Good morning, my name is Alexey Kreniv, I'm one and this is Wally John Geary, and both of us are second year OEM residents from the University of Cincinnati. The topic of our talk today is integrating chemical disaster response into occupational and environmental medicine residency training and curriculum. Before I start, I would like to acknowledge the contribution of our fellow co-residents including Erin Clark, Dania Keitel, and Taylor Buckley. Likewise we'd like to acknowledge the work and support of Dr. Victoria Wilson, our program director, and Dr. Nicholas Newman. Before we start, we'd like to make a few financial disclosures. We would like to acknowledge support from the American Academy of Pediatrics and the American Agency for Toxic Substances and Disease Registry. Likewise we'd like to acknowledge the support from the Cincinnati Children's Hospital Pediatric Environmental Health and Specialty Unit. And myself, I just wanted to acknowledge my work as a medical consultant and marketing researcher for the last two years. No further disclosures to make. So to start out with, our objectives will be as follows. One, we're going to talk today relating to relevant sources of toxicologic information for chemical disaster response, discuss some of the limitations of applying occupational exposure limits in community-based settings. And then finally, we're going to discuss the role specifically of OEM and disaster response and addressing spills and disasters in community settings. Specifically, we will discuss the railroad transport of hazardous chemicals and materials. We will do a brief overview of the East Palestine train derailment and how that is an excellent example of how environmental medicine and disaster response intersect. We will also discuss more specifically the limitations of occupational exposure limits in occupational versus community disasters and releases. And then finally, we're going to discuss our specific role in conjunction with the Cincinnati Children's Hospital, the PSU, and our collaboration with the ATSDR and Ohio Department of Public Health. So to start out with, I'm going to begin by giving a brief overview of the rail transport of hazardous materials. And basically, one thing I would like to emphasize is that unfortunately, rail derailments nationally are a common occurrence. Over the last year, according to the Federal Railroad Administration and FMCSA, there have been 1,164 derailments. Leading causes were human error and track defects. And then the question is, why don't we hear about these derailments on a regular basis? And the reason is quite simple. Most occur in rail yards and remote locations. And if we look at derailments over the last three years, the number has more or less stayed steady between 1,100 and 1,300. And multiple federal agencies, as well as industry groups, are involved in mandating safety and regulation for tanker cars and carts on the road. These agencies include, like the DOT, the Pipeline and Hazardous Materials Administration. Over the last 20 years, there have been some improvements in safety, one of which is known as the Rail Safety Improvement Act of 2008, which basically began to introduce kind of an autopilot for trains using the GPS system. And if we look at the rate of train derailments as reported by the FMCSA, it has remained more or less stable. This is basically the number of trail derailments per one million miles driven on track, and it's between 2.9 to 2.99 over the last three years. So despite advances in safety and despite the presence of some collaboration between industry groups and government, the number of derailments has largely remained unchanged over the last 20 years. Next I wanted to transition to chemical spills, because that's the other component, is not only derailments but also chemical spills. And that, too, is kind of an unfortunate story, because it turns out they're also quite common, and we also don't hear about them on the news. According to the EPA, and recently a piece done by the Guardian, investigative piece, there are close to 1,650 accidental releases over a 10-year time span between 2004 to 2013. Likewise, over a six-year time span most recently, there were 775 reported. Now these releases are of varying severity. Some have involved shelter-in-place orders, and some have involved evacuation orders. But more than 50,000 people have been affected in some shape or form. In terms of federal agencies that have a leading role, obviously one is the EPA, which I will kind of get to a bit later. But another one that is often overlooked is known as the U.S. Chemical Safety Board, which is an independent, non-regulatory federal agency. And basically what the Chemical Safety Board does is, any time there is a major spill, it undertakes a root cause analysis. It cannot really issue levies or fines, but it can give specific recommendations to industry groups and federal regulators such as the OSHA and EPA. And if we look at both rail derailments and chemical releases, over the last two and a half years, there have been 10 major ones that have been recorded. And once again, most have occurred in the confines of the chemical facility. And one of the limitations in defining and tracking these types of accidents and releases is that there is a lack of a national surveillance system. There have been attempts in the past, one of