session, AOHC, AECOM for years has let OSHA do a bit of an update of what we think are the most interesting things we've encountered in the last year. So we have three kind of talks of things, I'll mention those in a minute. We have about an hour and a quarter of stuff, so we've left time at the end so that people can ask about things that we don't have in our presentation mode. People often have questions about other OSHA stuff that they don't get a chance to ask. We're not able to provide the official OSHA response, but we can speak to you as private citizens who work at OSHA, and where things have been mentioned in public or are FOIA-able, we are happy to answer questions as best we can. So the three presentations this year are first, what have we done with COVID? So like everybody else, OSHA has been buried in COVID stuff, and so we'll go through some of what the Office of Occupational Medicine and Nursing has done there. I'll do that presentation. The second presentation will be by Dr. Dawn Cannon. Some of you may remember her from prior years. She is by training a pathologist, and we'll be talking about the various causes of death that we see that aren't so easily identified, explained, and that often cause troubles or difficulties or require bouncing back and forth between the medical examiner's office and OSHA until people come up with a plausible story. And then finally, Dr. Weaver and Dr. Hayes, who is our first nurse practitioner in the office, will be talking about some clinical scope of practice stuff that we think is probably worth a longer discussion. As in general, clinical systems have gone from just practicing something to state licensing in the 20th century through the formal credentialing process in institutions, and as employers now who have clinics include your average meatpacking facility, what are the implications of nurse licensing, nurse practitioner licensing, those kinds of things. So we hope for a lively discussion. So with that, let me see whether I can get the – yes. So I'm trying to figure out what's in the chat, what I have up there, and my next slide is a little bit of a juggling act. This presentation is really based on work that happened mostly in the first year of COVID, although I have some data from the second year. Don Cannon, Minda Nieblas, a new member, and Aaron Tustinar, physicians in the office. Amy Jordan is a public health type in one of our regions who has mucked around in the data systems trying to put together numbers that we can't easily access. And then Andre Taylor is a – well, an LPN, actually, but a techie who manages to pull much of our infrastructure together. So what do we see, actually? So OSHA has, as most of you probably know, 10 regions around the country, very different sizes as you go through – does this actually – okay, yeah. Region 1 is New England, region 2 is New York, region 3 is the Mid-Atlantic, region 4 is the Southeast, region 5 is North Central, Michigan, Indiana, Illinois, and the like. Region 6 is Texas and Georgia and – no, region 4 is the Southeast, including Georgia, region 6 is Texas and the Southern states, 7 is the upper – the lower Midwest, 8 is the East side of the mountain states, region 9 is the Southwest, and region 10 is the Northwest. So these are mostly state-planned states. You all remember that OSHA – you know, there are state-planned and federal states. The 20 – about half of the states do their own stuff. We don't really get to see their severe injury reports. The Bureau of Labor Statistics doesn't code those for us. So much of what we can talk about is only from the half of the states that are federal. So the big states for us are 5, kind of the old industrial states, 4, which is the Southeast, 2, which is New England – sorry, New York, New Jersey, and 1, kind of New England. So the size bars are what they are and don't represent population-extrapolatable information, but represent our – what we can talk about. So blue is the total number of kind of COVID inspections in those states. Red is the number of medical access orders. So most of you know 1910-1020, OSHA's standard where people are allowed to access their exposure records and their medical records, and employers must maintain those. OOMN issues medical access orders so that our staff in the field can request those records and look at them because, of course, they're protected by certain laws. HIPAA. We're a public health agency, according to HIPAA, but many providers don't like to give us those laws, so we have to give us those records, so we have to explain that. And you can see that most of the COVID investigations happened without even a medical access order, and then we only get consulted on about half of the medical access orders. But what does that mean practically? How many COVID inspections did OSHA do? Well, in the first year, starting from March 1 through September 30, OSHA did – Why can't I do it? This is not a very fast, responsive infrared – Please remember to speak into the microphone so we can hear you clearly. Sorry, yes, lavalier. Bad habits around lavalier mics. This 2020, 1,139 COVID inspections between March 1 and September 30, then in 2021, you know, four times that many inspections. The vast majority happened without medical access orders. Five percent of the first 1,200 wound up with an access order, where the COSHOs, our Compliance Safety and Health Officers, thought they needed help to get pertinent records. Last year, it was only one and a half percent. 62, NAICS Code 62 is healthcare, so that includes hospitals and nursing homes. Of the 1,100 in the first year, 713 were in healthcare. 36 – sorry, 132 are about a little over 10 percent. 31, NAICS Code 31, is food processing and manufacturing. So that's the meat and poultry industry. When you look at what proportion of MAOs each year, a lower proportion each year, although probably not in 62. So five percent of the healthcare inspections required a medical access order. And in 2021, almost the same number required a medical access order for meatpacking, poultry, and the like. But the numbers are pretty small. Why is that important? So actually, let me ask, who here has ever worked with CSTE, the Council of State and Territorial Epidemiologists? So CSTE is the State Public Health Action Group. It is the occupational health group in each state that does things like the occupational health indicators. And it's probably worth, for occupational physicians, to know the CSTE website, the occupational health indicators, how many asthma cases are reported, that kind of stuff. So CSTE.org will get you there. CSTE, in the first year of the pandemic, had varying case definitions of what is occupational COVID. And actually, the first issue that then, you know, we think about is, is there an outbreak or not? How do we define an outbreak? What are the criteria by which one could define that? And CSTE, you know, we can calculate a standardized incidence ratio, meaning the rate in a plant compared to the rate in the community around there, standard rate calculations. There's a whole complicated thing around age adjustment, working age populations. If you know that your plant only has people under the age of 65, you can sequester your comparison population. But if you have some 70-year-olds working, all of a sudden you have a different population you have to compare to. But calculating an SIR appeared straightforward, except that as we moved through that pandemic in the first year, remember how complicated it was to find out how many cases there actually were in your city, county, or state. And the numbers would change. And not all of the information showed up to the CDC because of various reporting issues. And when there was no elevated SIR, the question was, was a single case work-related? And CSTE came up with some criteria. And these slides should be online, so you shouldn't have to copy them. And if people can't get them downloaded, because I couldn't download some people's slides, you're welcome to email us and we'll send them to you. But so there, CSTE had worked out some case definitions. So as we looked at what we had done in the first