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' *'V MEDICAL DEPARTMENT MANUAL ETHYL CORPORATION Baton Rouge Plant P.O. Box 341 Baton Rouge, Louisiana 70821 Size: 200 Acres Employees: Approximately 1500 E-06A 96 ETC 00133 \ ETC 00134 ' ' ' GENERAL INFORMATION Products and Brief History of Company Medical Policy .1 2 MEDICAL SERVICE Plant Physicians and Department Supervisors Panel of Consultants Community Resources 4 5 7 GENERAL NURSING SERVICE INFORMATION Required Dress Laundry Medical Charts Procedure for Blocking Charts Ordering Controlled Drugs Medical Service, Non-Ethyl Employees Construction Coordinators Contact Lenses Death cn Company Property ! 8 9 .10 11 12 14 15 16 17 18 JOB DESCRIPTIONS Registered Nurse (Day Nurse) Shift Nurses MEDICAL DIRECTIVES -- ILLNESSES/INJURIES Description Medical Authorization Medical Directives and Nursing Procedures Plant Ambulance Emergency Situations Asphyxia Shock Unconsciousness Witnessed Cardiac Arrest Acute Abdominal Injuries External Abdominal Injury Internal Abdominal Injury Severe Chest Pain Sprains and Strains of Extremities . 19 20 / 23 24 25 29 31 32 32 32 34 35. 35 . 35 . 36 36 . E-06198 ETC 00135 CONTENTS Strain in Groin Hives Burns Lacerations Fractures Indigestion Insect Bites or Stings Chafing, "Jockey Itch," Prickly Heat Sunburn Poison Ivy or Oak Dysmenorrhea Headache Respiratory Irritation or Infection Bites, Animal Boils and Local Skin Infections Diarrhea Dry Skin Fever Blisters Sore Throat Sinus or Stopped-up Nose Influenza Earache Ear Wax Furuncle in Ear Canal Nausea and Vomiting Constipation Athletes Foot Hemorrhoids Conjunctivitis Arc Burn of Eyes Chemical Irritations and Burns of Eyes Eye Abrasions Sudden Loss of Vision Spontaneous Subconjunctival Hemorrhage Hordeolum (Sty) Blisters on Eyelids Blunt Trauma to Eye Chalzions Foreign Body of the Eye Friction Blisters Toothache Vertigo (Dizziness) Nose Bleed (Epistaxis) Back Injuries and Complaints Heat Exhaustion Heat Stroke Heat Cramps Asthma Head Injuries Abrasions Tar Burns Alloy Burns ii 37 37 38 39 39 39 40 40 40 40 41 41 41 42 42 42 43 43 43 43 43 43 44 , 44 ' 44 44 45 46 46 46 47 47 47 47 48 48 48 . 48 49 50 51 51 51 52 53 53 53 54 55 56 56 56 E-OA199 ETC 00136 CONTENTS Aluminum Alkyl Burns Permanganate Burns Sodium Burns Suturing Alcohol Intoxication, Possible Collecting Blood for Alcohol Cardiac Care, Emergency MEDICAL DIRECTIVES -- EQUIPMENT Autoclaving/Sterilizing Diathermy Nebulizer, Automatic Nebulizer, Manual Oxygen Banks, Changing Ultra Sound Whirlpool CHEMICAL HAZARDS Obtaining History Aniline Benzene Caustic Potash . Chlorine Cyanide Diazomethane DEA (Diethylaniline) Dowtherm Ethyl Chloride Ethylene Ethylene Dibromide (EDB) Ethylene'Uichloride (EDC) Flouride or Hydroflouric Acid Hydrochloric Acid (Aqueous), Hydorgen Sulfide Hydrogen Sulfide Methyl Chloride Organophosphates (DECTP and DMCTP), Phenol (Carbolic Acid) Phosphonitrilic Chloride (Pinkie) Lead Sodium Hydroxide (Caustic Soda) Toluene Trichloroethylene Vinyl Chloride (Chloroethylene) (Anhydrous) 56 57 57 58 59 60 61a-v 62 63 64 65 66 67 68 69 70 71 72 73 74 78 78 78 79 80 81 82 83 84 85 86 8_7_ 88 89 .90 95 96 97 93 ill F-06700 ETC 00137 CONTENTS IMMUNIZATIONS AND INJECTIONS Allergy Injections Injections and Treatments Immunizations Tetanus Smallpox Influenza . DISABILITY FORM PROCEDURES Occupational or Pending Occupational Injury Excusing for Personal Illness Return to Work After Personal Illness Excusing from Overtime Occupational Injury-Outside Physician New Injury Slips Write-up of New Injury on Blue Card Partial Duty Returning to Partial Duty after Personal Illness Excusing Home Compensation or Pending Home Compensation While on Shift Partial Duty, New Occupational Injuries on Shift Returning to Duty After Home Compensation When Not to Issue Excuse Personal Illness Slip Appointments, Outside Physician for Occupational Injury During Working Hours Consultations Records Non-Occupational Disability . Instructions to Nurses Work Schedule DISABILITY WAGE OFFICE 99 99 100 100 100 102 103 104 106 108 110 111 111 112 113 115 115 116 116 118 118 118 119 120 121 F-0620 ETc 00138 DUTIES, MEDICAL ASSIST/iNTS General Pre-placement and Periodic Exams Records Periodic Exams Electrocardiograph Procedure Laboratory Procedure Cleaning Tonometer 129 130 132 133 135 136 137 ANATOMICAL