which was through the National Toxic Substances Incidents Program between 2010 and 2014. This was in part sponsored by the ATSDR. This involved nine state health departments from California to Wisconsin. And then, obviously, the other agency that I mentioned earlier was really it's the EPA. The EPA helps administer the Toxic Substances and Control Act, RCRA, and CERCLA. Likewise, OSHA through the Department of Labor has mandates for explosive hazards and communication standards. And then, finally, you have other federal agencies such as the Nuclear Regulatory Commission that play a role. And then, more recently, since September 11th, you now have the Department of Homeland Security and also the Coast Guard, given that the sabotage of chemical facilities has an important security implication. And then this is just kind of an overview of what we went over. We know that TASCA and RCRA and CERCLA are all administered through the EPA. And the TASCA is set as a registry that the EPA keeps. And then the RCRA is kind of the cradle to grave means of regulating waste and chemical waste. And then, finally, CERCLA is the Superfund cleanup site. Next, I'm going to switch and give a brief overview of the East Palestine Trail derailment, which, as I alluded to earlier, is really an example of two things coming together, a chemical calamity and a train derailment. So what occurred, this occurred on February 3rd, 855 in the evening. There was a train with 149 cars, 20 of which were carrying known hazardous materials. And one of the wheel bearings on the 23rd rail car became overheated. However, there was a failure in the alarm system. As the rail car became overheated, there was concern for a fire. And the incident by 1053 was reported to the National Response Center. By the fourth day, there was EPA sampling at the site. And then, finally, one of the cars became overheated. And there was concern for an explosion potential. And so that's when the initial evacuation order came into force for a one to two-mile radius with approximately several thousand people impacted. By February 6th, a decision was taken by, from what we understand, a command center or committee of local first responders and also state safety officials, including the governor, to do a controlled drain and burn to avoid spontaneous combustion. And then by February 8th, the order had been lifted after reassuring air sampling. Multiple chemical agents were involved in the controlled release as well as the combustion. The primary one of greatest concern that, you know, we talk about is vinyl chloride. But also you have things like phosgene and hydrochloric acid. You have a slew of other agents from acrylates to petrol oil. In basically considering any type of chemical spill, one, we're always taught to, you know, emphasize and really think about the persistence of the agent in the environment, such as from the controlled release. What is the potential for bioaccumulation? What are the breakdown products of the agent? And what is the effect of dilution? And what are the effects of short versus long-term risks? So I'm going to go ahead and turn my presentation over to Dr. John Geary, my co-resident. Good morning, everyone. My name is Wally Johan Geary. I, like Alexi, am a second-year resident at the University of Cincinnati. I hope you found the first part of this presentation informative. We're going to shift gears a little bit. And as you know, occupational and environmental health professionals play a critical role in identifying and managing work-related hazards. However, these skills can apply to environmental disasters, significantly impacting nearby communities. Before we get into it, I'd like to open up the floor to you. And I'd like to understand how you think we can leverage our skills to manage and to address the unique challenges of environmental disasters, such as the East Palestine train derailment. And this slide here has some questions to get you brainstorming. And I was hoping that some of you would share your thoughts, your experiences, and your ideas related to leveraging occupational and environmental health skills to address environmental disasters like the East Palestine train derailment. And do we also have a microphone, too, in case this is going to be open forum, too? Thank you. We have a courageous one here. All right. I'll break the ice on this. You know, I think this was a perfect example of when you need an immediate response for information gathering, for example. Like, what are the chemicals, what is going to potentially be released, and what do we know about these things? And so perhaps that's a way to leverage the occupational environmental medicine expertise initially simply to just gather the information that can then be shared. And then translating that from a risk communication to the local community that needs to understand why are their eyes burning? Why do they have sore throat? What is this smell? You know, to be able to provide some kind of communication back. Absolutely. And to respond to that, that was one of the main concerns of the residents of Paulsboro, New Jersey. It's not too far from here. I think a few years back they had a derailment, too. 2,300 gallons of vinyl chloride were leaked. And the Department of Health, they surveyed the residents. That was their number one concern was that there was not enough messaging