year, you know, we do, we used to do about 50 outbreaks a year, field support. The last two years we've done more in the range of, well, that year it was 84. So 32 of our 84 cases were COVID. So a pretty big burden. Of those 32 cases, 22 met the case definitions for a workplace outbreak. Of those 22, 12 or 37% of our COVID investigations were in meatpacking, 14 of the 32, almost half, right, were food processing. So if you made packaged foods but weren't processing meats, you also fell into NAICS code 31. And only four of our 32 were in healthcare. The rest, crop farming, transportation, warehousing. And 10 of the 32 were random cases where some specific question had come up. What did we do with that? So we tried to calculate standardized incidence ratios to look at what the rate of COVID in those plants was as compared to the surrounding community. And I'm not going to go into detail on this. We'll talk at the end why not. But the bottom line, the best estimate we had for those, for example, 12 meatpacking is a forced plot, which shows the standardized incidence ratio, unity or one, and the rates going up to over 100. If you think back to occupational epidemiology, mesothelioma and asbestos has a relative risk effectively an SIR of 50, something like that. But smoking and lung cancer at its multiplicative risk somewhere, 40 to 60. So these are relative risks that we don't really see in occupational epidemiology, a pretty striking thing. But in fact, some of them were very low, didn't look like they were elevated. I don't have a plot here of the time in the course of the pandemic, but it didn't appear that the very elevated relative risks occurred earlier than later. They were pretty randomly spread through. And even now, every so often, we see really elevated rates. What did we find besides these dramatically elevated rates? So if you have a relative risk of three or five, chances are you have a workplace outbreak. Do you link individual cases to that workplace? Well, if it's within the incubation period, probably a reasonable thing. If there's no other case in the plant within the standard 12-day incubation period, you probably can't link that. What do you do with those? Well, so we wound up being asked about other things for those 10 random cases, including should they be considered work-related? So for example, two electric linemen driving around in a truck, the one was not COVID positive. The second one came down with COVID over a weekend, and our compliance officer wanted to know, could they have gotten COVID on the road? They spent all day together. They bought lunch at your local Hardee's. They weren't wearing face coverings in the truck. It took a while to find out that the driver in the truck had developed COVID over the weekend. It hadn't been reported to the employer, but so those kinds of things trying to document that there was actually work-relatedness because of work-related contact. We have seen a number of cases, and actually there have been at least three 5A1 citations issued, general duty clause citations issued, because employers prohibited the use of face coverings for employees and visitors into the facility. One of them asked early on, was it possible that people could get reinfected and reinfected at work? There was a question around the adequacy of respiratory protection programs. Those of you who have struggled with the controversy around N95s will remember that this has been a major topic of discussion and controversy over the last two years. Three months ago, CDC put up on their website that you get more protection from N95s than from other face coverings. They did that after the MMWR analysis from California showing the increasing protectivity of two-layer cloth masks, surgical masks, and N95s going from less than I think it was 30% to 50% to 85% protection. So what tools could our compliance officers use as they looked at whether, for example, hospitals were implementing an appropriate respiratory protection program if in fact they couldn't get N95s? We could have a lengthy discussion. Those of you who will be at MCOH tomorrow will likely hear some of that. There were some strong disagreements between our compliance officers and hospitals around what was technically feasible. First to acknowledge that when hospitals disagree, they have a formal process that is worth pursuing, namely challenging us as an agency and laying out what they can and cannot do. One model hospital wound up accepting a citation that some of us felt could have been dealt with differently. And so encourage questions when they come up. One of the actually several had to do with the adequacy of employer symptom screening forms and sick leave policies. One of the and for one of those, Dr. Cannon actually had to dig through the old CDC records to document what symptoms were recommended as a screening item at which point and where had an employer simply not stayed up with what we knew and the like. And there was one around PACU conversion for managing surge infections. So a lot of kind of random things, but interesting problems to work through. So there were a series of citations around respiratory protection, 1910, 134. There was an initial guidance document saying don't, you know, we recognize that you may not be able to get N95s. Here's a hierarchy of how to implement a protection program adequately. There was some that got a general personal protective equipment citation and there were a number of record keeping citations where people had not, you know, reported a hospitalization for COVID or a death for COVID and there were these general duty clause citations for thumbing their nose at public health recommendations. The thing that we're moving forward on is these dramatic SIR elevations. When we actually looked at it, meat packing, you know, the highest elevated risk, 106, health care around 50, all others around 50. So it wasn't so clear that meat packing had higher relative risks than nursing homes, for example. But when we started looking at that, and some of you will remember the Smithfield Sioux Falls outbreak, the first big meat packing outbreak. We did that in parallel to CDC. We had to do our own data collection and wound up not being able to use CDC's data. They wouldn't share those. But it was clear that the plant had an outbreak that preceded the outbreak in the community and so served as a nidus for spread into that state. It was a huge plant, you know, 5,000 workers, huge number of sick employees, structured housing. But those of us who worked on the original pandemic preparedness will remember that schools were a core risk factor for transmission and one of the essential elements for that pandemic preparedness plan and implementation was shutting down schools to keep them from transmitting disease. And that happened in a number of jurisdictions and we wonder now, based on some of the early outbreaks and we have some evidence from the ones that we've looked at, whether in the cases where there was an SIR above 10, whether those outbreaks were actually drivers for the county or state outbreak. Because if that's the case, there are some clear implications for us. Those of you who followed Doug Martin's JAMA discussions around face coverings will remember that he had a stack of N95s and he handed them out to the JBS plant in Sioux City and they did not have a huge outbreak. So there are some lessons around respiratory protection that we think are useful and the question of physical distancing and, you know, shutting down places is a big topic for the after action of this pandemic. I think that was the last of my slides. So questions about this specifically? If not, we'll go to Dr. Cannon and there is one hand. Please come to the microphone. And happy to answer more broad OSHA questions at the end after everybody's, there's a microphone. First, was vaccinations, were these cases when vaccinations were available or are they all before? These are all before vaccination was available. And the second question, can you characterize contact tracing in some of these cases? I mean, did you use that info? Was it, would employers be doing it? Were public