Document emVL4vroRDj321geKY3g3z9Qy

MEMORANDUM H. H. Bode I.;OK: M. R. Baker DATE: May 11, 1977 SUBJECT; SAFETY AND HEALTH SUBCOMMITTEE A& of today, I am advised that the Kaiser and Alcoa Subcommittees have not met or*received proposals from the Union, Yesterday, .Schwartz called and we agreed to have no meetings this v/eek and that I would call him near the end of the week. We have received the Kaiser Medical Manual. This memorandum will try to condense this large book to its essentials. 1. Issued by Dr. James P. Hughes on April 7, ?1977. Cover letter says audiometry section will be issued later. Instruction to have into effect by July 1. 2. Divided into sections: Preplacement Exams Medical Surveillance Exams (including Potroom) Toxicology Salaried and Executive Exam Program Audiometry (not attached at this issue) 3. Preplacement: a. Specific standards and procedures very detailed b. Reach/strength hiring standard based on a de scriptive paragraph of heaviest work in potroom-- raising flexes, using sledge, etc. c. Sputum-cytology for baseline purposes. d. Pelvis X-ray for baseline for potroom to compare - for fluoride absorption. e. No use of X-ray for congenital spine conditions. f. Standards for qualifying to use respirators. g. Quotations of handicapped regulations but no interpretations or specific standards. 4. Medical Surveillance Exams: a* MPolicy. The Corporation will provide annual TX TINER RMC0022I:: F. H. Bode 2 Hay 11, 1977 medical surveillance examinations of those workers exposed to toxic substances or de fined physical hazards such as noise or heat stress." b. Incorporated U.S. DOT regulations for physical exams every other year for regular vehicle drivers. c. Potroom atmosphere (fluoride, PPCM, heat) Boise (85 dBA for 8 hours) MEDICAL SUKVEILLAKCE AHKC&L Interval history Physical exam (height, weight, blood pressure) Laboratory (blood-hemoglobin or hematocrit? urine-screening test for sugar, protein, blood, fluoride) Lung function Chest X-ray Smoking history Complete blood count Skin exam ' Sputum cytology Fluoride in urine Electrocardiogram Audiometry AP. X-ray of pelvis - every 6 years d. A lengthy list of various chemical exposures ouch as acetone, fluorides, lead, nuisance dust and alumina have a specified annual exam procedure. Many only require an interval history but the rest have in creasing levels of exams specified. For example, for lead exams in addition to history, physical exam, laboratory exam, three others are listed of neurologic exam, CBC, and lead in blood/urine by laboratory approved by Hughes. e. Sputum test is listed for potroom workers, asbestos, and PPOM/CTFV (particulate polycyclic organic mat ter and coal tar pitch volatiles). f. A urinary pre-and post working shift analysis for fluorine is required annually for 1/4 of workers very 3 months exposed to fluorides. TX TINER RMC0022133 H. H. Bode 1 Hay 11, 1977 g. An extensive charting of airborne contaminants and physical stresses is included. Several pages are reproduced and attached. This chart lists principal source of emission, health effect, nodical surveillance required, threshhold limit values, sampling equipment required, and personal protection equipment. OSHA and MESA standards have been used where adopted but also incorporated are proposed standards--both federal and internal. 5. Toxicology a* Various toxics or irritants are listed separately shoving effect, treatment needed, and preventive considerations. b. No one*plant would have all of the above, but most listed chemicals appear in Reynolds plants. As a medical reference data sheet, this section would obviously be valuable to medical personnel and even by supervisors. In conclusion, much of this manual material is well organized-- although repetitive--and good reference guides. I believe most of our locations would like to have such a specific guide. However, these guides and standards would seem to go beyond the desire and recommendation of our hygene people in certain limited areas. These problem areas would seem to principally be the extensive use of hands-on physicals, use of sputum cytology and possibly thresh hold value standards as released. Reynolds was told by Kaiser that this manual was given to the Union and it is evident that the pro gram outlined is what is desired by Schwarts. /bcm Attachmentccs C. B. Rosser, Jr. Dr. E. C. Irbyj^ M. R. Baker TX TINER RMCOO 2 213 4 KAISER ALUMINUM (. CHEMICAL CORPORATION 43ia/t Q/r> /' fc.2 uO O*- uu a. oc wO ^O <w* -wC g*?, Ko o 6* o W o> o) ni o' u 52 a >- W Q U-i u > ^ U-0i y 3 y - 9u -Jx S^ <o ij c y s u v> &2 4Ug1"MUO >. L4i> 3U ?" 