from people in authority. And so I just wanted to echo what you had to say. Thank you. Well, I think that the ACOM has a long history going back just prior to 9-11 of concentrating on disaster management. That emphasis has been kind of attenuated and lost over the years. But there was a time around 2000 when we were putting a lot of effort, a lot of effort, into issues of homeland security and the rapid response to chemical and biological threats. Maybe the time has come to revisit that. We had a dedicated track at AOHC for precisely this sort of thing in disaster management. And if you look at the papers, the policy documents that were generated at ACOM at that time, that's when the disaster paper was first formulated as guidance for what the role of the occupational and environmental physician was. In a case like this, though, it points out just how highly specific these issues are. Because the reason why the material was drained was to prevent a very specific outcome called the BLEEV, a boiling liquid explosion scenario. And the BLEEVs are well known in the oil and gas industry, maybe not as quite so well known outside of the chemical sector. And without knowing that, even an occupational and environmental physician would be at something of a disadvantage in trying to explain that to the public and to provide guidance on appropriate response. So I think maybe discussions with public safety about the section on public safety, about revisiting ACOM's position paper and relooking at the past experience might be in order. Because as you quite correctly pointed out, these are not going to go away. Because transportation safety, if anything, is getting worse. So we have to be prepared for these things. Love that. We should probably switch spots. You should come up here and talk more. Thank you so much. Love that. Thank you. As occupational medicine physicians, many of us are, we have some toxicology awareness that we can apply in situations like this. We are familiar in many cases with industrial hygiene practices and sampling, environmental sampling techniques. We are used to working in interdisciplinary teams and within management structures that may be set up on an ad hoc basis. These are all skills that occupational medicine physicians, many of them, possess and can apply here. Wonderful. Thank you so much for that. So I've been involved with a large environmental and occupational disaster known as 9-11 for 22 years and actually initially leveraged occupational medicine in 1993 at the first bombing of the World Trade Center when occupational medicine residents did respirator clearance exams around the clock at the World Trade Center site for anyone going in. So we initially did that. One of the lessons that we learned in leveraging our skills is to make sure that people are aware, not only of the long, everyone's gonna go immediately to cancer. And what we found at the World Trade Center was that there was so much concern about cancer in the first week and the asbestos which was there, which is gonna be an issue going forward in the next few decades, or we hope it won't be, but that's when it will occur. But it didn't cause any initial health consequences. What you need to do is use the expertise to separate why do people have burning eyes, why are their pets getting sick, related to the initial health hazards, as well as what might come down the road. But make sure that people know to focus on the immediate and then what the medium and long-term are. Antibiotics probably were in short stead in New York City in 2001 because so many people inappropriately got them. If they had instead been treated appropriately for reactive airways disease, which they all had for breathing in the dust, we might not see so many of the consequences we do now. So it's really using the expertise to understand what the exposures can do in the short-term and also making sure people are aware what happens in the long-term. Thank you very much for that answer. And I touch on a few points that you made, which were very eloquently delivered. Thank you very much. Yeah, I think it's very important to recognize that when this occurs, there are immediately health effects. People are petrified about what's going on. They're disturbed, they're anxious. And then you add to it odors and irritants in the air. They have health, you know, so they got the whole thing going on. One of the other things that I recalled hearing in the news that people complained, you know, statements saying there was like the expectation that people would be able to measure what was in the air and what was causing symptoms. And I think that that was not conveyed to people that they don't have unlimited measurement capability, that there are a whole variety of complex substances that could be causing these symptoms that are more of a topical irritant type of thing that's happening right now. And we acknowledge them, even though the harmful things that we are specifically looking for are not detectable. And I think that could have been potentially conveyed in a lot better means, you know. And then, of course, you hear of vinyl chloride, and it's a known human carcinogen, et cetera. That's gonna create a lot of, you know, chaos and concern. And the fact that, number one, it was burnt up is number one and also that the exposures wouldn't nowhere near come close to what resulted