporcauses severe chemical burns. Low concentrationsin air can cause burning discomfort, spasmodicblinking or involuntary closing of the eyelids,redness and tearing of the eyes. Corneal burnsmay occur at high concentrations.10, 15

Exposure to elevated levels of chlorine should beterminated as soon as possible by removal to freshair. The skin, eyes, and mouth should be washedwith large amounts of water.15 A 15- to 20-minutewash may be necessary. If irritation, pain, swell-ing, or tearing persists, medical care should besought as soon as possible. Contaminated clothingshould be removed and isolated. Contact lensesshould be removed to avoid prolonged chemicalcontact with the eyes.12

PhosgenePhosgene is a colorless gas with an odor similar tomusty hay. It may be formed by the “cracking” ofchlorinated hydrocarbon molecules at high

temperature. Phosgene may be a decompositionproduct of other chlorinated chemicals. Phosgenereacts with moisture and slowly forms HCL andcarbon dioxide.16

Inhalation is the major route of phosgeneexposure. The onset of severe respiratory distressmay be delayed for up to 72 hours depending onthe concentration and duration of exposure.Olfactory fatigue may occur.17 The low irritantproperties of phosgene are not sufficient to warnindividuals of toxic concentrations. This allowsdeep inspiration of high concentrations, causingHCl to form in the lower respiratory tract.18 HClcan damage surface cells and cause cell death inthe bronchi and bronchioles. This causescongestion and pulmonary edema, which may bequickly fatal. Direct toxicity to the cells leads toan increase in capillary permeability, resulting inlarge shifts of body fluid and decreasing plasmavolume. Early symptoms of overexposure includechest constriction, painful breathing, and bloodysputum. Respiratory and circulatory failure are thecommon clinical findings in cases of phosgenepoisoning that result in death.16, 17

If the patient survives the initial 48 hours afterexposure, recovery is likely. Sensitivity to irritantsmay persist, resulting in bronchospasm andchronic inflammation of the bronchi. Lung tissuedestruction and scarring may lead to chronicdilation of the bronchi and increased susceptibilityto infection (bronchiectasis). Also, pulmonaryfibrosis and emphysema may develop after chronicexposure.18

Phosgene may also damage the skin and eyes.When phosgene gas contacts moist or wet skin, itmay cause irritation and erythema. High air con-centrations can also cause corneal inflammationand cloudy vision. Eye damage beyond the initialirritation is uncommon in vapor exposure.16, 17

Treatment measures would include moving thepatient to fresh air and monitor for respiratorydistress. Monitoring for 12 to 24 hours afterexposure has been recommended. Exposed areas


should be washed thoroughly with soap and water.Exposed eyes should be irrigated with copiousamounts of tepid water for at least 15 minutes. Ifirritation, pain, swelling, lacrimation, or photo-phobia persists, the patient should be seen in ahealth care facility.16, 17 There is no evidence thatphosgene is either carcinogenic or teratogenic.17

Nitrogen TrichlorideNitrogen trichloride (NCl3) is a brownish-yellowgas with a pungent, offensive chlorine-like odor.It is the most irritating of the chloramines and canimpart an odor at concentrations above 0.02 ppm.19

It is the by-product of several reactions, includingthe reaction between chlorine and nitrogenatedsubstances. NCl3 decomposes to ammonia andhypochlorous acid. Hypochlorous acid reactsrapidly with ammonia to form monochloramine.20

NCl3 is a strong irritant, but little else is knownabout its toxicology. Exposure to its fumes pro-duces excess tearing, irritation of the mucousmembranes of the respiratory tract, and nausea.The acute inhalation toxicity of NCl3 is similar tothat of chlorine.20

Animal studies have found that the respiratorytract is the primary site of damage in rats exposedto NCl3. Rats exposed for prolonged periods toconcentrated NCl3 died of pulmonary edema. Nochronic health effects have been demonstrated inhumans exposed to these fumes.21

Incident Command System(ICS)Management of fire department day–to–dayactivities is usually vested in a Fire Chief or othertitled person who serves as the commander of thefire suppression forces and their activities,including the safety of the fire fighters.22 To assistin the management (especially in the operation,

coordination, and effectiveness) of wide–scale firesuppression activities, a system has beendeveloped for controlling personnel, facilities,equipment, and communications. This system isknown as the ICS.23 This is a system of unifiedcommand and control designed to assure thesmooth implementation of operational proceduresby all agencies on scene in a coordinated manner.24

A further refinement of the ICS by fire serviceorganizations addresses all types of emergencyincidents and includes performance criteria for thecomponents of a system that incorporates specificsafety and health objectives. This has beendeveloped into a nationally recognized standardknown as the Incident Management System(IMS).25 Some common components of an IMSare: modular organization, integratedcommunications, common terminology, unifiedcommand structure, and consolidated actionplans.26 The National Fire Protection Associationhas documented the consequences of operatingwithout such an IMS which have resulted innumerous deaths and injuries of fire fighters.27

The National Fire Service has also publishedmodel procedures for an IMS that is specific forhigh–rise fire fighting.28

In establishing and utilizing the IMS, the firstpriority must be life safety.29 The responsibilityfor this priority issue is that of the officer incommand of the emergency incident.27,29 Theincident commander is responsible for the overallsafety of all members and all activities occurringat the scene. The Fire Chief, however, bears theultimate responsibility for the safety and health ofall members of the department.

FINDINGS ANDDISCUSSION

Preplanning and InformationFirst due companies (companies who respond first)commented in their interviews with NIOSH thatthey had previously been to American Ref-fuel forpreplanning exercises. Through this preplanning


they were familiar with the facility. Some firefighters indicated that the plant’s management hadalways been very accommodating during suchvisits and forthcoming with information about theprocess and facility. One fire fighter indicated thata trust had been fostered through these visits. Itwas also suggested that second and third duecompanies did not have this preplanning at thefacility, and extending preplanning to includesecond and third due companies in light ofcompanies rotating out of service would bebeneficial.