4J U U U1 a; <0 O Oy 4yJ V. O <0 iJ 6 civg Uo* -Mye <3> ^ iu N f> C ti (A O O *0 W * *J C U W U 4J 19 C - - <0 u ns M *J --*J a..j yJ .tg. yO g-3 UU O(A ^9 6{! u4 1u1 M U ** fc C "O 2 u<>oU (OLAi & O'1*-! Js e -3 4 (A (A --< H3<a9 <iou ca> 5<a (wQAi Q mC mw4) *&. C T3 O >- 3 2-t*Ws.2 *s <w o W J --4<> A6 (uI Aw y <0 .G - -1C U u TX TINER RMC00221" D yO Ou cuu uc o OO Oul l_J JUC & 20 c .S -a i> v. 8- 5 3 3 5 Q. 10 Qo aO. < -* oO. --u. 3 2.3 w0 oo> HiiQw C &i 01 Wg-wHo >. o 3 -i IO ID X o2 Q J 5 >, uH u3 s-w ^ Cl, in o-1 to in Ov- O t> C .C v- i_ -- o ti an>w. on Ojj |Q > u 30 O --i w --i u-i - 3 w O ~11 *J - l HUO. t> -h Ifl u --n w awo u0 >. u ?* 5 a 3 n- <0 --. 2S S' %3 H --> 11 ts E -- * o o 5 z *w --CO w *j O. ' SUi!. oCU *-IHh OciA-* 3UUQi>. 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D^O c, `8 -uU v---m<< Q'J, OX MUi sO: P^**<3 .X2 O(J < o<S 33 ac _ CoW O> Co *3 S2 I ^ 4 *-> v- O C C <33 8 V5 - u C <03 & o o -< no 4oJ uu uw o a i- a c ow<U Uo01 c - o o o S3 mS ^ H 3.5 33 01 S.a-< e * CO <* ^o *5. KAISER ALUMINUM & CiIEHICAL ^U?C #1 U O 3 --* IC M X 3SC > lU S'HH 4J -- 01 <5 tfl O fc u C 01 C 'D O --< u.C JU3 <M 0u-3w Q QI44 Uio r-< JZ X 3 2$?S uoco Uo> .Wa * OV)n C 15 <W S hi CO >, e - o oU 'O W* * "IH/I U C (IIDUH OC rt L4 ^ *05 a. ui)>H U L, W9a g-U o04 0O) <5 couoSw "O0 OOJ' **8 | 5<c3 0i--n 6>, h i: -5 a3. --<w< .** >, a 2 e -3 O 35 4 --Wi 04 9 8s* a U O* U) 05,<0w \5 fc .u & o* c *o o 81*15 <8 5. 04 2? o(0 N<-0* 4J i si U -4 3M- 4c->: <3 TX TINER RMC0022137 KAISER ALUMINUM & CHEMICAL CORPORATION Z /14318/p/ 3 30/77 y in O lj O OK W 1J Cu CO O L. Li V 25 25 - pi ai/l ow o ft. U -- a3U. 4 Uu1 L5 a <o awou ojO I/l p> O' U -2 "2 8, >. ^ <z u udU 3 O *< 9-c 5 w u O' < '2 o (0 in aa - 33 0 do o iJ O O*- OU '--O1 a WW OoO /ou-I 5* a Q, u MO Ou 4u O *8 t.-C O L- 4. iJ (/) -- -- -- O <<50* a>.- St 2.2 2Qwo-.5uOo' g"*4 -- u >i o in 0u 1 H __ ^ in""8in 3 44 (S3 fts<fl s6 Our 2^ 15 aL3i U3U <0*J< W d < O < * a> dOy *ouj do> gg u cj o /g *J H W U 6SS3-S 4/ 5 CC g -* Si --U 4c- *<3 <3 >* >u * O Ou o 43C4 -i>4n, u rdH g.s >, oc wO dJ in- in M Jj C Q 05 4J ud iwii n cn - id u- --u a uc 5i_i oy c= u n n S >< u o jS S8e C&6 .,2 -O-> W03C. V<J) W <c t-l <5 co nc uH .Cu* LOi ^u <0 uu 4>i >a- Gg ># H uU b O --iinn *-c*o< > O -X n OudC>D C3" Z d -< O' i M C1 at .m O ! C l o 41 <3 Li H>o VI c C Qt -f<two LWi *<J3 s* aiu . OC (0 *i* xw d 30 0 H Qi W b. {? 4c<Q/ 4c4J) --I TTK C_U <O3 cu is Ha SQ 22 SnsS 0 flO TX TINER RMC002212. c'V Cv^ /. /S' C r*'/* - SpJz <'r- DESIGN OF HOPKINS-MAYO-SLOAN-KETTERING EARLY LUNG CANCER GROUP STUDY I. Aims A. Can lung cancer detection be improved by adding sputum cytology to X-ray periodic exams? B. Can death rate be significantly reduced by cytology and X-ray followed by newer localizing methods? II. Study Design A. Study population - persons at high risk (^>20 cig./day) males -3^. 45 years females A 5 5 years 1. Mayo - general clinical exam program Sloan-Kettering 1 attendees of cancer clinics, periodic Hopkins y exams, etc. + certain occupationally ) defined group B. Time frames 1. Program - five years minimum from time of entry 2. Frequency of sputa + X-ray + questionnaire (a) Mayo -.S+X+Q every four months (b) Sloan-Kettering') S every four months (c) Hopkins C. Controls hX-ray every 12 months ^ 1. Mayo - entry S+X+Q, suggested stop smoking, recommend annual X-ray + sputa for high r^sk 2. J-H -'h entry X-ray + questionnaire 3. S-K - entry X-ray + questionnaire III. Other Questions Addressed `* A. Relative efficacy and concordance of X-ray & cytology 1. Proportion dx' by cytology with negative radiography? 2. Proportion dx by radiography found cytology benign? 3. Proportion dx simultaneous by x-ray & cytology? 