in cancer in people and back in, you know, the 1950s, 40s, 50s, and 60s. You know, that could also be conveyed. But you're not gonna have any effect with trying to soothe people about, we haven't measured things or we haven't, if you don't first acknowledge that, yes, there are real things going on, you are really experiencing something. And we recognize it's a complex problem and we're doing our best. Because the main thing is that you have a lot of secondary harm that can be prevented if you have misinformation. Because I think we all know, the more people focus on something, you know, the worse it's gonna get, the worse they're gonna feel. Great, thank you so much. I appreciate what everyone said and I'd love a chance to organize it and publish it or write it up in a way that's meaningful. So I did a little thinking too. And I came up with four specific OEM skills that can be leveraged to address unique challenges of environmental disasters. The first skill that we have is our expertise in worker safety and promoting safety as well. And I think that can be leveraged specifically to addressing the resource and support gaps many first responders have. So we know that it's a critical issue. First responders are firefighters, police officers, paramedics and National Guard. They face various hazards, physical, chemical, biological, and they face significant stressors that can take a toll on their mental health. Now, one of the things I wanna talk about here is, they face significant shortages in outdated PPE. They lack specialized training with dealing with particular hazards. And sometimes there's problems with interagency communication collaboration. Funding or the lack thereof exacerbates all of the above. Now, let's look at all this through the lens of the East Palestine train derailment. And I'm gonna talk a little bit about that. Let's look at all of this through the lens of the East Palestine train derailment. What do we know? Well, we know that 300 firefighters were brought to the scene and they were from 50 different departments. We know that many of them were volunteers and many of them lacked proper hazmat training or specialized equipment. Three of the firefighters were exposed because of insufficient gear. Gear is expensive and it's sometimes difficult to come by. They lacked something called telematic information. Telematic, I think one of the attendings in the audience mentioned something like this during the open forum, but telematic information is essentially real-time data. It provides situational awareness. It helps collect and transmit with hardware and software to inform decision-making for first responders. It helps track the vehicle's location and operation and performance. Norfolk Southern also failed to establish an early unified command. So these firefighters were going in blind. They didn't know what the threat or the hazard they were facing. That can be a very scary, I mean, imagine being a firefighter and not having the best PPE and walking into, essentially walking into the dark. And I mean, ideally, if there was enough equipment, they could deescalate. Their PPE, but they have limited resources. So it would be helpful to know what exactly the hazards are. So I wanna use the World Trade Center Health Program as an example of resource gaps that first responders often have. We know that a lot of people were victim to the 9-11 attack. We know that a lot of people were victim to the 9-11 attack around, and I wanna say the exact number because it's important, 2,974. Much more people, much more, many more first responders have died in the following years due to the latent effects of the exposures that they had, about 5,578. And they face, many of you know this already, but they face chronic cardiopulmonary disease, cancer, and mental health issues. And often their over, their cohort in particular is overrepresented with particular malignancies like thyroid, prostate, and leukemia. Now this is an important slide because this addresses what can we do as a specialty to fill these gaps in support and resources for the first responders. These gaps impact their ability for an effective response and it limits their ability to protect themselves, protect themselves and others and promote their own health and safety. Well, the first thing we can do is we can provide onsite support. This is guidance on hazard mitigation, exposure control, the proper use and maintenance of PPE. And I think a very important one is we can really, we can help in the urgent, in the emergent setting because we do have an understanding of medicine, but also we can coordinate their care so we can seek out the proper specialists that they need to see because we have a medical literacy. The second thing is post-incident evaluation. And this is basically a fact-finding mission. I think that all too often these tragedies happen and we don't learn from the mistakes. So we really gotta dig in, dig our heels in and learn and have a growth mindset about this. We can identify areas of improvement and help with medical surveillance. These are some examples. Finally, we can advocate. We can advocate by working with government and NGO organizations to increase available support to them. The second skill that I wanna discuss briefly here is our expertise in the principles of epidemiology and policymaking. Specifically, I think we can