Our next speaker is Dr. Lori Rolando, who is the Medical Director of the Occupational Health Clinic at Vanderbilt University and Medical Center, an Assistant Professor of Medicine at Vanderbilt University, and she is a dramatic improvement upon her predecessor in that role. So I'm very pleased to welcome her to the stage to talk with us about something that's not infectious. How about that? I'm going to be talking about something that's not infectious and might not necessarily be top of mind when we're thinking about medical center occupational health because I think the first thing that does come to our mind are infectious exposures, needle sticks, things of that nature, and particularly for those of you who just started in medical center occupational health in the last couple of years, you've probably been living in, well, I was going to say breathing, but hopefully not breathing, COVID. Over the last two years, some of these things really may not have been on your radar as much as they could have been, and so hopefully, while they might not have been top of mind, we don't want them to be overlooked completely. So first, we'll start with some physical hazards, and I'm going to talk really briefly about ergonomics, right? Ergonomics is the science of fitting the job to the person rather than making the person adjust to their job and their environment. And that's really important because if we can make our environment work for us instead of having to modify what we're doing, that decreases the stress and strain on our bodies. And that's really important because ergonomics is one of our most common injuries that we see in a medical center. You know, it can happen to anybody, although there are some areas that are of particularly increased risk. You know, our frontline healthcare workers, our nurses who are doing patient handling, they're lifting, they're, you know, repositioning in bed, they're getting people up to chairs and that sort of thing. Our ultrasound techs who, if you think about what they're doing, they're, you know, sometimes having to really adjust their body position, twist their arms, really provide a lot of deep pressure to get good images. So those are awkward body positions which can lead to injuries. Our patient transport folks, our housekeeping staff, and even some of the folks who are in our research laboratories, if you happen to be in a facility that is connected to a research lab. Or even in our clinical lab, we've got folks who are doing pipetting and, you know, things like that and doing a lot of repetitive motion. And again, they're one of our most common injuries and they're also one of our most costly. These graphs are just sort of three representations of the same thing from the Bureau of Labor Statistics, but if you look at the one on the bottom right, it's the number incidence rate in median days away from work for injuries and illnesses involving musculoskeletal disorders. And when you think about ergonomic injuries, that's what they are, they're musculoskeletal injuries. And in healthcare and social assistance had the highest number of injuries, one of the highest incidence rates, and while the number of days away from work wasn't as high as some of the other industries, a lot of those, in part, that's probably because a lot of us have really good, you know, modified duty programs, return to work programs, so there still is some lost productivity there. So when you think about the combination of the injuries themselves and potential lost or modified work time, you've got your direct costs and your indirect costs which can really have an impact on your organization in addition to the health of your employees. This is just another illustration of how ergonomic injuries can impact hospital workers. The dark blue are overexertion and bodily reaction injuries, and again, that's typically what we think of when we're thinking of ergonomic injuries. It's lifting heavy loads, it's awkward body positions, it's repetitive motion, things like that. So both NIOSH and OSHA have put together guidance as to how to address these ergonomic injuries, and they both, you know, mirror each other pretty well. The first thing that you want to do is make sure that you identify the risk factors, right? Where are your folks getting injured? What are they doing when they're getting injured? Involve your workers, okay, both management as well as the individuals on the front line to get the buy-in, to find out from them where their pain points are. Get your data. Again, see where your injuries are, what's causing them so you can address them appropriately, and then develop an ergonomics program, including an ergonomist who's either in your department or somebody that you're partnering with who can talk not only and do not only just individual evaluations, but who can go to those departments that you've identified as high-risk areas and develop a plan with them to figure out, you know, what the concerns are, what they can implement to mitigate those risks, implement those, and then follow your injury trends over time in those departments to see those injury risks changing and to see those numbers hopefully coming down. Then, again, just making sure that you've got good return-to-work programs in place and also doing that data tracking so you can follow it over time and you can do