Under Title III of the Superfund AmendmentsReauthorization Act (SARA), the owner oroperator of a facility is required to disclose thepresence of hazardous chemicals if they are kepton the property at greater than a thresholdquantity. This reporting is to be carried outannually through Tier I or Tier II reporting asindicated in 40 CFR part 370 of the Code ofFederal Regulations (CFR). SARA Title III, TierII reporting is retrospective; facility operators arerequired to report quantities of hazardous materialson site during the preceding year. The cleanerpresent in American Ref-fuel’s refuse pit wouldneed to be reported under Tier II, but not untilMarch 1999. Although the reporting requirementsare a good means for emergency responsepersonnel to receive information about chemicalsat a facility, the reporting system would typicallynot provide responders with such informationabout chemicals that are on site for the first time.This system, though beneficial, would not havebeen effective for preplanning in this case.

Although the main ingredient of the cleaner,sodium dichloroisocyanurate, would be classifiedas a hazardous waste, the composite mixture doesnot meet the definition. The material reportedlymeets the definition of a non-hazardous waste.This may have been a source of mis-communication between plant employees and firefighters as to the contents of the fire.

Based on fire fighters’ reports, there seemed to beconfusion throughout the incident as to the

location and contents of the fire. Much of theconfusion stemmed from misinformation providedby employees of American Ref-fuel. When thefirst engine arrived on the scene, fire fighters notedthat employees of the facility had begun to applywater to the refuse pit with a 1-inch hose line.They prepared to augment this effort with a 2 ½-inch hose line. While they were preparing for this,the BC arrived on the scene and reportedly wasinformed by an American Ref-fuel employee thatthere was a fire on the seventh floor rack. The BCasked the employee what was burning and was toldthat it was just garbage; however, several firefighters reported that they had smelled a chlorine-like odor during the incident. One fire fighterremained with the engine to man the hose linewhile the other fire fighters and the BC proceededto the seventh floor in search of the fire that wasreported there. Fire fighters were unable to locatea fire on the seventh floor.

Incident Command System(ICS)The NFD operates under the ICS. Departmentprograms reviewed by NIOSH are consistent withthe ICS. The department’s SOPs indicate that theNFD has established a succession of commandbased on rank. That is, command is initiallyassumed by the first ranking person/officer onscene. A command post is set up and its locationand the incident commander are identified to thedispatcher. Command is passed along to the nexthigher ranking officer that arrives, including thedeputy fire chief and fire chief. According toreports, this system was followed during theincident.

When the BC arrived at the scene he assumed amobile command. This allowed the BC to operatein the command role while he moved around thescene to size up the incident. Reportedly thisapproach is commonly used in the NFD for fullalarm responses. When the DC arrived on thescene, he established the command post in anoffice area on the first floor. The DC indicated


that he particularly liked this location because theoffice had a telephone system which he could useto communicate with fire fighters in variouslocations in the facility. At some point into theincident, the BC recommended that the DCrelocate the command post to the seventh floor.The rationale for this recommendation is unclear.The DC started to the seventh floor to determine ifa relocation of the command post would bebeneficial. As the DC ascended the stairs hereportedly encountered a strong chlorine odor onthe third floor. At this time, the DC decided tostop, and to keep the command post at the ground-floor office location.

Interviewed fire fighters indicated that they werealways aware of who was in command during theincident. One fire fighter further indicated that theDC takes a strong command and that it is clear thathe is making the decisions.

Hazardous MaterialsResponse UnitThe HAZMAT response unit consists of a four- orfive-person company and two apparatus (aresponse apparatus and spill/decontaminatonapparatus). This unit is housed at the fire stationlocated at 188 Mulberry Street. Two persons bringthe spill/ decontamination apparatus, and two orthree persons bring the response apparatus toHAZMAT scenes. The HAZMAT team isaugmented with a rescue unit (Rescue 1), whichresponds to all full alarms, and a fire companytrained to conduct the decontamination. Inaddition to being the designated HAZMATresponse, the HAZMAT company responds to firecalls. The company will respond to a fire in aladder truck (truck 1), as they responded to thisincident. This approach leaves a two-fold gap inHAZMAT response coverage. First, theHAZMAT response team, while occupied fightingthe fire, is unavailable to efficiently respond to aconcurrent HAZMAT incident at a differentlocation within the city. Second, as was the caseat American Ref-fuel, if the incident commander

at the scene of the fire determines that the hazardsof the incident dictate a change in responseapproach from fire mode to HAZMAT mode, theH A Z M A T t e a m m a y a l r e a d y b ecommitted/contaminated. The former Captain ofthe HAZMAT company indicated that there havebeen situations where the company was enroute (infire mode) and has had to turn truck 1 back and getthe HAZMAT apparatus.

Gaps in HAZMAT coverages were compoundedduring the American Ref-fuel incident due to theNFD’s policy of rotating companies out of service.In January of 1997, truck 8 went from beingrotated out of service on the second tour to beingretired from service. Having a truck company outof service increases the area that the other truckcompanies, including truck company 1, areexpected to cover. A full alarm will trigger twotruck companies to respond. Interviewed firefighters indicated that, given the location ofAmerican Ref-fuel, truck company 8 would havebeen the second due to the incident scene.Because, however, truck company 8 is out ofservice, truck company 1 became second due. Theresult of this is the latter of the two gaps incoverage discussed above; a HAZMAT responsewas compromised when the company wascommitted to the incident scene in fire mode.Although the incident was declared HAZMATonly at the very end, any attempts to make thedeclaration sooner would have been complicatedby the fact that the HAZMAT company wasalready committed to the scene and potentiallycontaminated with the chemicals involved. Thisdeficiency was manifest in the make-shiftdecontamination procedures used at the incident.