health, you know, it sounds like CDC wasn't playing very well. Yeah, so that was my question. So contact tracing was a huge issue. Many of our compliance officers did the kind of shoe leather epidemiology that EIS officers do. There are, in some of the investigations, there are contact tracing maps. There are contact, so there was a lot of work that went into each one of these. The question of how necessary that was for what we generally do, namely, we say something is an employer problem or not, and the employer did or did not adhere to national expectations of management, doesn't require detailed contract tracing for everyone, as long as we can document that there is enough evidence that it's a work-related outbreak. But happy to talk more about that later. Thank you, Dr. Hodgson, as always, you give such a wonderful presentation. I'm sorry to bother you with a very basic question, but it's been quite a burden. I don't understand what is an OSHA reportable COVID case. There seems to be a great deal of confusion within, and I'm talking, in my case, in the medical center, but we did a great deal of contact tracing. I know exactly who went to Vegas and got COVID the next day and who went to a wedding and who got it floor to floor. We did genotyping, we genotyped the patients, we have sub-variants, yet I'm being told, at least in the federal government, that every single case is to be reported, absolutely irrespective of where it came from, despite all this work. And so safety is writing up every single one of them, follow on to that, I don't know who got hospitalized unless they happen to call and tell us. How would we know? So I'm sorry about the basicness of that question, but if I have it, maybe others do too. And the Office of the Solicitor has sent out lots of information on this, and no, not every COVID case has to be reported. Employers are expected to do due diligence to figure out whether something is likely or possibly a work-related COVID case. If it is not unlikely that it's work-related, the employer is supposed to report it. And there is a mandate to report, and the only part of the COVID emergency temporary standard that's still being enforced is, in fact, the record-keeping rule, which is that you must report deaths and COVID cases, and you must put them on your COVID log. But if you have good evidence that something is not a work-related case, you do not have to put it on the log. And if the VA is still saying that, you might write a request for a letter of interpretation, and there will be a formal response documenting what the Office of the Solicitor has said. Anything else about COVID? If not, some of you may remember Dr. Dawn Cannon. She started out in OB, then decided to become a pathologist, was a faculty pathologist at Howard University for many years, along with associate dean for students. Sometime mid-career, decided she wanted to go back to seeing patients, did both complementary and alternative medicine and some toxicology at the NIH, and a preventive medicine residency when she rotated through OSHA, and she turned out to have, you know, she helped us see how useful pathology and forensic pathology knowledge and rigorous thinking would be for our office. So she has spent some time in thinking about this topic. We've come to think of this as, you know, death, syncope, all of these sudden things. Internists, family practitioners don't really know where to go with that. So this is a first cut at thinking about why people might die. Thanks. Can you switch to Dr. Cannon? Can everyone, can anyone hear me? Yes. Okay. I am sharing my screen, but please let me know when you can see my slides. They're up. They're up? Okay. Good morning, everybody, and thank you, Dr. Hodgson. You went way back with that introduction. That was good recollection there. My talk is called Dying in Low Oxygen, Learning Lessons Rather Than Lessons Learned Because We're Nowhere Near Finished. So I have a lot of things to operate here. If you see me looking around, it may not be because I'm confused. And, of course, slides are not advancing. Let's try that. Are you all getting slide advance? Let's try that again. Now we have you full screen. Okay. So my slides weren't advancing for me. Were they advancing for you? No. Okay. That was the problem. Let's try that again. First slide is up. Did you go to my second slide? No. Okay. Back at the A.V. desk, what key does she need to hit? That's my problem. They're not advancing irrespective of the key. Can you advance your slides? That's what I'm trying to do. Or would you rather have us go to the next presentation while you work that out? Why don't you do that? Okay. Thanks. So let me introduce the second, third presentation. Two colleagues, Dr. Virginia Weaver, some people may remember her from last year, longstanding Hopkins Residency Director, fortunate to come to OSHA a year and a half ago, trying to redo our OSHA rotation. And Melanie Hayes, nurse practitioner, they're going to talk about credentialing, scope of practice, and the weirdness that we see. Good morning, everyone. So for our next topic, we're going to talk about medical management to provide occupational health care for workers and associated scope of practice issues. So I wanted to start just by talking about the three common models that are used to provide occupational health for employees. The traditional approach is, of course, to have a corporate medical director with on-site workplace clinics or plant clinics, lots of terminology for this. And in that setting, the medical director may provide supervision for the plant's clinical staff, or there may be on-site part-time or full-time physicians, PAs, nurse practitioners. If that level of clinical supervision is not present, then you really have to look carefully at the care staff are providing to make sure that it's consistent with their scope of practice. And that leads us to model number two, which is an increasing approach to use EMTs, LPNs, sometimes RNs, to staff a worksite clinic. And in that setting, there needs to be some type of clinical supervision for most of the activities going on in these clinics, either from a physician or, depending on scope, a state law, PA, or nurse practitioners. A third model commonly used is to outsource the occupational medicine needs, in this case with a clinic or a hospital clinic. And then there's a range of health care providers. So clinical supervision is not an issue. What is an issue, though, in that model is having occupational training and knowledge in the staff and, importantly, knowledge of the individual hazards in a workplace of an employer using an outsourced clinic. Now, what are some of the implications of inadequate clinical supervision? Well, the first concern is that there's no opportunity for case discussion. If an EMT or an LPN is doing a more complicated case, who are they going to ask for assistance? There's no regular review of their medical records to ensure that they're evidence-based and quality of approach. Job modifications, restrictions, or transfers may not be provided early in the course of illness or, in fact, at all. And that's critical for work-related or work-exacerbated disease. So consider work-related musculoskeletal disorders, where job modifications are often a lot more important than ice and a few nonsteroidal tablets. If there's not opportunity for medical referral or job adjustments, employees may feel, what's the value in coming into our on-site clinic? Our symptoms are not improving, and we're not getting value out of it. So that increases employee turnover, which then increases employer costs and can run into scope of practice issues if the staff are not having appropriate supervision. And when we say scope of practice, we're talking about skills and clinical services that health care providers are licensed to perform under state law. Now, part of the scope of practice challenge comes from two very different definitions of first aid. When we think about clinical first aid, we're all thinking about that emergency care stabilization after an acute injury or illness where an employee is then taken to the hospital for