that continuous quality improvement and make sure that the processes that you put in place are actually working. Briefly, we'll talk about slip, strips, and falls, because, again, one of our highest injury risks, you know, I think probably for most of us, if we looked at our data, blood and body fluid exposures are probably, you know, the single biggest injury that we see, but ergonomics and slip, trips, and falls, at least in our institution, kind of fall two and three. And we're not going to prevent them all. People are going to fall. People are going to slip. But if you do identify proactively those risks, whether it's making sure cords are taped to the floor or having umbrella sleeves so that you're not tracking water across the floor, whatever it might be, and having good mechanisms for people to report those risks and report out your injury rates, whether it's to your safety committee or to departments, and when you see risks, know who to report that to so that you can mitigate them. Because, again, if you're looking at Bureau of Labor Statistics data, you know, this is all industry as well as, you know, the first yellow line is just all industries combined, and then the second is healthcare and social assistance. The blue is the slips, trips, and falls for healthcare, and, you know, there's over 40, almost 42,000 injuries per year. So, again, high number of injuries, which can ultimately have a significant impact on your workforce. Okay, now we'll move into something that is a little bit more common or, you know, top of mind when you're thinking about medical centers, and that's radiation. So radiation is generally just energy moving through space in the form of either particles or waves. And it can be non-ionizing. It can, you know, be that radiation that is, has a longer wavelength, lower frequency, to higher energy, high frequency, shorter wavelength ionizing radiation. And when we think about radiation in a medical center setting, that's what we typically think about is the ionizing radiation, right? It's our imaging. It's what we do. And, again, it's also very common. We see it in our diagnostic imaging, x-ray, CT scan, et cetera, interventional radiology, whether it's cardiology doing catheterizations, whether it's image-guided biopsies, vascular surgery, whatever that may be. Operating rooms, if you are, you know, an orthopedic surgeon and you're checking to make sure that, you know, rod you just put into the femur is in the right place, or you're a vascular surgeon checking to make sure the anastomosis you just sewed together isn't leaking, you're going to use C-arm and you're going to use imaging in your operating suites. You have to think about that as well, as well as nuclear pharmacy, because when you think about the radioisotopes that are being used for both diagnostic and treatment purposes, they're potentially exposed. And you want to know who is exposed because you want to monitor them and you want to know what their risks of exposure are. And again, that depends on the kind of radiation they're exposed to. So you've got everything from alpha particle radiation. So again, the nuclear pharmacy, the radioisotopes, that's primarily particulate radiation as opposed to what we think about when we're doing imaging like x-rays and CT scans. Alpha particles, it's essentially a helium nucleus, it's two neutrons, two protons. It's very high energy, but it gets stopped really quickly. So even just a thin piece of paper is going to stop it. So you're not necessarily going to have that risk of skin exposure, but if they're working with it, there is a risk for inhalational or ingestion and being exposed that way. So you have to think about that. Same thing with beta particles, it's a free electron essentially, also very high energy. It will penetrate the upper layers of the skin and go down into the dermis. So there is a bit of a risk from skin exposure with beta particles. But again, inhalation and ingestion are the primary risks. Radiopharmacists are primarily beta particle radiation, and so we do do bioassays on some of our radiopharmacy folks. We do thyroid bioassays if you think about the fact that they're giving a radioisotope to a patient to ingest, they swallow it, and then they cough right in the tech's face, for example. That could be a route of exposure. So we just want to make sure that we're not seeing increased uptake in our staff that would make us want to take a look at what the processes around that are. If you've got folks working with alpha or beta particles in the lab, depending on what they're doing, they might need some form of respiratory protection, again, because that inhalation or ingestion are the primary risks. And then we think about x-rays and gamma rays, which are not quite as high energy, but will penetrate much more deeply. And so that's why when we're working around x-rays, we need to wear our lead shields and that sort of thing. And there is an OSHA standard around radiation, ionizing radiation. It's 1910-1096, which kind of goes through everything that you need to know about protecting your workers, including who needs to be monitored. So you want to monitor your folks because we always want to minimize our exposure, right? And when we're talking about ionizing radiation, that's a principle called ALARA. So that stands for as low as