The Newark Hazardous Materials Annex indicatesthat the NFD is the lead agency for hazardousmaterials emergency responses, and that the NFDwill handle the initial response to HAZMATincidents. Meeting this responsibility requires theNFD to be fully prepared to respond to aHAZMAT incident at any time. Ideally, thisrequirement would be met by providing firecompanies solely dedicated to hazardous materials


response, rather than a company that responds ineither fire mode or HAZMAT mode, dependingupon early indications about the incident. Accord-ingly, incident commanders would have the optionto change from a fire to HAZMAT mode withoutthe logistical concerns of having no HAZMATteam readily available.

Safety ManagementThe IMS encourages the delegation of authority,but not responsibility, for the safety function at anincident to a fire fighter or other competent person,who is specially trained and knowledgeable in safeemergency operations.30 The failure to delegatemay cause conflict between the positions ofcommand and safety. IMS guidelines generallyrecommend that the command officer, who isresponsible for managing the incident on thestrategic level, establish and operate from astationary command post as soon as possible afterarriving on the scene.29 In contrast, the delegatedSO must routinely observe operations at the sceneof an incident. This means he must have fullauthority to move around the incident scene (fireground) to observe and control safety concerns.29

This safety officer would also have the emergencyauthority to stop and/or prevent unsafe acts. If thedepartment safety officer is also routinelyresponsible for other tasks, an assistant SO mayneed to be designated to address incident safetyfunctions.

The NFD has a policy for dispatching an incidentsafety officer to all full alarm fires. The policygives the SO the authority to correct safety andhealth hazards, immediately if they are deemed tobe an imminent hazard to personnel, and throughthe incident commander if they are not deemed tobe an imminent hazard. Consistent with NationalFire Protection Association (NFPA) 1500standard, the NFD places general responsibility forfire fighters’ safety and health with the Fire Chiefor incident commander.

An SO was dispatched to this incident. There isnot much documentation indicating what actions

the SO took during the incident. The SO’sincident report indicates that he worked to assurethat companies remained intact. NIOSHinvestigators interpret this to indicate that the SOwas working to keep companies accountable fortheir members. It was indicated to NIOSH throughinterviews that some fire fighters roamed freeduring the incident and were isolated from theircompany. The recent revision of the OccupationalSafety and Health Administration’s (OSHA)respiratory protection regulation (29 CFR1910.134), as adopted by the New Jersey PublicEmployees Occupational Safety and Health(PEOSH) program, includes measures designed toprotect fire fighters while working inside burningbuildings.31 The rule, referred to as a “doublebuddy system” or more commonly the 2 in/2-outrule, states that whenever fire fighters enter aburning structure, they must do so in teams of atleast two and remain in direct voice or visualcontact with each other at all times. Also, at leasttwo other fully equipped and trained fire fightersmust remain outside the structure to monitor thoseinside and be prepared to rescue them. Thisregulation was not in effect at the time of theincident, but the practice is a good safetyprecaution that has been followed by many firedepartments prior to the date on which theregulation came into enforcement.

TrainingThe training requirements for persons who willengage in hazardous materials response activitiesare outlined in 29 CFR 1910.120 (q).32 Thisparagraph states that the training shall be based onthe duties and the functions to be performed byeach responder of an emergency responseorganization. Five levels of training are outlinedin the paragraph: 1) first responder awarenesslevel, trained to initiate an emergency responsesequence by notifying the proper authorities of therelease; 2) first responder operations level, trainedto protect persons, property or the environment


from the effects of a hazardous material release;3) hazardous materials technician, trained toassume an offensive role in stopping the release;4) hazardous materials specialist, provide supportto hazardous materials technicians; 5) on sceneincident commander, assume control of theincident beyond the first responder awarenesslevel. Trainers who teach any level of trainingshall have satisfactorily completed a trainingcourse for teaching the subjects they are expectedto teach, such as the course offered by the NationalFire Academy.

CommunicationsFire department communications can beineffective or even completely unusable in ahigh–rise building.28 At some locations within ahigh–rise building it is difficult to send or receivemessages using portable radios. Successful radiotransmission may become intermittent as thesender or receiver of a radio message moveswithin the building.28

The NFD used portable radios during the incident.They also had the use of an on-site telephonesystem that was used to call to the seventh floorfrom the command post. It was indicated toNIOSH investigators that portable radio communi-cations were poor at times during the incident.This was evidenced in radio transcripts when theBC attempted to communicate information aboutthe contents of the fire to the DC. Reportedly,about 25 minutes into the incident, an employee ofthe plant approached the BC on the seventh floorand indicated to the BC that the plant had receiveda shipment of Drano® that day and that this wasthe material that was burning. At this time, the BCattempted to notify the DC of this information viaportable radio. At 2030 hrs, 18 minutes after thefirst company had arrived on site, the BC indicatedto the DC, “One of the workers reports they had aload of Drano® come in today”......no responsefrom the DC. “One of the workers reports that thesubstance was Drano®, a large amount came intothe plant today.”....no response from the DC. Theradio transcripts show no further mention of the

Drano®. Transcripts documenting telephonecommunications were not available.

Respiratory and OtherPersonal ProtectiveEquipment (PPE)Because the smoke was not very dense at timesduring the incident, and the crane operation roomsseemed to be isolated from the smoke, a few firefighters at the scene reported that they feltcomfortable removing their self–contained breath-ing apparatus (SCBA) in certain areas of thefacility. While a properly operating SCBA wornby a well-trained individual offers adequateprotection against smoke and chemical inhalation,even brief exposure without respiratory protectionmay present a health hazard. Fire fighting requiresstrenuous physical exertion, which increasesoxygen demand and respiratory rate and thusincreases the risk of exposure to inhalationaltoxins and hypoxia.33 Although fire fighters areequipped with respiratory protective equipment, itis not always used, especially during the finalextinguishment or overhaul phases, when smokeintensity and assumed exposures are thought to below. Inadequate respiratory protection at the firescene is an important risk factor in thedevelopment of toxicity from smoke inhalation.34

One study reported that 70% of fire fightersremove their mask at some time during knockdownand that as many as 30% wear their masks lessthan half the time.35

A fire fighter’s complete turnout gear typicallyworn during a fire incident consists of a helmet,hood, turnout coat, turnout pants, boots, gloves,and a SCBA with a personnel alert safety system(PASS) device. SCBA’s provide the highest levelof protection against inhalation exposures, even inatmospheres considered immediately dangerous tolife and health. Turnout gear is made of fire-resistant material that will provide protectionagainst flashover temperatures up to 1500 degreesFahrenheit (°F) for brief periods. Althoughturnout gear has the ability to withstand some


types of chemical contact, during a chemical fireit may not provide protection against chemicalexposure. Skin exposure is very likely becauseturnout gear material is not impermeable to manychemicals. Currently, PPE made of a material thatis both fire- and chemical-resistant does not exist.