full medical care. However, OSHA agrees with that but confuses the picture a little bit by using the term first aid in their record-keeping rule for the 14 therapies that do not have to be recorded on the OSHA 300 log because OSHA doesn't consider those medical. So as I know most of this audience is aware, we're talking about hot and cold therapy, non-prescription meds, non-prescription strength, certain wound coverings, massage, fluids for heat stress, et cetera. So the issue comes in recurrent therapy even providing something that OSHA considers first aid for record-keeping is not the same as clinical first aid because think about it. Each time a health care provider makes a decision to provide ice and ibuprofen rather than to refer for a full medical evaluation, that's a medical decision. That's not first aid. And if an EMT or an LPN is making that decision in the absence of clinical supervision, that's a scope of practice concern. Now OSHA is very clear on clinical first aid, and this is a wordy slide, but it's just to illustrate the fact that in OSHA's medical and first aid standards, they talk about first aid training and specifically mention the American Red Cross or equivalent which we all think of as first aid. There's a 2007 letter of interpretation and OSHA's best practices guide, Fundamentals of a Workplace First Aid Program for Employers, that also emphasizes that OSHA gets that clinical first aid is very different from their record-keeping standard. So what are the implications of this? So a couple of theoretical examples. Let's say a warehouse employer sets up an on-site workplace clinic for first aid and follow-up of workers. So as you can imagine, warehouse workers are going to have a high risk of shoulder and back pain. So let's say this employer hires an LPN to manage the clinic, assess the workers, give them first aid therapy, some ice, some non-steroidals. Under state law, an LPN can't work without having direct supervision by a higher-level provider. So this runs the risk of not referring workers in a timely fashion, delayed treatment, higher medical costs, and licensure issues for the LPN. A second example would be an EMT-staffed clinic. Let's say a maintenance worker works on a machine repair, doing overhead work for a prolonged period. Not surprisingly, at the end of the shift, that individual comes to the clinic, sees the EMT who does a full evaluation, gets some history, does an exam, comes up with an assessment of sorts, and then comes up with a medical management plan. And basically, ice, non-steroidals, come back and see me the next day. So although the ice and non-steroidals are first aid for record-keeping, that encounter is clinical and that's medical. And this slide is another wordy slide just to emphasize the point that we are fully aware that the scope of practice for EMTs is expanding to help meet the need for primary care in underserved areas, so the community paramedic model. We get that, but we want to point out that in all of this recent documentation about expanding scope for EMTs, proper supervision is fundamental in sentences on this. Then a few real-world examples that we've encountered in our inspections here at OSHA. Delayed or absent referrals for lacerations over joints, carpal tunnel syndrome, stenosing tenosynovitis, and other obvious abnormalities on exam. A particularly egregious example is cold therapy applied in a nursing station 94 times before the worker got referred for a physician evaluation. First aid providers should never be preventing a worker from seeing a health care provider for definitive diagnosis and treatment. We've seen instances where work modification is not provided when it's clearly a work-related musculoskeletal disorder. We've seen inadequate documentation of care in a medical record. I've seen instances where the only note for a clinical encounter is a couple sentences of subjective text from the worker. Another concern are facilities, particularly meatpacking, that hire employees who are immigrants from many different countries and don't speak English particularly well or at all. The clinic staff may only speak English or at best be bilingual English-Spanish. The result then is translation provided by coworkers or management, which leads to lack of confidentiality, discomfort. Employees likely don't want their manager to know all of their medical history or inability to communicate complex medical information. Another concern we have is lack of staff training in occupational health and workplace hazards. Now, you might think medical directives would be a way to resolve all these concerns, but I would encourage you to ask a lot of questions. If your local employer says, could you do me a favor? Could you just sign off on these directives? Maybe do a few edits here and there and we'll be good to go. We've seen instances where the physicians who've signed off on these directives are not employed or even a consultant to the company. The physician may assume that there's an appropriate clinical supervision mechanism in place or a clinical provider at the facility who has the appropriate scope of practice, but we don't want to assume. Often the directives are outdated, underutilized, insufficient detail. In fact, this was problematic enough that my colleagues in the Office of Occupational Medicine and Nursing published on this a few years ago with some recommendations, some of which I'll get into in the next slide, but clearly just for directives, making sure they have adequate detail and are evidence-based and avoiding employer interference to prevent OSHA recordables. So our overall recommendations, ensuring, of course, that staff at all sites do in fact have supervision by a health care provider whose scope of practice includes all the clinical care provided and can provide regular case discussion and medical record review to look for quality of care. We are big advocates of occupational health training and, importantly, board certification. And in that regard, let me shout out the American Boards for Preventive Medicine and Occupational Health Nursing, really important board certification that employers should be looking for. What do we do as OSHA when we encounter mismanagement? We send a hazard alert letter to the employer detailing exactly what our concerns are, why we have those concerns, and what recommendations we have to improve the situation. We are an agency that contacts employers. We do not report individual staff to their relevant state boards for scope of practice issues. However, if we identify truly egregious, unethical behavior, we will report that. Finally, a couple resources. OSHA has a best practices guide for employers in setting up a workplace first aid program. And, of course, ACOM has a scope of practice document. And OSHA is also working on a best practices for non-health care employers with on-site health care services. So with that, I am going to pass this off to my colleague, Dr. Melanie Hayes, who we're very excited to have at OSHA, our first DNP. And she's going to take you into the Respiratory Protection Program and scope of practice issues there. So thank you very much. So as Dr. Weaver mentioned, we're going to get right into the Respiratory Protection Program standard. The 29 CFR 1910.134. Obviously, many of you are very familiar with this standard. But it is a frequently cited standard during the COVID-19 pandemic. And that is possibly going to continue for quite some time. So I want to just outline some of the key elements of the respiratory protection standard. There must be respirators available in workplaces where there are hazardous airborne contaminants present. There must be a written respiratory protection program in place, and there must be medical evaluations. As you know, respirator use, the negative pressure tight-fitting respirators, cause a physiological burden on workers, and the medical evaluation is designed to ensure that those workers can withstand that burden without any adverse health effects. Medical evaluations must be performed prior to fit testing and respirator use. Additionally, the employer must identify an appropriate