reasonably achievable. So we're all exposed to some background radiation just living our daily lives. But when you're talking about occupational exposures, the Nuclear Regulatory Commission has set limits on the amount of radiation that you can be exposed to. Now, fortunately, when we're in a medical center setting, we're not going to be exposed to the degree that we're going to be worried about acute radiation sickness or anything like that. But there are still risks. There's risks of burn, chronic longer-term exposure. The longer you're exposed, the more you're exposed to your risk of, for example, malignancy development also is there. So we want to minimize that. And OSHA would say that anyone who is exposed at 25% of the quarterly dose, and you can see the different doses here, your limit for occupational exposures for your deep dose or your whole body is 50 millisieverts or 5,000 millirems. So 100 rem equals a sievert. For the lens of the eye, it's 150 millisieverts. Organs in your shallow dose, your skin exposure is 500 millisieverts. So you take that annual limit, you divide it by four, and you say if somebody has the potential to be exposed at 25% or more of that, they need to be monitored. And so your radiation, you want to have a good partnership with your radiation safety officers and your environmental health and safety folks because they're the ones that are doing this monitoring. And if your levels that monitoring gets too high, you may need to say, OK, are we going to transition from the typical badge monitoring where you wear it for a while, you turn it in, they read it, you get the numbers back, to sort of more real-time monitoring so you know just what that risk is. Or even people who get to that, especially if you're getting close to your annual limit, like 90% or more, we have a policy where people need a radiation holiday where you might say you don't get to work with radiation anymore until the next year starts because your exposure to this point has been so high. So you need to be able to know what that is. And then there's also the declared pregnant worker policy whereby institutions, individuals can voluntarily declare to our radiation safety folks that they are pregnant. And if they make that declaration, then their occupational exposure threshold is one-tenth of that of someone who is not pregnant. So then they go into monitoring at that lower threshold for the duration of their pregnancy. So moving on from the ionizing radiation that we're typically familiar with to non-ionizing radiation because we can see that in medical centers as well. That's lower energy. You know, ionizing radiation is energy that's strong enough, high enough that you're actually breaking bonds, you're potentially, you know, damaging DNA. Non-ionizing radiation isn't quite that high energy so you're not breaking those bonds but there are still risks. As you can see, it includes everything from radio waves, microwaves, visible light, UV radiation. Primary risks from non-ionizing radiation are thermal injuries. So burns and eye injuries from exposure, particularly to lasers, which is one of the things that we can see in medical centers both in the clinical realm and in the research realm. In the clinical arena you can use lasers for everything from, you know, ablation of lesions to tattoo removal to, you know, disclosure. I had a former life as a vascular surgeon and I would use lasers to ablate saphenous veins in people who had venous reflux. So you would see that use in the ORs as well. Lasers are—and then in research settings, of course, you have access to lasers. Lasers are classified from class 1 through class 4. And class 1 and 2 and even 3A are not typically terribly dangerous. I mean, even at 3A, your blink reflex, for example, if you have an eye exposure, your blink reflex will typically help protect you. But the lasers that you want to be particularly concerned about are those lasers that are class 3B or class 4. So class 3B definitely has a risk of eye injury, retinal injury from either direct or reflected exposure. And class 4 are definite eye injury risk as well as burn risk and can potentially be flammable. So if you've got folks who are working with lasers in class 3B or 4, you want to make sure that they understand the risk. You want to make sure that you identified who they are, that they understand the risk, that they know what PPE they need to use and they know what to do if they have a potential exposure. Because they're going to need eye protection while they're working with the laser. And if they do have an exposure, you want to make sure that you evaluate that very thoroughly. And again, it's primarily going to be an eye exposure, so you want to make sure you do a thorough eye exam. Everything from their visual acuity to their central vision, color vision. And there should be a very, very, very low threshold for referring them to an ophthalmologist. I am not an ophthalmologist. I can look in the back of your eye, but if you're asking me to get into the nitty-gritty of just how, whether there's any retinal pathology, I'm probably not going to be able to tell you that. So I'm going to refer you to an ophthalmologist. So that's really important. The ANSI has a standard for working with lasers, and it's sort of been modified over time. And it talks about a medical