4. Relation of cell type to above proportions B. Proportion dx by cytology with negative X-ray that can be localized C. Survival efficacy 1. With radiography negative and cytology dx and subsequently localized, what is 3-5 years survival study vs. control experience? D. Predictors of Adherence with Program 1. Determinants = age? race? sex? smoking habits? symptoms? others? E. Problem of False Positives 1. Proportion F-P as defined by surgical pathology, i.e., no tumor found F. False Positives and reproducibility 1. Proportion of F-P as defined by non-malignant pathology or cytology, when read by same or other readers XX TINER RMC0022139 0 T-X TliVp R^C0022U* APPENOIX A INSTRUCTIONS FOR SPUTUM INDUCTION BY AEROSOL INHALATION Instructions: It is advisable not to oat for at least 4 hours prior to tost. A small quantity of sputum is normally produced in the bronchial tubes and lungs. The sputum contains cells which can be examined under a microscope. We do not want saliva, or spit, which accumulates in the mouth or postnasal drip from the nose and sinuses. To in crease the quantity of sputum that you cough up, you will breathe moist air. - You will be instructed and guided by a trained person. - Remove any dental appliances before starting the test. - Clear the back of your throat of mucus and rinse your mouth with water to remove saliva and any retained food particles. A. Ultrasonic Isotonic Technique: 1. Set the timer for I minute. 2. Insert the mouthpiece into your mouth and breathe gently end normally. 3. After 1 minute of normal breathing of mist: 3-Breath Deep-Cough Routine a. Breathe in through the mouthpiece as deeply as you can. b. Hold your breath for a moment. c. Remove the mouthpiece from your mouth. d. Place a tissue over your mouth. e. Breathe out forcefully through your mouth against the tissue. 4. Repeat this procedure (3a-e) one more time. 5. a. Breathe in deeply through the mouthpiece a third time, b. Hold your breath for a moment. 47 T* tiner KMC002214J c. Cover your mouth with a tissue. d. Cough forcefully and deeply. 6. Spit out everything from your mouth into the sample cup provided. B. Heated-Mist Hypertonic Techniques 1. Insert mouthpiece in mouth and breathe deeply in and out through the mouthpiece. After a moment or two a rhythmic pattern of breathing is established. 2. The heated mist (15% saline and 20% propyiene Glycol) is inhaled for 2 to 3 minutes (flexible timing). 3. At that time, or earlier if a desire to cough is indicated during the breathing period, inhalation is stopped and the subject is encouraged to cough until material is produced. 4. Regardless of whether a productive cough is achieved or not, this procedure is repeated several times more for a, 10- to 15-minute period depending on the quality and quantity of the sample obtained. During the test the subject is advised to keep his mouth tightly about the mouthpiece to prevent admixture of room air that lowers the efficiency of cough induction. The subject is also likely to breathe through his nose, and the technician, who is in attendance through-out the procedure, either compresses the subject's nostrils with his/her left hand, instructs the subject to compress his nostrils, or provides nose clips. The technician adjusts the flow of the nebulizer and the mouthpiece when necessary 48 TX TINER RMC0022142 IV. BRONCHOSCOPY (ENDOSCOPY) Introduction 1. When the chest roentgenograms identify a definite abnormality, diagnostic and therapeutic efforts can be directed to that local portion of the tracheobronchial tree. 2. Bronchography may indicate specific areas of abnormality or suspicion toward which attention should be focused. 3. If the radiographic studies are not diagnostic, but the cytopathologist reports that the sputum contains either markedly (gravely) atypical cells suspected of being cancerous or cells diagnostic of cancer, one is faced with, the challenge of identifying their origin accurately. Prebronchoscopic Routine or Preparation 1. Excessive bronchial secretions tend to interfere with accurate evaluations and create a special problem in the meticulous search for subtle mucosal dhanges. 2. Every effort should be made to reduce or eliminate bronchitis and bronchorrhea prior to endoscopy. a. Smoking should be discontinued and other respiratory irritants avoided for as long as possible prior to examination, preferably for at least 24 hours prior to examination. b. Patients may require antibiotic therapy in selected situations, e.g., in bronchitis with copious infected sputum. c. Preoperative use of bronchodilators and heated aerosols may be helpful, and postural drainage and-chest physiotherapy should be utilized where it is anticipated that the presence of bronchial secretions may interfere with optimal bronchoscopy. 