PLC-P. Now, you've heard this term before, but for those of you who may not be familiar with it, a PLC-P is a physician or other licensed healthcare professional. Those are the ones that must do the medical evaluations. And the questionnaire in appendix C of the standard is mandatory unless there's a medical examination completed that elicits that same information. Sections one and two of part A are required. They gather medical information, medical history, both general medical history and medications and personal habits of the workers, as well as a more specific targeted cardiopulmonary history as well as review of symptoms. So the medical evaluation must be done by that questionnaire or the medical examination that obtains that same information. And for any employee that gives positive answers to those history questions, they must get a follow-up medical examination. The other instance where they must have a medical examination is if the initial exam requires additional follow-up. And finally, employees must be given an opportunity to discuss the answers on their questionnaire and the results of their examination directly with the PLC-P. Additionally, respirator medical evaluations must be done confidentially during the employee's normal work hours or at a time that is convenient for the worker, in a manner that ensures confidentiality and in such a manner that the employee understands the content of that evaluation. Also, employers and supervisors must not look at that medical information. That is confidential. If the medical questionnaire is utilized for the evaluation, there should be mechanisms in place such that the employer can deliver that medical questionnaire directly to the PLC-P. So in a case study, this is kind of a conglomeration of some things that we have seen at OSHA since I've been there. In long-term care facilities, rehabilitation facilities, behavioral health facilities, usually these cases did not have an internal occupational health or employee health clinic. There were supply issues. We know from the beginning of the pandemic, the scramble that employers were involved in trying to get respirators for their staff. And while I can appreciate that many directors of nursing and long-term care facilities were really trying to take care of their employees and their patients, ensuring that they met those staffing ratios, they often were tasked with doing medical evaluations that were outside of their scope of practice. We also saw outdated infection control and respiratory protection programs. In many cases, if they had one, it was developed in 2009 during the H1N1 outbreak and had not been updated since then. And also the final thing that we really saw was there was no designated PLC-P available to do the medical evaluations or follow-up medical examinations. We saw that employers, not medical officers or qualified PLC-Ps were delegating these evaluations to registered nurses, and in some cases, LPNs, without PLC-P oversight or written protocols in place. As you recall, that questionnaire gathers clinical history, medical history, and that is within a scope of nursing practice to gather that history, that information. But if those answers were yes, that they had hypertension or heart disease, then if they were making a decision on that and they were a registered nurse, not an advanced practice nurse, they were acting outside of their scope of practice because at that point, it required medical decision-making. There were also documentation issues. In many cases, there was no documentation of medical evaluations being completed or there were no PLC-P written opinion documents available for us to review. So a long-standing question that comes up is who is qualified to be a PLC-P? Often, we know that physicians can do that, nurse practitioners can do that, PAs can do that, but can every physician, PA or NP, do that? The first criteria is that the person who's conducting that and is designated as a PLC-P must have within their scope of practice the ability to independently assess, diagnose, and treat medical conditions. Okay, that's pretty straightforward. However, as Dr. Weaver mentioned, it's also critical that they have sufficient occupational health experience to understand the physiologic burden of using a respirator in the conditions where they will be used. So as you can see, just having the title, NP, PA, or physician may not always qualify them as a PLC-P. We also want to be careful when we're delegating tasks to nurses in written protocols, to RNs and LPNs. Typically, we wanna consider the complexity of the task. RNs are basically licensed to do complex nursing tasks, whereas LPNs are usually licensed to do basic nursing tasks under the supervision of a higher level healthcare professional. In any case, there should be written protocols in place with appropriate oversight for personnel who are doing those tasks. So I'm not here to say that nurses cannot participate in the medical evaluation or be delegated those tasks, or even in some cases, respond if there's a yes question on the questionnaire. However, there should be protocols in place that very clearly define if there are positive answers, these are the next steps. So what we often saw is directors of nursing or nursing supervisors were now the designated PLC-P and were administering these medical questionnaires to their own staff. They would hand the questionnaire to the staff member, they would fill it out, give it back to the supervisor who was an RN, and he or she would make that designation of whether they could wear a respirator or not. And we also saw that in some cases, the nurses knew they weren't supposed to make those decisions. So they said, hey, go to your primary care doctor, have them fill this out and clear you. However, the standard does require employers to pay for the PLC-P fees and the worker's time away from work to do that. Obviously, there were privacy concerns in that last scenario and I've listed here some of the primary ones. Obviously, we know about the Americans with Disability Act and the ADA Amendment Act and HIPAA that requires personal health information be maintained confidentially. But OSHA health standards also have privacy requirements in there, including the respiratory protection standard. OSHA regulations require that all information obtained in a respirator medical evaluation must be kept confidential and not released to the employer. The PLC-P has some privacy requirements as well. They issue a written opinion and there's limited information they can give back to that supervisor. They can say whether the worker is medically able to wear a respirator or not with or without limitations based on the medical condition or the work conditions. They can advise whether there's a need for a follow-up medical examination and there should be a statement that the PLC-P has provided a copy of this opinion to the employee. So just some reminders here, key points. The employer must designate and train a respiratory protection program administrator. These are key players in a RPP. They maintain, they assess and determine what respirators are needed, maintain supplies. They can designate and contract with a PLC-P. They can ensure that medical evaluations are completed in a timely manner. So they're a key player in a respiratory protection program. They must be trained, however, and that is critical. There are some good resources available through OSHA and the CDC and NIOSH. There are guidebooks and guidance and toolkits that are available. I also want to just mention that the American Association of Occupational Health Nurses has an RPA program available online for free. You do not have to be a nurse or a member of AAOHN to take that course. And an RPA can be a health and safety professional, a nurse, it can be someone in HR, but again, they just need to be trained. Just a reminder, there must be a designated PLC-P to conduct those evaluations and the employer must pay for those and give the time off for the employee to do that. There should be written protocols in place and the supervisor must not review medical information. These are some resources that we have available and again, our slides will be available. But first, you'll see a small entity compliance guide with OSHA. That's a really good resource. There's also one specific for hospital respirator program administrators. There's an OSHA info sheet on respirator medical evaluation questionnaires and there's a clinician's page with OSHA that goes into the privacy rules. So if you're looking for more information about that or you're getting questions that you can direct people to these resources as well. If someone is looking for a qualified PLC-P, the Association of Occupational Environmental Clinics Directory of Member Clinics is available. You can go there, put in your state and your zip code and it will give you a list of board certified occupational medicine physicians in your area who can serve as a qualified PLC-P. And finally, I listed the website for AAOHN for the respiratory program administrator course. And with that, we'll take your questions about medical management and scope of practice. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. And then we'll get started right away. My topic is dying in low oxygen, entitled learning lessons rather than lessons learned because it's a work in progress. Great. I have nothing to disclose. It's working? Yes. Great. Okay. Nothing to disclose. Okay. Oxygen deficient atmospheres occur in a variety of work settings driven by organic, biological and inorganic, physical or even human created processes. Some are associated with elevated carbon dioxide levels. Some low oxygen levels have elevation in other displacing or toxicant gases. There can be dramatic variations in the level of low oxygen hazard. Using examples from OSHA files, this presentation will provide a typology of settings, review of criteria for oxygen deficiency, intervention and prevention measures in certain settings and areas for further inquiry. Per OSHA, an oxygen deficient atmosphere has less than 19.5% oxygen by volume as compared to the 21% oxygen by volume in air at sea level. The OSHA respiratory protection standard which you've heard so much about in the prior presentation requires in general that all oxygen deficient atmospheres be considered IDLH, immediately dangerous to life or health. And so if an employer demonstrates that under all foreseeable conditions, the oxygen concentration can be maintained within the ranges specified in table two of the respiratory protection standard and you can find that online in table two of this section by according to the altitude, then any atmosphere supplying respirator can be used to protect the employee from that IDLH environment. In order to get a feel for the scenarios at work that may play a role in creating oxygen deficient environments, I first looked at consultations within our own office over the last five years. Understanding that we see a very small subset of what may be seen nationwide in terms of these kinds of exposures, I decided to search a similar agency fatality inspections over the same five-year period. At OSHA.gov slash fatalities, anyone can search work-related fatalities for cases inspected by federal and state OSHA over the last five years. I did this to see how our consultations related to what was being captured nationally and also to see which unusual cases we were not consulted on. In fact, this is not an all-inclusive database and they state that as a disclaimer on that website. So the keywords I searched were those you might surmise. I didn't wanna look at explosions, death from fires, deaths related to cleaning chemicals or pesticides, any heat-related deaths or carbon monoxide-related deaths. So hypoxic work environments are generated in a number of ways, including production of hydrocarbons or carbon dioxide and other toxicants from leaking materials in storage tanks, natural gas lines, and from process valves. As well as asphyxiation hazards in welding and related processes that cause accumulation of gases that are known to displace oxygen. This slide graphically shows gases that will tend to accumulate in low-lying areas at the bottom of the slide and those that are lighter than air at the top. I also wanted to see which work spaces were categorized for the purposes of citation as confined spaces or permit-required confined spaces. And so to refresh, everyone, confined spaces include but are not limited to tanks, vessels, silos, storage bins, hoppers, et cetera, et cetera. The photograph that you see here shows a setting from an actual inspection where you can see the ventilation hoses that provide air and exhaust toxic vapors during confined space entry. It also shows that the employer was missing the guardrail needed to protect workers from potential falls. So to continue, a permit-required confined space has the additional requirements beyond a confined space of a hazardous atmosphere or material with engulfment potential that may have a particular physical configuration but must also have another recognized safety or health hazard. Whenever a worker needs to enter a permit-required confined space, a permit is required to be completed and the employer's written process and procedure for the permit-required confined space must be carried out. So this slide summarizes the findings of my look at the fatalities through the keyword search on the website I showed you, as well as our OOMN, Office of Occupational Medicine and Nursing consultations that would also fit the timeframe and case description. In fact, most of our cases were not included in the fatalities database. And thus, that's the reason I labeled this slide as OSHA O-M-N, low oxygen deaths over the time period, even though all of the deaths are OSHA deaths, obviously. So 24 incidents led to 31 deaths in total with almost half of the deaths in confined spaces and 80% of the confined space deaths were in permit-required confined spaces. Nitrogen accounted for over half of the deaths and are likely not among the OOMN consultations because our compliance safety and health officers are able to cite what the area offices would like to cite in those cases without our assistance. But do note that nitrogen was the killing toxicant in the three incidents where more than one worker died. And I'll talk a little bit about specific incidents as we go on. So in terms of prevention in confined spaces, four gas monitor is required for permit-required confined spaces and traditionally detects carbon monoxide, oxygen, hydrogen sulfide, and combustibles. The combustible sensors on these monitors are nonspecific but will detect what they're calibrated to detect but are able to detect a variety of toxicants including hydrocarbons, acetone, industrial solvents, alcohol, ammonia, halon, refrigerants, and toluene. In addition to the four gas monitor, we want to have loud, audible, and visible alarms and if possible, wireless transmission of the readings on the monitor and alarms remotely. Two-way system of communication inside and outside of the combined space is needed and audio should be clear in what are oftentimes loud environments. 