surveillance program for folks who are working with lasers. And it used to include everything from a pre-employment exam to an annual exam and a post-exposure exam and an exit exam, eye exams for folks working with lasers. I think the most updated version really focuses primarily on post-exposure evaluations. So that's key. But depending on what work people are doing or your level of risk tolerance, sometimes even a baseline just to have something to go by can be helpful. So you want to think about that when you're thinking about folks who are working with lasers. Okay, moving to MRI, another imaging modality that I think we're all really familiar with in the medical center setting. And when we think about MRIs, I mean, we all know that there are potential risks to patients, right? We need to screen our folks, our patients when they go into MRI to make sure that they don't have metal in their eye or a new implant or a new device like a pacemaker or an insulin pump that could potentially malfunction. They don't have something that's going to heat up and cause a burn. But we need to remember as well, and the American College of Radiology put out a guidance document in 2013 that talks about MRI safety and it does include information about screening our healthcare workers. Because we do have folks who are working around MRIs as part of their job and they could have an implant or a medical device that could also potentially be impacted by their exposure to MRI. So our screening program, when we put it up, when we set it up, we look at if you're in the MRI suite, there's four different zones. Zone one is completely a public area. Zone two is a little bit more restricted. Zone three is fully restricted access and includes the control room for the MRI. And then zone four is the actual room where the MRI sits. And so we have a program whereby we identify all of our employees who, number one, who need to be around MRIs as part of their daily work. So radiology folks, MRI techs. Because if they have something that would preclude them from being around an MRI safely, they may need an accommodation, right? Because it's a routine part of their job and if they can't do that because it's unsafe, then they might need an accommodation. We also have folks that we consider visitors to the MRI suite, the unit nurse who might have to escort a patient down to MRI a few times a year. We don't necessarily need to provide accommodations for them because if I'm a unit nurse and I can't go down there because I've got something that might be unsafe, I can trade patients with another nurse who can go down to MRI and that person can escort my patient down there. But we want to make sure they're all screened. So to make sure that they don't have anything that would be a problem. And we do that pre-placement for our MRI folks and on an annual basis. And then for the visitors, we'd like for them to be screened well prior to them coming down to radiology. And then they can do that annually as well. And we have the screening tool. It's a questionnaire and it's built into the MRI safety training. And folks will get a sticker on their badge if they're cleared. If they're not cleared, we'll have somebody from occupational health reach out to them. And it's really important when you're talking with these folks about their ability to be cleared to not just know what medical condition they might have, but also what strength of MRI they might be working with. Because most clinical MRIs that we use for patient care are 1.5 or 3 tesla. But apparently the FDA very recently approved even a 7 tesla for clinical use. And some implants, some devices may be safe at 1.5, but they might not be safe at 3. Or if you've got a researcher who's working in an animal imaging facility and they've got an 11 tesla MRI, it certainly may not be safe in that context. So knowing your medical physicist who can help you make these determinations, there's a guidebook that you can buy that has lists of all of the different implants and things of that nature so you can determine what's safe. And I mentioned that we screen folks if they're going to be going into zone 3 or zone 4. Not just zone 4. Even though that's where the magnet is. Because if you think about it, if you're in zone 3 and you're in that control room and you've got a patient in that MRI suite, there's always a possibility that something could happen and you could need to go into zone 4. So we want to know ahead of time before you even get there whether it's safe for you to do that. And I mentioned we give stickers for folks who get cleared. They get that sticker once they've gotten their medical clearance and once they've done their radiation safety training. Because if they're not clear about what is safe to go in an MRI suite, you could end up unintentionally with a really tragic consequence. And these are just some headlines of different incidents that have happened in MRI suites when something ferromagnetic. Because again, remember, this is a magnet. This is a really, really, really, really, really strong magnet. And so anything ferromagnetic, an oxygen tank, trauma shears. I mean, we've had our MRI folks have to physically barricade the door to prevent a nurse from going into the MRI suite with an oxygen tank. And it's intuition. It's instinct. You want to go in. You want to help the