3. Atropine or scopolamine in therapeutic doses (from 0.6 to 2.0 mg) is essential as part of the preoperative medication. Atropine has been a more frequent choice. Preoperative (Preanesthesia) Medical Evaluation 1. Since this localization effort and subsequent surgical treatment constitutes formidable procedures under general anesthesia, evaluation of the patient's general medical status is imperative. 64 TX TINER RMC0022143 2. Similar requirements are mentioned under Section V, paragraph D related to preoperative testing of pulmonary function. 3. Emphasis will naturally be placed on other signifi cant illnesses or health hazards including cardio vascular disease, pulmonary disease and respiratory reserve, and known allergies. 4. Physical examination of head, neck, and thorax should be performed. Examination of the Upper Respiratory Tract 1. Preliminary examination of the oral cavity, naso pharynx, oropharynx, and larynx by a larynogoligist or similarly trained observer is essential to identify any possible lesions in these areas. 2. The examination of the upper airway may be done as a separate procedure or at the same time as bronchoscopy. Initial Bronchoscopic Examination 1. While topical anesthesia generally cannot provide sufficient patient comfort for a lengthy procedure, it has been found very satisfactory for cursory inspection of the main airway and larger bronchial segments. 2. The option of performing a brief initial examination of this sort will be at the discretion of the endo scopist, and will be based upon clinical assessment and patient acceptance. Utilization of General Anesthesia 1. The duration and complexity of the comprehensive localization studies usually require general anesthesia. 2. Close cooperation between endoscopist and anesthesio logist is vital, and the anesthesiologist must be fully cognizant of the goals of the examination. 3. When it is desirable alternately to eliminate and to reestablish the cough reflex for the initial collection of secretions, sodium thiopental with high concentrations of oxygen and intermittent succinyicholine may be satis factory. Otherwise, general inhalation anesthesia of the larynx and trachea plus adequate muscle relaxation may be used for this portion of the study. 4. Subsequent anesthesia for the completion of the study 65 TX TINER RMC0022144 will be administered as determined by the anesthesiologist with special attention to adequacy of ventilation. 5. Serial arterial blood gas determinations may help assess the adequacy of ventilation during the phase. 6. Postoperatively the patient is susceptible to bronchospasm and further respiratory acidosis. Observation in a postoperative recovery area, and appropriate treatment when necessary, should continue until the patient has fully recovered from the procedure. G. Collect of Differential Dronchial Secretions 1. Before other instrumentation occurs, bronchial washings should be collected in such a manner that separation of specimens from the left and right sides can be assured. Currently, use of a rigid bronchoscope fitted with an inflatable cuff at the distal end is recommended. 2. Simultaneous irrigation and aspiration should be repeated 2-4 times on each side. Election of either intact cough reflex or muscle relaxation techniques shall be at the discretion of the anesthesiologist and endoscopist. After initial sampling from the left main bronchus the cuff is deflated. After an interval for ventilation in the trachea, the bronchoscope is repositioned in the riqht main bronchus, the cuff is reinflated, and the procedure repeated with clean lavage equipment. -' 3. Pulsatile-flow irrigation may be helpful but needs confirmation as to ultimate usefulness. 4. Currently available techniques are inadequte for accurate differential irrigation of upper and lower lobes but may be improved in the future. H. Inspection of Tracheobronchial Tree and Documentation of Observations 1. The rigid bronchoscope is withdrawn following completion of the differential bronchial lavage, and a cuffed endo tracheal tube with "T" adapter or a tracheoscope is inserted. 2. All accessible areas of the bronchial tree are then carefully inspected with a fiberbronchoscope. This examination will be recorded in its entirety on color videotape for documentation and later comparison. Simultaneous audiorecording is essential for orientation and later correlation. 