Following the incident, turnout gear was tested forsurface contamination by wetting the surface andusing litmus paper. This would indicate if therewas surface contamination present on the gear thatwas either an acid or a base. The tests indicatedthat the surfaces were neither acidic nor basic.According to interviewed fire fighters, the gearwas placed in truck one after the incident andreturned to the fire stations the following morning.Reportedly, the gear was replaced with cleanturnout gear a few days later. Some fire fightersindicated they had worn the turnout gear in theinterim. The use of chemically-contaminated gearmay result in skin irritation when worn by firefighters at other fire scenes.36 The NFD uses aQuartermaster system to supply fire fighters withtheir gear. Elements of a Quartermaster systemshould include the replacement, repair, laundering,and decontamination of turnout gear. If feasible,an adequate supply of replacement turnout gearshould be made available to fire fighters whilenecessary replacement, repairs, or laundering isrendered.

Medical Confidential interviews were obtained from 20 firefighters, and self-administered questionnaires werecompleted by an additional 8 fire fighters (37 firefighters were at the scene). The average amount oftime spent at the scene was 3.7 hours (range: 2 - 6hours). The average amount of time spent at thescene without respiratory protection was 2 hours(range: 0.25 to 5.50). Twenty-one fire fighters(75%) reported that they smelled a chlorine-likeodor while they were at the scene. All reportedthat they wore SCBA for some amount of time atthe scene. The most common symptom reportedwas burning or irritation of the eyes (18participants, 64%). The next most common

symptoms were throat irritation or hoarseness (15,54%) followed by cough (12, 43%). Eight firefighters (29%) reported a burning sensation intheir chest. Three fire fighters (11%) reported thatthey began wheezing at the scene. Five firefighters (18%) reported that they developed nosymptoms at the scene or afterward.

Decontamination of the fire fighters occurred afterit was determined that the scene was a hazardousmaterials incident. Decontamination took place inthe shower facilities of American Ref-fuel. Allfire fighters reported that they decontaminatedthemselves by showering with water from 2 to 10minutes. In addition to showering, 7 (25%)reported that they flushed their eyes with waterwhile in the shower. There were complaints thatthe water was too cold and this decreased thedecontamination time. They also reported thatthere was an inadequate number of towels to drythemselves and inadequate clothing to protectagainst the cold weather. Many fire fighterscontinued to wear their under garments while inthe shower.

The 37 fire fighters were transported to five localhospitals. Most were transported by emergencymedical services (EMS), but others drovethemselves to the hospital. Twenty-two hospitalmedical records from the five hospitals werereviewed. The number of medical recordsreceived from each hospital ranged from three tofive. These records revealed that the treatingphysicians were aware that the fire fighters wereexposed to chemicals at a fire, and the physicianswere concerned about the inhalation of toxicfumes and smoke. However, it was unclear to thetreating physicians in most circumstances whatspecific toxins were present at American Ref-fuel.Several medical records specifically mentioned“possible phosgene” and “possible chlorine gasexposure.”

Fire fighters’ symptoms were consistent in thedifferent hospitals; however, the extent ofdiagnostic testing differed. The university-basedhospital performed the most diagnostic tests on the


fire fighters. The tests included chest x-rays(CXR), electrocardiograms (EKG), arterial bloodgases (ABG), pulse oximetry, carboxyhemoglobinlevels, methemoglobin levels, serum electrolytelevels, and complete blood counts (CBC).Pulmonologists were also consulted for furtherevaluation of the fire fighters’ pulmonary status.The fire fighters were monitored for a median of24 hours to assess late pulmonary effects of theinhaled exposures.

The other hospitals performed consistently fewertests. One hospital performed only pulseoximetry, while others performed pulse oximetryplus carboxyhemoglobin level or chest x-ray.Some hospitals contacted the New Jersey PoisonControl Center, while others did not. Thesehospitals did not perform prolonged monitoring toassess the late pulmonary effects of the inhalationexposures. In the non-university hospitals, the firefighters were monitored a median of 3.75 hours.

Two of the 37 fire fighters were admitted toseparate hospitals from the emergencydepartments. The hospitalizations were reportedto be the result of the inhalation exposure at thescene. One of the fire fighters was hospitalized forfive days and the other for six days. A third firefighter had persistent respiratory symptoms, andhe was placed on limited duty for 3 weeks andcontinued to take medications for his respiratorycondition at the time of the NIOSH interview (4months later).

Several fire fighters had persistent symptoms forseveral days to weeks. The most common persis-tent symptom was burning eyes. Several reportedthat they saw an ophthalmologist for their eyes andwere given antibiotic drops. One fire fighterreported that he did not remove his contact lensesat the scene and his eye symptoms persisted up tothe time of the NIOSH interview. Otherscomplained of persistent burning in their chestsand coughing, which lasted a few days to a weekafter the incident.

Seven fire fighters made an appointment to be seenat the occupational medicine provider for the NFD.Five medical records were reviewed from thisclinic. Chest x-ray and pulmonary function tests(PFT) were ordered on all five fire fighters. Twoof the PFT’s showed evidence of mild obstructivedisease, and the others were normal. There wereno comparison PFT’s that were available.Surveillance examinations, including PFT’s, areperformed at another clinic and not at this clinic.