24-hour video monitoring is certainly desirable and should be as high definition as is affordable, located both inside and outside the space and strategically placed to avoid blind spots as well as clear transmission in what are oftentimes dusty settings. And then finally, and importantly, the rescue plan. All permit-required confined spaces must identify procedures for rescuing entrants from permit spaces and preventing unauthorized personnel from attempting a rescue. So training and drilling are things that have to be addressed in terms of keeping workers who are not to be part of the rescue team out of the danger zone, even though that is their first inclination. In fact, many confined space fatality victims are those who tried to rescue coworkers without proper knowledge, equipment, and or training. They accounted for over half of the worker deaths in a 1984 NIOSH series, but in our series, much less frequently. But clearly, this is something that should be zero. So a few words about deceptive spaces. Workers sometimes assume that the space is not fully enclosed with one entry and one exit. It is not a combined space. Examples of open-top spaces include aeration basins at wastewater treatment plants, where maintenance may require traversing catwalks like the one you see in the photograph located above or risers placed within tanks. Work in open-top valve pits, for example, for water fountain displays, pose potential asphyxiation hazards, as workers must crawl inside these pits to perform valve adjustments and maintenance. Workers can be subject to unanticipated sewer gases or oxygen deficiency and displacement due to mechanical corrosion or vegetation decomposition. Surprise, post-mortem oxygen saturation is not helpful in determining the oxygen available in air at the scene of death. So moving on to some more cases. Three maintenance employees passed out inside a freezer room after one modified a portion of a liquid nitrogen supply line in an effort to get poultry properly frozen. They had been having some problems with their flash freezing of poultry not working properly. And so a maintenance worker kind of bent the nitrogen supply line a bit, causing a nitrogen spill. The three maintenance workers went down. Three co-workers came to rescue the downed maintenance workers, but in the end, all six died. So in our series of 31 deaths, where more than half the fatalities were caused by nitrogen, workers died from vapor, from the liquid nitrogen leaks, from tanks carrying liquid nitrogen, and from nitrogen purged tanks as well as nitrogen supply line accidents. Three incidents with more than one worker death were all nitrogen deaths. And nitrogen displaces oxygen, but has not been documented to have its own toxicity apart from this. So moving on, opening thief hatches can lead to release of high concentration of gases and vapors, possibly resulting in low oxygen levels and toxic conditions around and over the hatch, as well as nearby, depending on prevailing winds in the area. Oil and gas workers have experienced dizziness, fainting, headache, nausea, and in some cases, death while gauging tanks, collecting samples, or transferring fluids. Another case, an employee who had soaped a well, that is exactly as it sounds, added soap to the well, containing crude oil in order to improve gas production from the well was found dead, slumped over, and opened tank hatch. The autopsy report indicated that the cause of death was hypertensive and atherosclerotic heart disease, and that death was due to natural causes, except that the heart was not heavier than reference values, and coronary atherosclerosis was mild. Subclavian blood was negative for methane. No other volatile organic compounds were tested, but methane was not present in a subsequent sample obtained from the crude oil tank. OOMN determined that the employee's death was most likely due to exposure to hydrocarbons and oxygen deficiency, resulting in sudden cardiac death, likely from an arrhythmia due to opening the hatch of the crude oil tank. Only on the second round of testing of a remaining blood sample for an expanded VOC panel were N-butane and propane, as well as methyl ethyl ketone, detected. Methyl ethyl ketone is an N-butane metabolite. A hydrogen sulfide metabolite, additionally thiosulfate, was identified, but at a level below the lab's lower limit. And so, this was the critical testing that wasn't done on the initial sample that allowed our colleague, Dr. Weaver, to rightly identify what the worker was exposed to and probably killed him. And so, perhaps the drawings done by humans in caves in the Paleolithic area may have been inspired by altered mental states triggered by low levels of oxygen and also carbon monoxide from their torches. Another case, a maintenance technician was tasked to replace metal bars at the bottom of a pit furnace. Working alone, and this is an example of the type of furnace that he would have descended into, working alone using a step ladder, the employee entered the pit furnace to remove the old metal bars. Sometime later, another worker noticed the ladder sticking out of the furnace and upon investigation saw the employee at the bottom unresponsive. He also saw that the switch on the furnace control panel for argon gas was in the on position. The employee, number one, had been in the space for 10 to 15 minutes. The employee was retrieved and transported to the hospital. He died from asphyxiation secondary to argon exposure. The maintenance department employees did not obtain a confined space permit and did not follow lockout tagout procedures for the argon gas system prior to entering the furnace, among other violations. Argon is used in several processes, including heat treatment processes for manufacture of precision parts in aerospace, automotive, and petrochemical industries. As an inert gas, like nitrogen and helium, argon provides a chemically nonreactive environment. Unfortunately, there is no good method to measure the level of argon in a workspace where such an incident occurs. In another case, a welder using a tungsten inert gas torch, titanium filler, and welding on titanium was found unresponsive. A hose had been run inside of his purge box for a few minutes before the welder was able to remove the hose from the furnace. The welder was able to remove the hose from the furnace, but the hose was not able to be removed from the furnace. The welder was able to remove the hose from the furnace, but the hose was not able to be removed from the furnace. A hose had been run inside of his purge box for pumping in argon to purge the atmosphere. So when welding stainless steel or reactive metals like titanium, an inert weld environment is critical to maintaining the integrity of the welding joint. And this is what argon provides. The photograph shows a nice makeshift argon purge box with the, I don't know if you can see it, I can't see it on my view, with a pallet situation created to put the purge box at the angle that the welder desires to use his welding equipment. Moving on, we now know that carbon dioxide accumulation and oxygen deficiency can be hazards even when there is no connection of the worksite to an active sewer. We also know that the carbon dioxide and oxygen levels can vary unpredictably over time in some cases. The above table is from an OSHA investigation where a supervisor entered a manhole to verify that an employee had created a proper vacuum seal. The supervisor lost consciousness as his head passed into the manhole and he fell to the bottom. A second worker was called to the manhole by the supervisor's assistant and he entered the manhole and also lost consciousness. A third worker saw the two workers at the bottom of the manhole. He entered, made it to the bottom, but collapsed as he was attempting to exit. A fourth worker finally called 911. A short time later, a fire department responder removed worker three after he was found to still be alive. But the first two individuals to enter were dead at the scene. The third individual eventually died at a local hospital. Smith et al brought together a partial listing of OSHA-inspected confined space fatalities and near misses. So in the first sub-bullet, in the subset of eight incidents where there was no active sewer connected to the work, low oxygen and high carbon dioxide were documented, causing 11 deaths and seven near miss injuries with five in one accident. In nine other incidents, low oxygen alone was documented, causing 14 deaths and two near misses. The bottom line is employers sending workers underground must prepare for the possibility of low oxygen and other hazards that may be unanticipated because they are working in newly constructed confined spaces that are not connected to any sewer systems. So a couple of notes on two special industries. An employee was pumping wine lees out of a tank. He entered the tank and was found unresponsive and died. Wine making does have its hazards. One of the workers in the OSHA case series died after being exposed to the atmosphere created while pumping lees from a wine tank. Now, lees are the tan colored dead yeast particles that collect at the bottom of a fermentation vessel. Fine lees, as opposed to gross lees, are in