66 TX TINER RMC0022145 3. Any mucosal lesions or suspicious areas should be documented by still photography as well. 4. In every case, visualization and recording should be extended to include at least the fourth generation bronchi, if possible. I. Fluorescence Detection of Cancer 1. In those patients in whom hematoporphyrin derivative i (Hp-D) has been injected (Mayo Group), endoscopic examination will include inspection with violet "activating" light using a fibe-rbronchoscope con taining a special violet light carrier. 2. If characteristic fluorescence is encountered, its locat-ion should be recorded for subsequent detailed study. i 3. Biopsies will be deferred until the entire bronchial tree has been examined for fluorescence. t J. Collection of Specimens for Cytolocic and Histologic Study 1. Gross Abnormality Indentified a. As a localized carcinoma becomes visible, it should be brushed first to secure material for cytologic examination. 1 i b. Following this, biopsy material is obtained for histologic confirmation. c. Equally important is collection of brushings and curettings, and biopsy of adjacent mucosal areas. This will assist the surgeon in planning subsequent resection. The bronchial spur proximal to the .! lesion is particularly critical in this regard. * d. Recognition of a specific lesion must not deter in i spection of all other segments of both sides of the bronchial tree. The possibility of multiple or multifocal neoplasia must not be overlooked. 2._ No Abnormality Visualized a. This problem presents one of the greatest endoscopic i challenges, demanding thorough visual examination and meticulous collection and labeling of material for -4 cytologic and histologic examination. b. Bronchial brushes should be guided under direct vision into each bronchial segment and into as many subdivision d bronchi as possible. \ TX TINER 67 RMC0022146 c. The bronchoscope is withdrawn after each brushing in order that the brush retain as much material as possible. d. Each brush is appLied to giass slides which are immersed immediately in fixative. (An alternate approach is to dislodge the specimen into Hank's solution for laboratory processing as soon as possible.) e. The advent of disposable brushes offers the possibility of cutting off the entire brush for subsequent pro cessing, thus minimizing loss of cellular material. f. The operator may also obtain curettings from the seg mental bronchi. g. "Spur" biopsies from various sites should be obtained in.a specific predetermined pattern, employing either antegrade- or retrograde-Loaded flexible forceps. These biopsies are particularly important since car cinoma in situ can be more accurately localized by biopsy than by brush sampling. Correlation of Bronchoscopic Observations with Other Diagnostic Studies 1. Accurate assessment of all available data requires close surveillance by all members of the team involved in lung cancer detection and localization. The radiologist, cytopathologist, endoscopist, and surgeon must all participate in evaluating results and planning treatment. 2. Hopefully, the detailed localization procedure will enable initiation of specific treatment at this point in the sequence of investigations, but in selected circumstances, it may be necessary to repeat portions of the examination. The choice, sequence, and timing of additional procedures must be determined on an individual basis depending on re view of all earlier studies and correlation with other clinical data. 68 TX TINER RMC0022147 VI . PATIENT MANAGEMENT A. Management _of Persons with Negative Chest Rad inqr.ims According to Results of Sputum Cyrologic Tcsr. ing: (see ChaTt 1 Sputum Cytologic Result Flow Chart) 1. Persons with sputum specimens that ace cither negative (NEG) for cancer cells or exhibit onLy slight cellular atypia (SLI) will submit the appropriate Col low-"up specimen in 4 months. .2 All those with moderately atypical cells (MOD) in the sputum will submit more specimens for cytologic examina tion at once. The additional material obtained will in clude a 3-morning ''pooled'* spontaneous-cough specimen, and, if possible, induced sputum specimens. a. .If moderately atypical cells (MOD) are again encoun tered, the cytopathologist will review all previous specimens, and based on all specimens a summary classification will be made* to serve as the basis for further decision making. b. If the next two sputum examinations are negative (NEG) for cancer ceils or show only 'slight (SLI) cellular atypia, the regular 4-rnonth follow-up schedule will be resumed. 