Three fire fighters had more severe lowerrespiratory tract injury. One of these fire fightershad a severe viral infection on the day of theincident, and perhaps this illness could have madehis respiratory tract more vulnerable to the irritantsthat were present. The reason the other twodeveloped more severe symptoms is unclear. Theymay have received a higher dose of the irritantgases, but their description of their job activities,PPE, and location does not differ significantlyfrom those with less severe pulmonary injury.

The medical evaluation of fire fighters differed byhospital. The university-based hospital performedconsistently more tests than the other hospitals.The evaluations at the university-based hospitalwere consistent with recommendations andguidelines on medical evaluation of fire fightersafter exposure to toxic substances and smoke.5,

6,7,8,9,10, 15,34 However, from our interviews andreview of the medical records, it appears that thedifferences in the medical evaluations did notresult in worse clinical outcomes among the firefighters receiving fewer tests. Thus, it is likelythat most fire fighters did not receive sufficientdoses of the toxins to cause significant pulmonaryor systemic health effects; however, thisinformation was not known at the time of thehospital evaluations.

Appropriate diagnostic studies for symptomaticpatients with smoke inhalation and asymptomaticpatients with significant risk factors (from historyof exposure and past medical history) includepulse oximetry, arterial blood gas (ABG) analysis,chest x-ray, electrocardiogram and cardiac


monitoring, and carboxyhemoglobin (COHb)level.6 Carboxy-hemoglobin level is importantbecause it is the most direct biological measure ofexposure to carbon monoxide (CO). COHb levelsshould be measured in all patients with smokeinhalation and cannot be inferred reliably fromclinical signs and symptoms. Elevated COHblevel should raise the concern for CO poisoning aswell as potential exposure to other smokeinhalation toxins, such as coexisting asphyxiantsand irritants.4

Chest radiographs are a low-yield procedure andare commonly normal in the early course of smokeinhalation.5, 6 Most often, abnormal findings suchas local, patchy, or diffuse infiltrates are notevident until 24 to 36 hours after exposure.37

Subtle findings such as perivascular haziness, peri-bronchial cuffing, bronchial wall thickening, andsubglottic edema may be apparent within 24 hoursof exposure. Serial chest x-rays may be useful inmonitoring severe smoke inhalation.38

Pulmonary function testing can aid in the medicalevaluation of patients with toxic pulmonaryinsults. Pulmonary function testing is aninformative but underutilized source of diagnosticinformation in the acute setting. Obstructiveventilatory defects, characterized by reducedexpiratory flow volumes and flow rates are earlyfindings that are related to primary airway injury.Also, these abnormalities generally precede chestx-ray findings or arterial blood gas alterations andpermit early identification of patients at increasedrisk for more severe subsequent pulmonarydisease.5, 6

In 1992, University of Medicine and Dentistry ofNew Jersey (UMDNJ) Robert Wood JohnsonMedical School, in conjunction with U.S. PublicHealth Service, Division of EmployeeOccupational Health, and the New JerseyDepartment of Health, produced “Guidelines forthe Emergency Management of Firefighters.”39

These guidelines were produced to assistemergency departments and other health careproviders to recognize and treat various conditions

for which a fire fighter is occupationally at risk.These guidelines were written because toxicexposures in fire fighters are not often recognized,and morbidity and mortality may be lessenedthrough early recognition and treatment of medicalproblems.

Subsequent to the testing performed in the acutecare setting, few fire fighters had additionalmedical tests performed to assess the long termhealth effects of their exposures at American Ref-fuel. Seven fire fighters reported that they wereevaluated by the department’s occupational healthprovider. The most persistent health concern wasburning eyes which lasted several weeks after theincident. Also, a few fire fighters had persistentpulmonary symptoms. However, the surveillancemedical evaluations were performed by anotherhealth care provider. This information was notavailable to the occupational medicine providerwhen they were evaluated after the American Ref-fuel incident because the two providers do notroutinely share medical records unless requested.The surveillance information would be helpful todetermine if there were differences betweencurrent and previous evaluations, such aspulmonary function tests.

The decontamination procedures at American Ref-fuel were not consistent with guidelines. It wasfortunate that the shower facilities were availableat the facility. Skin decontamination wasacceptable in most cases, but there was inadequateflushing of the eyes in most cases. Most firefighters reported that they were not aware that theyshould flush their eyes with water. Guidelinesrecommend flushing the eyes for at least 15minutes after such exposure, and this may takeplace during showering or at other early phases ofthe delivery of health care.10, 15

CONCLUSIONSThe elements leading to fire fighter exposures atAmerican Ref-fuel on December 17, 1998, arecomplex and multi-factorial in nature. Clearly,


fire fighters did encounter exposures to irritantgasses at the scene. The NFD approached theincident in fire mode, when in fact, a hazardousmaterials response approach would have beenmore appropriate. The reasons for using a firemode at the scene stem largely frommisinformation provided to the arriving firefighters about the true nature of the materialsinvolved. Early into the incident, the BC wasprovided information about the chemical nature ofthe fire. This information would have providedjustification for revising the strategy employed.Efforts by the BC to communicate this informationto the DC via portable radio were unsuccessful. Itis not known if this information wascommunicated in person or via the American Ref-fuel telephone system. Controls, which shouldhave limited exposures, either failed or werecircumvented. Exhaust ventilation at the plant wasreported to have operated only intermittently,occasionally allowing the smoke and gas toconcentrate in the areas where fire fighters wereworking. This intermittent smoke condition,coupled with several reports of fire fightersremoving their respiratory protection during theincident, ultimately led to the inhalation ofharmful concentrations of smoke and gas.

Most fire fighters suffered irritant symptoms thatwere the result of their exposures to irritant gasesat American Ref-fuel. Those fire fighters who didnot develop symptoms or who had recovered areunlikely to develop health problems in the futurebecause of this exposure. These irritant gases mayproduce chronic respiratory diseases, but only inthose with high exposures and severe acutesymptoms. The fire fighters who suffered moresevere injuries continued to receive medical careat the time of the NIOSH investigation.