utilize it to address the limitations of occupational exposure limits. Most of you are familiar, I hope all of you are familiar with occupational exposure limits. They work in a very specific fashion in a specific setting and they're not very dynamic. It's difficult to apply them to environmental disasters. For one, the dose is low and it's typically chronic. The studies are based on healthy workers. The route of exposure typically tends to be discrete and predictable and the risk that is assessed or the risk that is attributed to these chemicals is in isolation. Now let's compare it to the messy reality that happens in the environment. Well, for starters, the dose tends to be high. It's acute. It involves women and sensitive populations like children, fetuses, and the elderly. Oftentimes, the routes of exposure are multiple and unpredictable. For example, it could be in the drinking water or it could be in the soil. Like if you're a medical professional at PCP and one of your patients was exposed to the derailment of the chemical release and they ask you, Doc, is it okay if I can take a shower? I mean, we should be able to have an answer for that. Also, it ignores the cumulative risk for multiple chemicals when there could be synergy happening in terms of risk when you mix chemicals together. This is sensitive populations here. So infants, children, fetuses, asthmatics, people with coronary artery disease. I mean, we all have coronary artery disease eventually. Again, so we have to go on a fact-finding mission. We can't just let these things happen and not do anything about it. We need to engage the community with health surveillance. We need to do environmental monitoring and really advocate for improved policies. I mentioned this earlier in the open forum, but Poulsboro, New Jersey, not too far from here, they had 2,300 gallons of vinyl chloride leak out. There's a photo of it and this was a missed opportunity. What did the New Jersey Department of Health recommend? Well, some of the things are kind of intuitive. Age-appropriate care, establish PPE guidance and regulation for first responders. That's something I touched on. And I mentioned this in the open forum, but the residents had a resounding dissatisfaction with the amount of direct communication on how to protect themselves. I mean, put yourself in their shoes. If something happened, what would you do? It's scary. You want an authority to come in and speak to you. And I think as physicians, we have that credos and people will listen to us. Also, they called for community health surveillance and exposure registry, which we'll get into later. This is the third skill that I think is unique to our specialty that we can leverage. Well, we know preventive medicine and we also know health surveillance. We can address environmental disaster, I'm sorry, environmental justice issues and health disparities as well. So, train derailments is an environmental justice issue. It disproportionately affects rural, low-income, racial and ethnic minorities. There's an economic and social toll, even on top of what was a result of the disaster, the environmental and health cost. I'll give you some numbers here. So, about 51% of all deaths and 55% of all injuries nationwide are at passive grade crossings in rural areas. So, what can we do as a specialty? Well, I suppose we could track health outcomes and we can look for patterns that suggest health disparities and then come up with interventions to address that. I think we need to involve communities in the data collection for transparency and community ownership. And I think we need to advocate for stricter hazard control regulations. And I hope that's not a controversial suggestion. I think we also need improved infrastructure and we need policies that decrease or address inequities. We have to collaborate. Like someone mentioned in the open forum, collaboration is our skill set. So, we have to collaborate with stakeholders, NGOs, government organizations, community members to address the root cause. That's something that we're learning in our MPH. So, the root cause of the issue and then coming up with a way to promote justice. Now, interesting enough, we're at the University of Cincinnati and close to us is Fernald. I don't know how many of you are familiar with Fernald, but it was a uranium processing facility, right? A lot of workers, and not just workers, but community members exposed to uranium were enrolled in this cohort. And we find that they actually had better outcomes than the general population. And this isn't just due to the healthy worker effect. There were community members enrolled too. And this was because they had regular access to health screening and high quality care. And this resulted obviously into faster identification and treatment of cancers than the usual population. So, really this is, I mean, this is a health care access issue, but especially for communities that are affected by these disasters. Now, the final topic here, the skill that I think that we have is our clinical and toxicological expertise. And we can really help address the gap that other health care professionals have regarding environmental medicine. So, what did University of Cincinnati do? Well, we got called upon to respond and we discussed briefly what we did, our contribution to the emergency response to the East Palestine