3. Those whose sputum is found to contain colLs exhibiting marked (grave) atypia (GKA) or suspicions of carcinoma (SLIS. will be reevaluated at once. Whenever possible, the reevaluation will include examination of induced sputum. a. If the reevaluation confirms the finding of marked (grave) atypia (GRA) or suspicions of carcinoma (SUS) or reveals cancer cells (CAN), a "full locali zation workup will commence, as described in Section IV, Bronchoscopy. If a cancer is not found during this workup, the individual will be placed under continuing reevaluation with further locali zation studies on a frequently recurrr ing basis or as dictated by subsequent findings until his situation is resolved. b. If the reevaluation discloses only a moderate degree of cellular atypia (MOD) or less, multiple sputum cytologic examinations and evaluations will be required to resolve the problems. 4. Any person whose sputum contains frankly cancerous cells (CAN) will be immediately recalled for induced sputum studies and for comprehensive localization workups on a frequently recurring basis, until the site of the cancer is identified. TX T1NER 80 RMC0022143 Management of Persons with Ne g ative _Sr> atum Cytology Tests According to Results of Chest Rad logracnic examinations 1. Persons whoso chest radiogruphs arc deemed to be negative will continue with foiiow-up. 2. Patients whose chest radiographs arc deemed unsatis factory will have repeat radiographs at once. 3. Patients whoso radiographs are determined to be suspect (SUS OR SNj) will have a review of all the patient's previous radiographs and sputum cytology tests, as well as clinical history and physical examination - a. Repeat radiographs may be taken to aid in the decis ion. b. If the results are deemed to indicate a negative status, the patient will continue with follow-up. c. If the results arc considered to be suspicious but probably not cancer, tue patient will be seen in 2 months (approximately). d. If the results are considered to indicate cancel, the patient will receive appropriate confirmatory and localizing studios. 4. Patients whoso radiographs are considered to be indica tive of cancer (CAN or SN'2) will receive additional diagnostic studies as indicated. Management of Persons with Negative Cytologic and Rad iologic Examinations According to Results of Clinical Information 1. Patients whose history is suggestive of cancer will have a thorough history and physical examination and will receive such additional diagnostic studies as may be indicated. 2. All information available can bo used in reaching a decision in this particular group of patients (Group C). 81 TX TINER HMC0022149 / I CHART I l iac l i ,.k CJ Clinical joDvIVEnt mki. .( a PHYSICAL t\AM SA NON Wt t st IMVf vl An ..'m ; i i . .wit -it 11 i:i not > i van* > ; .'* J t LOCALIZATION INCLUDES >HYSH All! AMINA NON and 'S OMJALI - . Ai | E fl on 8> ANY I l.ANCi R Al-f'lMtN 0 AN I "MAR AE 0 ' SPECIMENS a2 TX TINER RMC0022II0 raiser Aluminum & Chemical Corp. Oakland, CA 94643 J.P. Hughes, M.D., Medical Director N.H. Proctor, Ph.D., Toxicologist v Category 3 ; (/ r< '/f: /: 3 i. (Reduction Plants - GUIDE TO PLANT .MEDICAL SURVEILLANCE EXAMINATION POLICY The Corporation will provide annual medical surveillance examinations of those workers exposed to toxic substances or defined physical hazards, such as noise and heat stress. PURPOSE To judge whether or not the health of the worker is being adversely affected by the work and conditions of work. SCOPE OF EXAMINATION ./ Scope is determined by the nature of exposure to chemical or physical hazards for specific jobs by means of industrial hygiene assessment. See KACC Medical Surveillance Requirements, pages C-3 to C-6 following, for scope of periodic examination listed by chemical and physical stress exposures. For all employees who regularly drive KACC vehicles of 10,000 pounds GVW or greater on public roads or who drive KACC vehicles that carry hazardous materials on public roads,,the scope of their examination has been determined by the U.S. Department of Transportation, and is reproduced on KACC 6706 (See at end of this Section.) C-l TX TINER RKC00221-1 jvACC Category 3 EXAMPLES OF MEDICAL SURVEILLANCE Example 1. No chemical or physical stress exposure No driving of KACC vehicles on public roads (See page C-l) MEDICAL SURVEILLANCE = None Example 2. Driver of certain KACC vehicles on public roads (See page C-l) MEDICAL SURVEILLANCE = Department of Transportation EVERY OTHER YEAR exam Example 3. Exposure: potroom