Health care providers were uncertain of thespecific exposures of the fire fighters, even whenthey were discharged from the emergencydepartments. Obtaining fewer medical tests didnot appear to adversely affect the health outcomeof the fire fighters who received care at thosehospitals. However, following the guidelines

developed by the New Jersey Department ofHealth for evaluating fire fighters after acuterespiratory exposures would be preferable in thefuture. Decontamination procedures were lessthan optimal at the scene. Inadequate flushingmay have resulted in persistent irritation of theeyes in some fire fighters. Also, the persistentirritation may be due to the initial chemical injuryto the mucous membranes of the eye.

RECOMMENDATIONSThe following recommendations are based on thefindings of this survey, previous HHEs, and thecurrent scientific literature. These recommen-dations are intended to reduce the potential forwork-related injuries and illnesses to fire fightersof the NFD.

1. The NFD should ensure personnel are trainedto handle the duties and functions they may becalled upon to perform in a hazardous materialsresponse. These training requirements are outlinedin 29 CFR 1910.120 (q). At a minimum, all mem-bers of the fire department should be trained to thefirst responder awareness and operations level.Members of the HAZMAT team should be trainedto the hazardous materials technician level.Anyone who may be called upon to assumeincident command over a hazardous materialsresponse should be trained to the on scene incidentcommander level. This should include all captainsof the HAZMAT unit and chiefs. This trainingshould be followed up with annual refreshertraining as indicated in 29 CFR 1910.120 (q).

2. Department records indicated that theresponsibility for HAZMAT operations did notconsistently fall with one person. Rather, respon-sibility for HAZMAT operations and/or trainingappears to have shifted among a few differentpersons. There should be a clear line of commandfor the administrative aspects of the HAZMAToperation. This person should have ultimateresponsibility for assuring that the HAZMAT unitis stocked with appropriate and operational


equipment, which is maintained in good workingorder. Clear command over all HAZMAT toursshould be established to assure consistent andadequate training beyond the training provided bythe individual HAZMAT captains.

3. Fire fighters may often face chemicalexposures when responding to incidents such asthe American Ref-fuel chemical fire because theylack appropriate protective equipment. No PPEcurrently exists that will protect against both fireand the chemical exposures associated with suchan incident. To reduce the likelihood of firefighters sustaining undue chemical exposuresduring these types of incidents, all fire fightersshould properly wear all PPE while in establishedhazard zones (i.e., hot, warm, and cold).

4. The Newark Hazardous Materials Annexindicates that the NFD is the lead agency forhazardous materials emergency responses. Ideallythis requirement would be met by providing firecompanies who are solely dedicated to hazardousmaterials response, rather than a company thatresponds in either fire mode or HAZMAT mode,depending upon early indications about theincident. An increase in resources would need tobe directed to HAZMAT in order to meet theincreased staffing a dedicated unit would require.Short of providing a fully dedicated HAZMATunit, the NFD should consider modifying responseprotocol so that HAZMAT companies are lesslikely to be occupied by fire calls. For example,not having truck company 1 respond as first orsecond due to a fire would offer the IC the optionto change from a fire mode without havingcompromised the HAZMAT company.

5. Reports indicate that some fire fighters werealone at times during the incident. The SO’sreport suggests that he was trying to follow adouble buddy system or some other form ofaccountability. The NFD should implement andenforce a fire fighter accountability consistent withPEOSH’s two-in-two-out rule.

6. Immediately following fire suppression andoverhaul activities involving chemical fires, allpotentially contaminated PPE should bethoroughly inspected, tested, and laundered in atimely fashion. Fire fighters should also beinstructed to promptly discontinue the use of anypotentially contaminated PPE and equipment.Whether a Quartermaster system or an Allowancesystem is used, an adequate supply of backupequipment should be available to fire fighters.36

7. Since fire fighting is a highly hazardousoccupation, safe work habits and use of PPE isstrongly emphasized. During a fire incident, theassigned Safety Officer must have full authority tomove around the scene to observe and addresssafety and health hazards, including such unsafepractices of not wearing respiratory protection inhot and warm zones. At future fire incidents, theSafety Officer should enforce the use of allnecessary PPE in hot and warm zones and alsoidentify other unsafe practices on the fireground.

8. The NFD should consider issuing a written“Alert” to small businesses to inform them aboutfire protection issues, including emergencyresponse preplanning and the importance ofreporting any chemical storage and use at theirfacility to the fire department. Businesses shouldbe encouraged to report the initial or intermittentuse of chemicals, which the NFD would beunaware of until the subsequent SARA IIIreporting period.

9.9. Communication between the NFD and localemergency departments and hospitals should beimproved. At this point there is no standardprocedure to relate fire fighter exposureinformation from the NFD to local hospitals. Thiscould be accomplished by assigning a liaisonbetween the fire department and the hospital(s).

10. Fire fighter medical surveillance informationshould be better integrated with acute careoccupational medicine services. The medical sur-veillance examinations will have baseline healthresults. Acute changes in health conditions may


1. Karter MJ, LeBlanc PR [1998]. 1997 U.S.fire fighter injuries. NFPA Journal, Vol. 92(6),November/December. Quincy, MA: National FireProtection Association, pp. 48.

2. IAFF [1999]. 1998 death and injury survey.Washington, DC: International Association ofFire Fighters.

3. Nelson GL [1987]. Regulatory aspects of firetoxicology. Toxicology 47:181-90.

4. Lui D, Olson KR [1991]. Smoke inhalation.CMCC Crit Care Toxicol 1:203-24.

5. Orzel RA [1993]. Toxicological aspects offiresmoke: polymer pyrolysis and combustion.Occup Med 8(3):415-29.

6. Haponik EF [1993]. Clinical smoke inhala-tion: pulmonary effects. Occ Med 8(3):432-67.

7. Teixidor HS, Rubin E, Novick GS, AlonzoDR [1983]. Smoke inhalation: radiographicmanifestations. Radiol 149:383-7.

8. Gochfeld M, Szenics J, Boesch R, Fontus H[1992]. Guidelines for the emergencymanagement of fire fighters. Division ofOccupational Health, UMDNJ- Robert WoodJohnson Medical School, Piscataway, NJ.