fact desirable to some degree in wine making because allowing the wine to incubate with fine lees creates complex flavors that appeal to onopheliacs. In this context, however, it sounds less than appetizing. Possibly, asphyxiants include carbon dioxide, as well as nitrogen, which is used when purging wine in transfer or adding inert gas during manufacture or bottling and deoxygenation of dissolved oxygen in wine. Carbon dioxide we've already mentioned, and argon is used as a more expensive alternative for oxygen displacement. Apart from low oxygen hazards, other hazards in this industry beyond the scope of the presentation include certain wine additives, yeasts, ozone, anhydrous ammonia, and sulfur dioxide, diatomaceous earth, caustic cleaners, copper sulfate, and carbon monoxide. And finally, artificially created hypoxic conditions as a means of fire suppression. There are work settings, as a work setting, where the hypoxic condition is man-made. So normobaric, or sea-level hypoxia in fire suppression, is created by increasing the percentage of nitrogen in the air, thus displacing oxygen and preventing combustion. Also, with the added benefits of avoiding sprinkler systems and the damage that water creates when fire is extinguished, and altogether avoiding the beginnings of the fire, because it is a preventive measure. So no fire damage, no water damage, if it works appropriately. And the health hazards are looked at in the context of the kinds of hypoxia that we see in acute malnutrition. The kinds of hypoxia that we see in acute mountain sickness, and all of those subheadings. But just in terms of an extreme short exposure, as opposed to a longer high altitude exposure. And so this technology is used currently in places like server rooms, and data centers, and storage areas for various valuable or hazardous materials. But because the oxygen in these facilities is less than 19 and a half percent, as defined by the respiratory protection standard, this constitutes an IDLH environment, and therefore supplied air or SCBA respirators are required. The thoughts I want to leave you with today, are that per the table on your left, we can see that the country abbreviations for Switzerland, that is CH, Germany, DE, France, and the UK, have workers in these industries working in the above levels of hypoxia that you can see on your right, without the respiratory protections that OSHA requires in similar systems. Maybe that'll be a talk for another meeting, but it's actually how I ended up discussing hypoxic deaths. Anyone who has seen the movie Tenet, which I recommend for action movie lovers, knows that fire suppression by halon is an element of this movie plot. Halon actually chemically disrupts combustion and does not displace oxygen, so Tenet does provide an example of fire suppression, but not via a hypoxic environment. I thought it was too great of a photo to just pass up. Workers in an oxygen deficient environment are required here in the states to use supplied air respirators, but if they didn't, what might be the concerns, and at what oxygen levels? Thank you for listening. My references are listed at the end, and my handout should have been available to you for this presentation. I can't figure out how to get slides for any of the presentations. We're hoping they're going to show up at some point in Swapcard, but if people send us emails, we can email those around. We have questions for Dr. Cannon. Cathy Fagan, this was a wonderful presentation. All of your presentations have been wonderful. I'm wondering where you're going with this. Can you talk about prevention? Have you thought about prevention for some of these? And then a second question was you didn't do the bathtub refinishers, and I'm assuming that's because in most cases those were methylene chloride deaths, but sometimes we found not much methylene chloride in the blood and started wondering about oxygen deficiency in those deaths. So those are my questions. Thank you. Thanks, Dr. Cathy Fagan. For people who don't know, Dr. Fagan used to be one of us. So this was really my first sort of rush over these cases in aggregate, and apart from the items that I mentioned with respect to confined space type of prevention, I don't really have anything to give you right now. And so that answers your last question. As to your first question, hopefully I will have time to drill down on some of these as the days pass, because this ends up being quite an interesting series of fatalities. But apart from what I gave you in the presentation, I don't have anything for you today, sorry. So Dr. Cannon, as a pathologist, has a number of intersections with the National Association of Medical Examiners, and increasingly we see that MEs and forensic pathology don't always view what we think of as occupational deaths in the same way. And so Dr. Cannon is leading an activity that we hope will, down the line, lead to a more systematic kind of collaboration across the country with them looking at the workplace. So these deaths from a variety of causes may also present as syncope. Sometimes people recover. So from our perspective, we are trying to look at where the gaps are between occupational medicine and other specialties, and where the clinicians could point to things. Each of these events had a violation of either good practices or common sense. Actually, almost all, not quite all of them. And that wasn't part of what Dr. Cannon was trying to do here. But when you think about permanent confined space, there are a ton of OSHA citations on that. That wasn't the goal of this presentation. Other questions for Dr. Cannon? Dr. Cannon, hi, my name is Luke Mies. My question is regarding the N2, and specifically, is an enclosed space requisite for that to lead to death, or is it just the fact that folks are working with a lot of nitrogen that can displace the oxygen? So are we seeing those deaths in places that aren't necessarily enclosed spaces, or were all of those enclosed spaces plus the nitrogen? Thanks for that question. Most of the deaths in the series, just about half, actually, were in some type of confined space. The nitrogen deaths, as I said, and I'm thinking as I'm talking, were mostly supply line types of issues, issues with liquid nitrogen exposure, and then the vapor. Yeah, as I think about it, most of them were confined spaces. And just, you know, a word about this confined space, as I'm telling you it, and the permit-required confined space, it really, in some cases, ends up being kind of a tug-of-war, because the employer will be cited for, perhaps, a confined space for something that it did not believe was a confined space, and that will be kind of the basis of the legal argument, was this or was this not a confined space. And so, you know, as I tell you what it is, it is the judgment of either the compliance officer who entered the data, or me, in the case of looking at this data and making a determination based on the description that I think something is a confined space, even if that keyword is not mentioned in the case description. So hopefully that answers your question. It is my impression that most of these were in combined spaces, and since most of them were in nitrogen as well, I think that that overlap exists. Thanks, Dr. Cannon. There was a liquid nitrogen rail car death where somebody popped the hatch, and the nitrogen came out and displaced oxygen, and we've seen a number of hatch deaths. I think, do you want to talk about your recent one? We're out of time. Hatches are a growing interest, pressure and tanks, the plume displacing oxygen, people who remember the MMWR a few years ago. So there's stuff going on that we don't quite understand yet. It's been an issue for the Coast Guard on shipboard hatching and transportation. We're not there yet, but I'm told we're out of time. Thank you. I don't think there was anything more. No more chat questions either. Thanks all.

oxygen deficiency

asphyxiation

work settings

hazardous conditions

gas monitors

clear communication

rescue plans

proper training

identifying hazards

addressing hazards

oxygen deficiency risks

work environments

prevention