atmosphere (fluoride, PPOM, heat) noise (85 dBA for 8 hours) MEDICAL SURVEILLANCE - Interval history ANNUAL Physical exam (height, weight, blood pressure) Laboratory (blood - hemoglobin or hematocrit; urine - screening test of sugar, protein, blood, fluoride) Lung function Chest X-ray Smoking history Complete blood count Skin exam Sputum cytology Fluoride in urine Electrocardiogram Audiometry AP X-ray of pelvis - every 6 years (See page B-10) 4/7 /77 TX TINER RMCOO 2 215 2 KACC KACC MEDICAL SURVEILLANCE REQUIREMENTS Category 3 By Chemical Exposure: NIOSH RECOMMENDATION - prior to assignment to a work area where exposure to the chemicals named below will be above 0.5 times the 8-hour time-weighted TLV, additional tests as listed below, if not already being performed, are required before exposure occurs and at yearly intervals. (Note: Asbestos exposure at 0,1 fiber/cc or greater requires tests listed below for asbestos.) Use KACC 560 and 567 for preplacement exams and forms listed below for annual exams. Subs tance Medical Tests Acetone ........ 1 Alumina ............................................ 1 Ammonia..................................... 1, 2, 3 Antimony pentachloride. 1, 2, 3, 4 Asbestos................................1, 2, 3, sputum cytology Bauxite (may contain . 1, 2, 3 silica) Beryllium................................1, 2, 3, skin exam Butanol ..................................... 1 Butyl cellosolve ... 1, 2, Complete Blood Count (CBC) Cadmium oxide ..... 1, 2, 3, cadmium in urine Carbon monoxide .... 1, 2, carboxyhemoglobin if intoxication suspected Carbon tetrachloride . 1, 2, liver function 1 KACC 564- Interval history 2 KACC 568 KACC 561 H it ft u 3 KACC 561 KACC 567 Physical exam - describe by systems Height, weight, blood pressure, vision; Laboratory - blood: hemoglobin or hematocrit urine: sugar, protein, blood .. (screening test) Lung function (FVC, FEV- 1.0 sec) Chest X-ray Smoking history 4 Electrocardiogram C-3 TX TINER RMC0022153 KACC Substance Medical Tests Category 3 Cellosolve acetate ... 1 Chlorine and chlorides . 1, 2, 3 Chloroform ................................ 1, 2, liver function Chromates (lead & zinc). 1, 2, CBC Chromic acid..................... ..... 1, 2, 3, CBC Chromite ore ...... 1, 2, 3 Coke and calcined coal . 1 Copper fume and dust . ..1 ,Cyanide . . . . . . . .1,2 Epoxy resin . . . . . . 1, 2, skin inspection Ethyl acetate ....! Fluorides ..................... ..1,2,3, Fluoride in urine; AP X-ray of pelvis - every 6 years (see page B-10) Fluorocarbons ...... 1 Hexane .......................................... 1, 2, neurologic exam Hydrogen chloride ... 1, 2, 3 Hydrogen sulfide .... 1, 2, 3 Graphite ........................... ..1,2,3 Isophorone ....... 1 Lead .......... 1, 2, neurologic exam, CBC, lead in blood/urine Lime (Hydrated) . . . . 1 1 KACC 564 2 KACC 568 KACC 561 tt m tt it 3 KACC 561 KACC 567 4 Interval history Physical exam - describe by systems Height, weight, blood pressure, vision; Laboratory - blood: hemoglobin or hematocrit urine: sugar, protein, blood (screening test) Lung function (FVC, FEV-1.0 sec) Chest X-ray Smoking history Electrocardiogram TX TINER RMC002215 4 KACC Substance Lime (Quicklime) . . Magnesium oxide . . . Manganese fume , . . Mercury ....... Methanol ...... Methyl chloroform . . Methyl ethyl ketone . Methyl isobutyl ketone Nitric acid ..... Nitric oxide/ .... Nitrogen dioxide Nuisance dust .... Oil mist particulate Ozone ..................................... PPOM/CTPV ........................... Perchloroethylene . . Phosgene ........................... Phosphine ........................... Phosphoric acid . . . Polychlorinated . . . biphenyls Medical Tests 1, 2, 3, skin exam Category 3 1 1, 2, 3, neurologic exam, CBC 1, 2, neurologic exam, mercury in blood/urine 1 1 1 1 1, 2, 3 1, 2, 3 1 1 1, 2, 3 1, 2, 3, CBC, skin exam, sputum cytology 1, 2, liver function 1, 2, 3 1 1 1, 2, liver function, skin exam 1 KACC 564 2 KACC 56S KACC 561 tt >t it it 3 KACC 561 KACC 567 4 Interval history Physical exam - describe by systems Height, weight, blood pressure, vision; Laboratory - blood: hemoglobin or hematocrit urine: sugar, protein, blood (screening test) Lung function (FVC, FEV-1.0 sec) Chest X-ray Smoking history Electrocardiogram C-5 TX TINER RMC0022155 Substance Silica ...................... Sodium hydroxide mist . Medical Tests Category 3 1, 2, 3, tuberculin skin test 1, 2, 3 Sodium silicate . . .1 Stoddard solvent 1 Sulfur dioxide Sulfuric acid . . 