9. ATSDR [1994]. Introduction. In: Managinghazardous materials incidents. Vol. III, Medicalmanagement guidelines for acute chemicalexposures. Agency for Toxic Substances andDisease Registry. Washington, DC: U.S.Government Printing Office.

10. ATSDR [1994]. Chlorine. In: Managinghazardous materials incidents. Vol. III, Medicalmanagement guidelines for acute chemical expo-sures. Agency for Toxic Substances and DiseaseRegistry. Washington DC: U.S. GovernmentPrinting Office.

11. Proctor NH, Hughs JP, Fishman ML [1996].Chlorine. In Chemical hazards of the workplace.4th ed. New York, NY: Van Nostrand Reinhold.

12. Wexler P [1998]. Chlorine. In: Encyclopediaof Toxicology. Vol. I. San Diego, CA: AcademicPress.

13. Parkes WR [1994]. Non-metallic gases,vapors, and mists. In: Occupational LungDisorders. 3rd ed. Oxford, England: ButterworthHeinemann.

14. Das R, Blanc PD [1993]. Chlorine gasexposure and the lung: a review. Toxicol IndHealth 9(3):439-55.

be noticed more readily if this information isavailable to the acute care provider. This could beaccomplished by making surveillance informationreadily available to the occupational medicineprovider who provides acute medical care.

11. Decontamination procedures stress the impor-tance of flushing the eyes and other exposedmucous membranes when exposed to contaminantscapable of causing damage in those parts of thebody.

12. In the aftermath of acute chemical exposure,fire fighters should undergo exams to determine ifthey have any acute health effects related to thatexposure. The components of the exams should bedetermined by the nature of the chemical exposure.

13. Although the NFD conducted an internal auditof their communications systems in 1997, whichdetermined that the portable radios used by the firedepartment were “state of the art” and that therewas “little that could or should be done to improvetheir performance,” the NFD should periodicallyreview the radio technology available that mayserve to improve communications in high-risestructures and update the departments communi-cations equipment as more effective radios becomeavailable.

REFERENCES


15. Poisindex® [1999]. Toxicological Manage-ment: Chlorine gas. Micromedex Inc. Englewood,CO.

16. ATSDR [1994]. Phosgene. In: Managinghazardous materials incidents. Vol. III, Medicalmanagement guidelines for acute chemicalexposures. Agency for Toxic Substances andDisease Registry. Washington DC: U.S. Govern-ment Printing Office.

17. Proctor NH, Hughs JP, Fishman ML [1996].Phosgene. In: Chemical hazards of the workplace.4th ed. New York, NY: Van Nostrand Reinhold.

18. Poisindex® [1999]. Toxicological Manage-ment: Phosgene. Micromedex Inc. Englewood,CO.

19. Kroschswitz MH, ed. [1993]. Chloraminesand Bromines. In: Encyclopedia of chemicaltechnology. 4th ed. Vol. 5. New York, NY: JohnWiley and Sons.

20. Barbee SJ, Thackara JW, Rinehart WE[1983]. Acute inhalation toxicology of nitrogentrichloride. Am Ind Hyg Assoc 44(2):145-6.

21. Massin N, Bohadana AB, Wild P, Hery M,et al. [1998]. Respiratory symptoms and bronchialresponsiveness in lifeguards exposed to nitrogentrichloride in indoor swimming pools. OccupEnviron Med 55:258-63.

22. NFPA [1989]. Recommendations fordeveloping fire protection services for the public.Boston, MA: National Fire ProtectionAssociation, NFPA 1201–1989.

23. NFA [1987]. The incident command system.Emmitsburg, MD: U.S. Federal Emergency Man-agement Administration, U.S. Fire Administration,National Fire Academy, NFA–ICS–SM.

24. NFPA [1992]. Hazardous materials responsehandbook. Quincy, MA: National Fire ProtectionAssociation, p. 711.

25. NFPA [1990]. Standard on fire departmentincident management system. Quincy, MA:National Fire Protection Association, NFPA 1561–1990.

26. IFSTA [1998]. Essentials of fire fighting. 4thed. Oklahoma State University: International FireService Training Association, p. 14.

27. NFPA [1987]. Standard on fire departmentoccupational safety and health. Quincy, MA:National Fire Protection Association, NFPA 1500–1987.

28. NFS [1996]. Model procedures guide forhigh–rise fire fighting. 1st ed. Stillwater, OK:Fire Protection Publications, Oklahoma State Uni-versity, National Fire Service IncidentManagement Consortium.

29. NFPA [1987]. Fire command. Boston, MA:National Fire Protection Association.

30. Oklahoma State University [1983]. Incidentcommand system. Stillwater, OK: OklahomaState University.

31. CFR [1998]. OSHA 29 CFR 1910.134.Respiratory protection. Code of Federal Regula-tions. Washington, DC: U.S. GovernmentPrinting Office, Office of the Federal Register.

32. CFR [1999]. OSHA 29 CFR 1910.120.Hazardous Waste Operations and EmergencyResponse. Code of Federal Regulations.Washington, DC: U.S. Government PrintingOffice, Office of the Federal Register.

33. Terrill JB, Montgomery RR, Reinhardt CF[1978]. Toxic gases from fires. Science 200:1343-9.

34. Hung OL, Shih RD [1997]. Firefighters. In:Greenberg MI, Hamilton RJ, Phillips SD, eds.Occupational, Industrial, and Environmental Toxi-cology. St. Loius, MO: Mosby.


35. Jankovic J, Jones W, Burkhart, Noonan[1991]. Environmental study of firefighters. AnnOccup Hyg 35:581-602.

36. NIOSH [1998]. Health hazard evaluationreport: International Association of Fire Fighters(IAFF), Indianapolis, IN. HETA 97-0034-2683.Cincinnati, OH: US DHHS, CDC, NIOSH.