train derailment. We created fact sheets. We worked with PSHU. PSHU is the Cincinnati Children's Pediatric Environmental Health Specialty Unit. We were briefed by ATSDR. We were briefed by Ohio Department of Health. Basically, community members were instructed to conduct their PCPs and poison control for environmental medicine management, like what to do. And how to be managed. Unfortunately, both poison control and the local PCPs didn't know what the appropriate response was, what the appropriate management was. So, what we did was we developed a fact sheet. This is our specialty, so we made some fact sheets. And so, the root causes here is multifactorial, but one of them is there's a knowledge gap among health care providers. And it's lacking in medical school curriculum and in medical training. This is the timeline of what had happened. As you can see, the derailment happened on February 3rd. About 10 days later, our organization was briefed. The residents and I, we all worked together to make fact sheets. And we got those fact sheets on the 28th, so almost a month later. But we did our best, and we can see those fact sheets floating around. I think Ohio Board of Medicine put out an email with our fact sheets. But more work is needed, and we got additional review from UPenn and University of Kentucky. And it was put on the NIEHS repository. So, we made seven fact sheets on some high-volume chemicals. Vinyl chloride, hydrogen chloride, phosphagene, all these acrylates. But each fact sheet had contents. And I think something that was discussed frequently in the open forum, at least more than once, was the latent effects of these chemicals. And we did address that. And the surveillance, you know, we did our best. And this is where we got our information from. ATSDR at NIOSH, we even went to LIDU as well. So, in conclusion, there's a lot to be said. But trained derailments are a reality. And so are chemical releases, and they're actually quite common. We lack a national surveillance system. And OEM plays a crucial role in responding to these environmental disasters. And this is an environmental justice issue. Firstly, we have to address gaps in communication, medical surveillance, training, and resources for first responders. We have to prioritize medical surveillance and communication with the impacted communities as well. We can't just leave them in the dark. And then these are perfect fact-finding opportunities. We can't just let these happen and just stand by. We have to have a growth mindset as an organization. We should conduct the research on health effects of the disasters to improve the OELs so they can better protect all people, not just a certain type of worker. And we have to advocate for stronger environmental policies and regulations. Okay, thank you very much. Appreciate it. 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. Environmental exposures are necessarily higher than occupational exposures. I think that would be sort of patently not correct. But I think that you meant to say that there is a subset of environmental exposures that are emergent. And in those situations where there are disasters and environmental emergencies, there may very well be quite high levels. But generally speaking, occupational exposures are much higher than environmental exposures. And I think we all know that. But I just wanted to point out that that slide needs correcting. Because there's ambient and there's emergent. There's ambient and there are emergent environmental situations. And they're quite different. But on the whole, the environmental exposures are less. And that causes a lot of problems in interpreting OELs for the community. But the other thing I mentioned is that there does exist a set of standards for emergent situations, the EGLEs. The acute emergency guidelines that are in use for emergency response personnel that are in fact specific to susceptible populations. And they exist in three levels. And they're not intended to be used routinely. They're intended specifically for emergency situations. And you might want to incorporate that in the discussion. Thank you very much. So the, I think probably many people in this room, if called in at the time this event occurred, could probably have put together information and assessments related to PPE and the potential risks and hazards of the exposures within 24 hours. So the question I have, since you guys looked at this, is when something like this happens, who's supposed to take charge of a situation like this and handle it? If you have any concepts on that, on what did happen and maybe what could have happened. Well, I can respond to that. And this is actually not our first involvement with the environmental emergency. We've been involved with the ATSDR and the Ohio Department of Health. There was another leak at a Superfund site for 1,4-Dioxane. And usually this is really initiated by the Ohio EPA in conjunction with the ATSDR. And then we are brought in through the Pediatric Environmental Health Specialty Unit as a medical consultant. And that's really kind of what Dr. Newman does. And where we assist in terms of generating educational content and the fact sheets for the providers as necessary. So for the people who are here in this room, if you wanna play in this arena, I strongly encourage you to, if all you wanna do is deal with things three