patient. But if you're bringing in something that's going to be sucked straight into the bore of the MRI and potentially hit the patient in the head, that can be tragic. So they have to understand the safety. And that just, again, alludes to the fact that the MRI is always on. And you have to remember that it's not something that the magnet just turns on when a patient comes down there, so You don't want to have to be in the position where you have to shut the magnet down It's called a quench. You can do it. You can quench an MRI, but it's not necessarily Like I said, it's not an optimal situation. It can be time-consuming It can be costly it can damage the MRI machine and at the very least it's gonna put the MRI machine out of commission for a while The other risk and the most important risk with a quench Potentially is the fact that it can cause asphyxiation Asphyxiation could be a risk when an MR the the reason that the magnet is always on and it can always be on is that either helium or in some Cases nitrogen is used to cool the coils to decrease resistance down to like a temperature of absolute zero That allows the magnet to stay on at all times So in order to stop that and in order to shut the MRI magnet down You have to raise the resistance raise the temperature by releasing that helium or releasing that nitrogen. So MRIs are vented to the outside If something were to happen in that venting to the outside Didn't occur and the helium or the nitrogen were released into the MRI room. It's gonna displace the oxygen remember They're simple asphyxiants. So it's going to put displace the oxygen and put the person at risk for suffocating So again, lots of potential risks. It's not an easy thing to do. So it's really important to understand all of the potential Hazards that can be associated with that MRIs are also very loud so this is a good time to talk about noise because Increased noise levels are also a potential risk that you can see in some of your folks Again, I mentioned, you know having a good partnership with your radiation safety folks. I think in general It's just a good idea to get to know your environmental health and safety or industrial hygiene or whatever Whatever their title is in your institution because they can be absolutely wonderful partners for you And do a lot of different monitoring for a lot of different things To make sure that you're identifying hazards and noise is one of them because you want to be able to identify Individuals who are exposed at high levels for us For example our air ambulance crew the folks who work our life flight crews are exposed to high noise for a period of time We had folks in our research facility Who were doing? Cage wash for the animals that area was a really high noise level So we had enrolled all of those individuals in our hearing conservation program and again OSHA standard around hearing. So, please Make sure that you take a look at that if you aren't familiar with it Because there are multiple components of a hearing conservation program that you have to put in place once you identify those individuals who are at potential risk Noise monitoring needs to be done again, which is typically done by the environmental health and safety folks You want to make sure you've got appropriate controls in place to minimize the noise as much as possible They need to be trained if they're enrolled in a hearing conservation program on how to use PPE for example And how to use it appropriately how to put in the earplugs how to wear earmuffs not wear your headphones underneath your earmuffs which happens And make sure that you're getting your audiograms. And so we provide the audiograms for our staff who are enrolled in these programs And you need to do a baseline audiogram as well as an annual audiogram and know what to do with abnormal results whether it's reporting a standard threshold shift or identifying other abnormalities that are sort of outlined that might need referral to ENT and you need to enroll folks in your hearing conservation Program if they are exposed at a time-weighted average of 85 decibels or more over eight hours Okay, that's the trigger for enrolling them in the program doing their hearing tests, etc They have to wear hearing protection if they're at the permissible exposure limit of 90 decibels over an 8-hour period now You also need to wear your hearing protection at 85 if you haven't had a baseline Hearing test yet, and we really encourage and basically tell our folks if they're at 85 decibels They need to wear their hearing protection and you also need to be aware of the fact that there's an inverse relationship between The noise level and how long you can be exposed to it So I mentioned, you know you have your permissible exposure limit is eight hours at 90 decibel and It decreases by half the amount of time of exposure for every 5 DB increase in noise levels So if it's 8 hours at 90 decibels, it's 4 hours at 95 decibels 2 hours at 100, etc, etc so again you need to know how your folks how much of an exposure your folks have and Put all the processes in place to make sure that you're protecting them Okay, I'm gonna switch gears to chemical hazards and I think this is a Alliterative holdover from Melanie the potions poison pills and poisons but that's just a caveat to say that you know, there's no way we The