1, 2, 3 1, 2, 3 Toluene . . . . Trichloroethylene 9 1, urinalysis for hippuric acid 1 Vinyl chloride 2, 3, serum: total bilirubin, alkaline phosphatase, SGOT, SGPT, gamma glutamyl transpeptidase, etc. Welding fume . . * f 1, 2, 3 Wood dus t . . . 1, 2, 3, skin exam Xylene ..................... I, 2, CBC, liver function By Physical Stress Exposure Stress Medical Tests Noise (85 dBA for . . . Audiometry 8 hours) Heat.................................................1,2,4 Radiation ....... 1, 2 Vibration................................1, 2 1 KACC 564 2 KACC 568 KACC 561 u ti it 11 3 KACC 561 KACC 567 4 a/7/77 Interval history Physical exam - describe by systems Height, weight, blood pressure, vision; Laboratory - blood: hemoglobin or hematocrit urine: sugar, protein, blood (screening test) Lung function (FVC, FEV-1.0 sec) Chest X-ray Smoking history Electrocardiogram C-6 TX TINER RMC0022156 *Biologic Monitoring for F: Urinary postshift F analysis shall be made available at an interval not exceeding every 3 months to at least one-fourth of all workers subject to occupational exposure to inorganic fluorides. Participating workers shall be rotated to provide all exposed workers the opportunity for urinalysis every year. Spot urine samples shall be collected at the conclusion of the workshift after 4 or more consecutive days of exposure. Urinary preshift F analysis shall be made available to all exposed workers at least annually. Preshift spot samples shall be collected at the start of the workshift at least 48 hours after a previous occupational exposure. Results shall be corrected for a specific gravity of 1.024. If an individual's postshift urinary F level exceeds 7.0 mg/liter, preshift spot urine samples shall be collected within 2 weeks at the start of a workshift at least 4S hours after a previous occupational exposure and a repeat postshift spot sample shall be collected at the conclusion of the workshift. This shall be done at the end of the workweek in which the preshift sample is collected. If the F level of the second sample is above either the preshift limit of 4.0 mg/liter or the postshift limit of 7.0 mg/liter, steps shall be taken to evaluate dietary sources, personal hygiene, basic work practices, and environmental controls. In case the group (job classification) median postshift urinary F levels exceed 7.0 mg/liter, the working environment shall be evaluated through an industrial hygiene survey and steps shall be taken to ensure compliance with the environmental limit. Urinary F analyses shall be performed monthly until the cause of elevated urinary F has been corrected as demonstrated by a return of the group median to a value not exceeding 7.0 mg/liter. The primary method of control will be engineering and work practices. Use of administrative controls for the individual or group can also be considered. ^National Institute for Occupational Safety and Health, U.S. t Department of Health, Education, and Welfare: Criteria for a recommended Standard....Occupational Exposure to Inorganic Fluorides, HEW Publication No. (NIOSH) 76-103, U.S. Government Printing Office, Washington, D.C., 1975. 4/7/77 C-7 TX TINER RMC0022157 nr\CC Category 3 Schedule for Sputum Cytology Potroom, Carbon Plant, Rodding, Pot Repair, Casting (Ravenswood Casting not included) For all employees who are employed in the above areas or who are otherwise exposed to Particulate Polycyclic Organic Matter/Coal Tar Pitch Volatiles for at least 30 days per year, the Corporation will provide the opportunity for a cytologic examination of sputum at the time of job placement. Thereafter, sputum cytology examinations shall be conducted annually for employees with five or more years of exposure to PPOM/CTPV or who are 45 years of age or older. Specimens are to be collected only by personnel trained for this purpose. Selection of pathology laboratory will be made by James P. Hughes, M.D., Corporate Medical Director. Any employee who refuses the sputum cytology examination shall be informed of the possible health consequences, and may be asked to sign a statement indicating that he/she understands the risk involved in the refusal to be examined. The above schedule for sputum cytology is adapted from the Coke Oven Emission Standard, Federal Register, Vol. 41, No. 206 - Friday, October 22, 1976, pp. 46742-46790. 4/7/77 C-8 TX TINER RMC0022153