37. Teixidor HS, Rubin E, Novick GS, AlonzoDR [1983]. Smoke inhalation: radiographicmanifestations. Radiol 149:383-7.

38. Lee MJ, O’Connell DJ [1988]. The plainchest radiograph after acute smoke inhalation.Clin Radiol 39(1):33-7.

39. Gochfeld M, Szenics J, Boesch R, Fontus H[1992]. Guidelines for the emergencymanagement of firefighters. Division ofOccupational Health, UMDNJ- Robert WoodJohnson Medical School, Piscataway, NJ.

Glossary of Medical Terminology

Airways. Any part of the respiratory tract (e.g., lungs and windpipe) through which air passes duringbreathing.

Alveoli. Microscopic air sacs in the lungs in which gas travels between the blood and the lung.

Arterial blood gas. A procedure that measures the oxygen content, carbon dioxide content, and the pH inarterial blood.

Asphyxiant. An agent, especially a gas, that will cause the insufficient intake or utilization of oxygen.

Asthma. A chronic health condition in which constriction of the bronchial tubes occurs in response toirritation, allergy, or other stimuli.

Atelectasis. Partial collapse of the lung.

Bronchiectasis. Chronic dilation of a bronchus or bronchi, with a secondary infection that usually involvesthe lower portion of the lung.


Bronchus ( bronchi). Large division of the windpipe that carries air to and from the lungs.

Bronchiole. A small diameter airway branching from a bronchus.

Bronchitis. Inflammation of the mucous membrane of the bronchial tubes, usually associated with persistentcough and sputum production.

Bronchospasm. Contraction of the smooth muscle of the bronchi, causing narrowing of the bronchi. Thisnarrowing increases the resistance of air flow into the lungs and may cause a shortness of breath andwheezing.

Bronchotracheitis. Inflammation of the membrane lining of the bronchi and trachea.

Carboxyhemoglobin. Compound formed in the blood from hemoglobin upon exposure to carbon monoxide.

Complete blood count. Enumeration of the components of the whole blood, such are red blood cells andwhite blood cells.

Conjunctiva. The delicate mucous membrane that covers the exposed surface of the eyeball and lines theeyes.

Conjunctivitis. Inflamation of the conjunctiva; can result in redness, irritation, and tearing of the eye.

Co-oximeter. A device that is used to measure oxygen saturation in samples of arterial blood. It uses at leastfour wavelengths of light and is capable of distinguishing oxyhemoglobin, deoxygenated hemoglobin,carboxyhemoglobin, and methemoglobin.

Cornea. Transparent membrane that covers the anterior part of the eye.

Corrosive. A substance with the ability to destroy the texture or substance of a tissue.

Decontamination. The process of removing hazardous material from exposed persons and equipment.

Dermal. Relating to the skin.

Dermatitis. Inflammation of the skin.

Dyspnea. Shortness of breath; difficult or labored breathing.

Edema. Accumulation of fluid in the body cells or tissues; usually identified as swelling.

Electrocardiogram (EKG). A record of the electrical activity of the heart.

Electrolytes. Ionized salts in the blood. Commonly measured electrolytes include sodium, potassium,chloride, and bicarbonate.


Emphysema. A chronic lung disease characterized by increase in size of air spaces beyond the terminalbronchiole with destructive changes in their walls.

Hemoglobin. The iron-containing pigment of red blood cells. Its function is to carry oxygen from the lungsto the tissues.

Hypoxia. Condition in which below normal levels of oxygen are present in the air, blood, or body tissues.

Inadequate warning property. Characteristic (e.g., odor, irritation) of a substance that is not sufficient tocause a person to notice exposure.

Irritant. An agent which produces an inflammatory reaction upon contact.

Lacrimation. Secretion of tears, especially in excess.

Larynx. The enlarged upper end of the trachea below the root of the tongue.

Methemoglobin. A transformation product of hemoglobin in which normal iron is oxidized. Methemoglobincontains oxygen that if firmly bound to the oxidized iron, which prevents release of oxygen to the tissues.

Necrosis. Death of one or more cells or a portion of a tissue or organ.

Obstructive lung disease. Increased resistance to the passage of air in and out of the lung due to narrowingof the bronchial tree.

Ocular. Pertaining to the eye.

Olfactory fatigue. Temporary loss of the sense of smell due to repeated or continued stimulation.

Oxidation. To increase the positive valence (usually by adding oxygen), or to decrease the negative valence(usually by the loss of electrons).

Photophobia. Unusual intolerance of light, usually painful.

Pneumonitis. Inflammation of the lungs.

Pulmonary. Concerning or involving the lung.

Pulmonary edema. Accumulation of excess fluid in the lungs that impairs gas exchange; usually due toeither increased pulmonary artery pressure or leaky pulmonary capillaries.

Pulmonary function test. A procedure that measures the flow of air through the lungs.

Pulse oximeter. Photoelectric device for determining the amount of oxygen in the blood. Usually done bymeasuring the amount of light transmitted through a translucent part of the skin.


Reactive airways dysfunction syndrome. Increased or excessive constriction of the bronchial tubes inresponse to chemical exposure.

Respiratory. Pertaining to breathing.

Rhinitis. Inflammation of the mucous membranes of the nose.

Routes of exposure. The manner in which a chemical contaminant enters the body (e.g., through the lungsor gastrointestinal tract).

Secondary contamination. Transfer of a harmful substance from one body (primary body) to another(secondary body), potentially permitting adverse effects to the secondary body.

Stridor. A harsh, high-pitched respiratory sound often heard in acute respiratory obstruction.

Toxic. Having the ability to harm the body especially by chemical means.

Trachea. The tube that runs from the larynx to the bronchial tubes. Also called the windpipe.

Wheezing. A whistling or sighing sound resulting from narrowing of the respiratory passages.

For Information on OtherOccupational Safety and Health Concerns

Call NIOSH at:1–800–35–NIOSH (356–4674)or visit the NIOSH Web site at:

www.cdc.gov/niosh

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