weeks later and then you don't need to do anything special, just wait till your phone rings. But if you wanna be active earlier on, I think it's worth spending the time to take the training that the other emergency responders have. Take the ICS courses, or whatever they call it this week, NIMS, they keep changing the name, but it's the same stuff. That's not just take the 100 and 200 classes, take the 300 and 400 classes, take them live. Go rub elbows with the firefighters so you can learn words like blevy and you can learn their vocabulary and be able to actually understand where their concerns are and what they're really talking about. And if you can, if you're gonna be in this arena, there are sometimes they offer a hazmat-specific version of the class, because you gotta understand where your role is as a staff advisor. As a physician, you're not in charge, you're a staff advisor to the incident commander. And you have to understand that and what your world is and how you can effectively communicate to the people that the incident commander cares about. And so if you don't have that training up front, you're not gonna do it on the first day and it's gonna go really badly. If you know how you fit into the big picture, because it's the same picture for every emergency response, it'll go much better. 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. 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. That's question one. And the reason I ask that is because I work in Philadelphia and we actually got a lot of calls from the community members and the providers. And it turned out that, like, as you've alluded, the transmission of information to the frontline providers, there's a lot of work that could be done about that. As evidenced by the fact that, for example, they later, when a lot of the journalists went out to interview them, the residents were telling them that CDC advised against testing for vinyl chloride, fire dye, glycolic acid. And so then the residents were saying, oh, the CDC is saying don't test. Whereas, like, the information should have been test immediately, not a month later, because that's useless. So I just wondered, what was your experience with these frontline providers and or community members? And what can you say about transmission of information immediately to these people who should be maybe testing immediately and not a month later? I think that's a really excellent question. What I will say is that a lot of times, by the time that the PSHU is involved, we're already kind of, the Ohio Department of Public Health gets most of the inquiries from the residents and the communities. And they kind of distill things into specific questions for us. And we really more or less interface through them. But we haven't gotten to the point yet where we're going out into kind of clinics in the exposed communities and talking with the people. So it's all kind of filtered down to us. And we kind of interface through the Ohio Department of Public Health. Wally, do you have anything else? Thank you. Thank you. I would like to just share with you what we do in Denmark. How to have these silos collaborating when there is a disaster. We have yearly training, practical training, where the EPAs, practical chemists, come together with the hospital acute department together with the firefighters and the OEMs. We actually are active in our poison centers, National Poison Center. So when do you actually, the experience has been that they forget to call each other. So this practical training has been really good. Now you actually call the OEM and this is the chemical. What are the acute effects? So they sit together and they say, okay, we'll put in 18 ambulances here. So we have a big table. So they try to play this game through and when to call who. So that could be a good way of doing it like we do. Thanks. Thank you. My name is Cameron. I'm an incoming resident at Mount Sinai. First, I wanna acknowledge, am I too close to the mic? Yeah, go back a little bit. Dr. Jahangiri as a tireless advocate for OEM, who is also my neighbor who recruited me into the field. He is also my part-time dog sitter and occasional therapist. Okay. So I know you've been working on this really hard and it was a great talk. I wanted to ask whether you felt there was a general knowledge that occupational environmental medicine doctors were one of the people that should have been called in this situation. And I guess the second part of the question, I'll open up to anyone else who's coming up to speak or might be able to address the latter part, is if that wasn't the case, why that is and how we can bridge that gap. I think the answer to, let me start out by answering that. We were called to the situation but as one of the earlier members of the audience saluted to, we weren't really in a leadership role. We were, I mean, very much in an advisory role. Wally, do you want to add? Yeah. NIOSH has a epidemiological intelligence branch and I think OCMED doctors are being deployed to disasters like this and, I'm sorry, CDC, thank you. And a lot of times the physicians, because of their credentials, the community members like to talk directly with the doctors and apparently there's a lot of questions that they have, so. What was the second part of the question again? Yeah. Yeah, the, well, also just want to acknowledge Dr. Grin, who's also