sheer number of chemicals that someone can be exposed to in a medical center is innumerable and so There's no way to be able to cover them all so we're just gonna touch on some of the high points But just a couple of things to remember is always make sure that you have availability to your safety data sheets Because that can be a really important guide to knowing What the person was exposed to and what to do in the event of an exposure? I will also say that poison control if there's a question is always a great resource You know and and I would never hesitate to call them if there's a question and just making sure that there are appropriate Mechanisms for decontamination making sure folks have I wash stations in place. We actually have a shower in one of our bathrooms in In our clinic that we have had to use on occasion to decontaminate somebody who got Lab chemicals significant exposure to lab chemicals So with that said we'll talk first briefly about chemicals for disinfection and sterilization so again when you're thinking about a medical center and all of the Operating room instruments and other instruments that need to be sterilized need to be disinfected, etc It's not uncommon for folks to potentially have exposures to these chemicals the first is ethylene oxide and That OSHA standard up in the corner 1910 1047 is a is the ethylene oxide standard so there is a standard for ethylene oxide again that Elucidates all of the different controls and processes that need to be in place For folks who are exposed and for ethylene oxide the action level at which medical surveillance would need to be instituted is 0.5 parts per million over an eight-hour time weighted average And so again your environmental health and safety folks Industrial hygiene will be doing this monitoring for you so they can let you know whether you have folks who are exposed at that level and there is a caveat or a little bit more to that that folks need to be enrolled in medical surveillance for ethylene oxide if They are exposed at the action level for 30 days or more out of the year There's also a permissible exposure limit below which you need to be able to keep that exposure through engineering controls administrative controls Etc of one part per million and a short-term exposure limit or a 15-minute exposure limit of five parts per million And the reason this is important is because there are potential health effects to ethylene oxide exposure You can have primarily its skin exposure or lung exposure And acute high exposures can cause things like nausea vomiting GI issues as well as lung injury more chronic long-term exposures do run the risk of sensitization there are reproductive risks things like spontaneous abortion and also Primarily hematologic but cancer formation with Significant exposure and medical surveillance includes a pre-placement exam questionnaire risk assessment occupational and health history physical examination And then a CBC as well as anything else that the provider might feel is appropriate Along with annual exams and an exit exam and then certainly as with any other exposure a post exposure exam if an exposure were to occur Glutaraldehyde is also a potential health risk There's not a formal OSHA standard that I'm aware of for glutaraldehyde, but it's important to be aware that you can have Health effects again primarily with all of these chemicals. It's primarily skin exposure or pulmonary exposure Can cause a risk and for glutaraldehyde? It's primarily irritation sensitization things of that nature activation or exacerbation of asthma for example and then finally OPA or ortho phalaldehyde or pardon using a Commercial term Cydex if folks are familiar with Cydex is another high-level disinfectant that can potentially cause sensitization irritation Skin issues that sort of thing So it's always just important and you know, there are other chemicals, you know our environmental safe I mean our environmental services folks Had an issue with one of the chemicals that they were using to clean surfaces and we started to see a trend of folks coming In complaining primarily of respiratory issues. So we actually, you know started keeping track of it And after a while we were able to I think we actually switched chemicals to something that was a little bit less Of an issue for the folks that were working with it Formaldehyde Is also something commonly used primarily in our pathology lab Areas both clinical pathology and our anatomic pathology lab So we had folks enrolled in our medical surveillance programs there. There's also an OSHA standard for formaldehyde right next to ethylene oxide So again gives you the outline of what needs to be done But it also has an action level of 0.5 parts per million at which folks need to be enrolled in a medical surveillance program Unlike ethylene oxide. There's no caveat about Having to be exposed, you know 30 days out of the year For example, it's just if they're exposed at or above the action level. They need to be enrolled in the medical surveillance program Their permissible exposure limit is 0.75 and their short-term exposure limit for formaldehyde is 2 you know our Anatomic pathology or our autopsy area was one of the areas that for quite some time we had our folks enrolled in medical surveillance, including our pathology residents because As interns at