a tireless advocate. Thank you. I think the second part was just about, things like this happen all the time, these sort of environmental exposures. And a lot of times people don't know that we're the ones potentially to call. I'm just thinking back to COVID where I saw a lot of EM doctors, Sanjay Gupta, providing recommendations that didn't seem to be the most informed potentially. And I guess kind of how to increase awareness and bridge that gap so that we're always top of mind. And that's kind of a big question, so kind of open it up to the floor. Thank you. Thank you. Well, having gone to the environmental medicine section, we actually talked about this. The other thing I'd say is the agency you didn't mention is National Transportation Safety Board, who would have to, by law, investigate derailment of this sort. And they were out. And typically they try and get at the root cause, what caused it, so that, in theory, it'd be nice if we never had derailments. Unfortunately, their report, the final report often takes several years. But they'll look at the monitoring data, they'll look at were the train crew impaired, did they malfunction, what was going on with this problem with the wheels, and look at the health effects, look at soil contamination and all that. And so I think we should be brought in. Often they'll call the Poison Center, and a lot of the Poison Centers do have an OEM doc on call. And if you look at the database that the Poison Centers use, it's mainly acute health effects. So they don't really have data that we have, and concerns about chronic effects. And then the other thing they often call is the health departments and the federal agencies. So it'd be nice to get OEM in there. Yeah, that's great, yeah, thank you for that. Thank you very much for the presentation. I thought it was very nice and quite clear. It's a huge elephant, and you're describing part of it, which is very important. We too, at the University of Illinois, were getting numbers of calls from different stakeholders about issues that they were concerned about as this process began, and it's continuing, of course. I just have one question for you. As you were looking at the command structure, and for your participation from the university, what was the role of the unions in the process? Which unions were involved? Were the teamsters involved? Were the rail unions involved? Were there emergency responder unions involved? I believe that's an Alexi question. To answer the question just very shortly, the answer is, to our knowledge, no. I believe the unions were not involved. We don't really recall ever having to intersect with them. I think they are important stakeholders, especially there is a specific industry group I mentioned on an earlier slide. It's the American, I think, Train Car Committee, and they help set some of the safety standards that, specifically for brakes and things like that. But no, we never had a chance to do that yet, but it's an area that needs to be addressed. So there's my teachable point for the moment, and bears inclusion in some of your slides. Thank you. Yeah, great talk. Great work, you guys. Given the aging infrastructure in the US, it's only a matter of time that there's gonna be another derailment, like guaranteed. So based on that, how many more chemical fact sheets do you think we need to put together? Because we're transporting chemicals throughout state lines like air, by land, either the road or railways, and if we were to look forward, what can we do now to prepare for another disaster so that information is properly deployed immediately at the time of need? Right, right, and I think I'll answer your question this way. I don't think we can at this point, because our toxicologic base of knowledge cannot advance that quickly in such a short amount of time. However, I think what we can do and what is very reasonable is we can establish a better and more comprehensive national surveillance system for derailments and chemical releases, and also be more proactive in setting up registries and follow-up cohorts like we have at Fernald, because one thing, you feel you have some acute effects for several weeks, but a lot of these people, they do not wanna feel like they're forgotten and that people are just gonna move on. They wanna know that people are gonna follow them and look for long-term effects. So I really think that's kind of the low-hanging fruit, at least we can shoot for, is some kind of a surveillance system. And I can open this up for anyone who knows the answer to this, but this was asked in the open forum, or in the online chat. Let's see here. Was the medical director of Norfolk Southern consulted or involved, and actually there was an answer on there. Someone said that, found out yesterday that chief medical officer of Norfolk Southern is our very own Natalie Hartenbaum. So I don't know if anyone knew that, but. Yeah, I mean, that was the only question that was already answered, so. I think, yeah, I think we're done. Thank you very much. I appreciate it. Very much so. Thank you.

chemical disaster response

occupational and environmental medicine residency training

toxicological information

occupational exposure limits

OEM in disaster response

hazardous materials transportation

national surveillance system

environmental medicine and disaster response

environmental disasters