least during their intern year because as interns they would do a rotation In autopsy and so we had to have them enrolled as well Formaldehyde is a respiratory tract irritant So it can cause respiratory issues and it also if it is a potential carcinogen And can cause things like nasal pharyngeal cancer, etc so again you want to minimize that risk and we do put our folks who are in our medical surveillance program because of having Having potential exposure at or above the action level in pappers when they're working so they also get screened and cleared for their respirators and The medical surveillance includes again a pre placement as well as annual and and exit Evaluations and for those folks who are wearing respirators, they need to have pulmonary function tests annually as well So that's another component of medical surveillance for your formaldehyde workers Just to be aware Waste anesthetic gases so this has always been a bit of a concern for folks and something else that we do monitoring through our environmental health and safety folks for Because of the potential risks of health effects and the primary one. I think that most folks are aware of are the respiratory Issue or I mean, excuse me the reproductive Potential reproductive risks with waste anesthetic gases, but acute high concentrations of these halogenated anesthetic gases isoflurane sevo fluorine Those sorts of gases if you have a high acute exposure Typical symptoms that you would expect things like headache nausea Potential if a high enough exposure you could see issues with your LFTs kidney issues And definitely fatigue and drowsiness I mentioned before that I had a former life as a surgeon and I can still very clearly remember coming home every day after my Anesthesia rotation and wondering why I was so wiped out Probably because maybe there were some Waste anesthetic gas was escaping into the environment that I was exposed to every day because I was certainly pretty fatigued for that entire month but And then chronic low low level concentration exposures certainly again there have been Potential risks for things like you know, you cancer Liver damage kidney damage, but the primary concern has been reproductive Risks whether it's infertility spontaneous abortions birth defects things of that nature And interestingly a lot of that a lot of that literature is is older and involved some of the Anesthetic gases that aren't being used anymore. If you look at some of the newer literature, it's a little bit less settled as to the significance of a correlation between Exposure and reproductive effects So there are still some studies that would suggest that and there are animal studies that have indicated a potential risk And that also makes me just stop to say when you're thinking about these anesthetic gases I mean, I know in the clinical setting and in our ORs is where we primarily think about it But don't forget if you are in a research facility Don't forget your Researchers and your animal care staff who are working in and anesthetizing animals because you want to make sure that they're not exposed as well So and the other thing to note particularly in the clinical setting is that that you're using nut while with some of these newer Halogenated inhalational anesthetics that that reproductive risk might not be quite as settled if you're using nitrous oxide that definitely increased your risk So you want to be cautious about the combination use of nitrous oxide and these other anesthetic gases And you want to make sure that all that you have the appropriate protections in place And again, this is another good partnership between the departments between your environmental health and safety folks who can you know? Give you the monitoring results. You want to have good scavenging systems in place Closed loops so that you're not leaking anesthetic gases into the environment You want to make sure you have the appropriate air exchanges not just in the ORs But also in the recovery room because your patients, you know, the air exchange requirements are a little bit different But your patients can off gas these anesthetics for a period of time when they're in the recovery room Double masking when you're inducing an individual can be helpful making sure you have a good seal particularly in the pediatric world sometimes you can see increased Exposure or leaks because you're either you know you're a little more hesitant to really put a tight seal on that little child's face or you're using an LMA or an uncuffed ET tube which can potentially increase the risk for leaking And exposure and then making sure that you turn off the gas when you're not when you're not using it OSHA does have some guidelines. There's not a standard, but they do have some some good resources and guidelines for that And I think I'm talking fast enough that I'm gonna make up maybe a little bit of time here because the final Topic that I have for you is I think everybody's favorite or maybe least favorite topic of the last few years in that cytotoxic drugs and that's just NIOSH has a list of all drugs that they consider to be cytotoxic and that's any drug that could be potentially hazardous by virtue of being potentially carcinogenic carcinogenic toxic from a reproductive standpoint Toxic to organs, I mean and when you think about The medications that they're talking about it's things like chemotherapeutic agents It's in certain antivirals or hormone therapies and the purpose of those Medications is to prevent cells from growing and replicating and really killing those cells. So it makes sense. They are cytotoxic Potentially to our workers as well if they have significant exposures So NIOSH has had a recommendation for how to handle folks who are working with cytotoxic drugs as has OSHA But a few years ago, I think everything got heightened again because the USP 800 was published Which is a guidance document. Let's say guidance document, but not everything is just simple guidance Some of those things are musts if you look at the USP 800. It's a very comprehensive Outline for how to handle, store, dispose of, compound hazardous drugs including Information on medical surveillance. Now, I will say some of the things in the USP 800 are as our Legal folks kind of identify must shalls That you have to do other things are may should The medical surveillance is a may should but we know that there is a risk So I think it behooves us all to really kind of think about what we want to do to help protect our our employees The challenge with this is that if you look at the recommendations, it talks about things like a pre-placement of a questionnaire Periodic surveillance possibly a physical exam and then it talks about laboratory Studies and I think the challenge and a lot of the Consternation about this is well, what tests can we do because when you're doing testing for surveillance ideally you want a test that is going to allow you to make a really good correlation between The exposure that you had and the potential finding that you see on that that test, right? But unfortunately, none of the tests that we have are really all that sensitive or specific to saying Oh, you have this armed abnormality on your CBC. For example, it's because you had an exposure to cytotoxic drugs It's really hard. I think to make that correlation a lot of times and so that kind of makes Folks a little concerned about well, what do we do with this information when we get it? How do we you know not chase abnormal results that that don't have anything to do with an exposure? How do we settle down anxiety that now the individual has? You know now we've got an abnormality and now they they are convinced it's because they had an exposure when it may not be You know, how do we know that if it's out if it's normal there wasn't an exposure, you know So it gets to be a little bit of challenging. And so you've You've seen different recommendations and different institutions doing different things understandably I mean because there's not a sort of one-size-fits-all here is a specific You know, here's a specific process Different entities have provided different guidance. I think Wendy mentioned WOMA Earlier, I think they put out a guidance document that basically stressed Their recommendation for primarily focusing when it comes to doing these sort of surveillance exams on post exposure examinations Making sure that if somebody's had a document exposure, they do that evaluation But also ensuring that you are identifying the folks who are potentially at risk identifying the folks who are potentially at risk making sure you've got training in place make sure you've got all of your other controls in place And making sure that folks know who they can talk to if they have a concern And that they do report exposures when they happen Alternately Mayo Clinic Posted and I think it's a reference in If in your packet They published an article in JOEM a couple of years ago. I think it was in 2020 Outlining what their program is to to provide it as sort of a guide if folks would like to use that As to what they're doing and that involves, you know Doing as always doing a risk assessment to identify those individuals who have an elevated risk based on What they're doing the amount of exposure the amount of time they're working with them that sort of thing And for those folks who have an elevated exposure they do a questionnaire They're automatically enrolled in this program Though they can opt out so individuals do have the ability to say, you know what I understand the risk. I don't want to do this But it involves a questionnaire as well as a cbc at baseline and then every two years They follow up with another questionnaire in a cbc so that they can collect data longitudinally to determine, you know patterns You know issues i'm not sure, you know, if you have any thoughts melanie some Women of reproductive age have iron deficiency anemia It's a shock I know but um Yeah, so again, you'll get noise. That's kind of what we talked about Earlier, so it's figuring out how to interpret the data and figuring out how you might tweak your programs Um, and again, I think if we probably pulled the group how many folks let's do it I've got a little bit of time how many folks have a program in place to monitor for cytotoxic drugs? What do you mean program do you mean do you have are you doing any sort of medical surveillance? And how many are doing a questionnaire Okay, how many are doing a physical exam How many are doing lab work Okay All right. I think that's my time and we can take some more questions later if anybody has them. Thank you so much You

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