CHARTS Simplied Guide of Anatomical Charts * Extent of Injury -- 9 Percent Rule Head, Face, Neck Nose External Eye External Ear Dorsal View, Left Hand Volar or Palmar Region Ventral or Anterior Arm Dorsal or Posterior Arm Anterior Area Leg Posterior Area Leg Dorsal Area Foot Plantar Area Foot Posterior Area Foot Anterior Chest -- Abdomen Area Posterior Chest and Dorsal Area Back Spinal Column Back Formation of the Teeth 153 159 160 160 161 161 162 163 164 165 166 167 167 168 169 170 171 17 2 173 ETc 00139 PRODUCTS AND BRIEF HISTORY OF COMPANY Product or Service: 1. Corporate-wide: Chemicals - 48%; plastics - 30%; paper - 11%; aluminum - 10%. 2. Baton Rouge: Alkyl lead antiknock fluids; solvents; polyvinyl chloride resins. Brief History of Company: The Ethyl Corporation originated with the discovery by Charles F. Kettering of tetraethyl lead as an antiknock agent which prevents knock in gasoline engines and thereby increases their efficiency. Incorporated in 1924, Ethyl was owned equally by General Motors Corporation and Standard Oil of New Jersey. Its first president was Mr. Kettering who was also responsible for the development of the electric cash register, the electric automobile starter and the rail road diesel locomotive. In 1962 the parent companies sold their interest and Ethyl went public. Formerly a one-product company. Ethyl immediately began diversifying into other products which increased sales volume fivefold to one billion dollars in 1974. Ethyl is a worldwide manufacturing company with foreign plants in Canada, Greece and Belgium. The Baton Rouge plant was constructed in 1937. It is the principal alkyl lead manufacturing facility for Ethyl Corporation. The principal Research and Development facility for the Corporation is located within the boundaries of the Plant. t t-v n r / ** A /*7C F-06P03 ETC 00140 MEDICAL POLICY Ethyl Corporation recognizes that health maintenance is primarily the responsibility of the individual. Because of its interest in the health of its employees and the possi ble relationship of its operations and products to health, the company supports an occupational health program. Objectives: 1. To protect employees -against health hazards in their work environment; 2. To facilitate the placement and insure the suitabil ity of individuals according to their physical capaci ties, mental abilities, and emotional make-up in work which they can perform with an acceptable degree of efficiency and without endangering their own health and safety or that of their fellow employees; 3. To assure adequate medical care and rehabilitation of the occupationally ill and injured; 4. To encourage personal health maintenance. 5. To provide emergency care for personal illness as necessary to preserve life or limb; and 6. To provide minor medical assistance -for personal ill ness in order to enable the employee to finish his work day or for conditions for which he would not ordinarily seek the care of personal physician. f-06204 ETC 00141 Principles 1. The professional staff should be ethical, capable and alert to the advances in medicine and changes in the social, legal, and economic aspects of medical care. 2. The full support and understanding of all personnel is necessary for the success of the medical program. This requires adequate stature for the medical staff and their active participation in matters affecting employee health. 3. The program does not interfere with the relationships of employees with their personal physicians, hit supplements rather than replaces or competes with the services of the latter. 4. The participation of employees in the health maintanance program is on a voluntary basis wherever this is compatible with their own safety and that of others, as well as with applicable legal regulations. 5. The information obtained in the course of the occupational health program is held confidential and is not revealed to anyone except at the written request of the employee concerned or when required by law. 6. The medical program should function within the generally recognized scope of occupational medicine as an integral part of the community health resources. F~06?os etc 00142 PART II MEDICAL SERVICE ^~06P07 ETC 00144 -A - PLANT MEDICAL DIRECTOR INDUSTRIAL HYGIENIST Frank M. Buckingham, M.D., 7388 Sheffield Court Baton Rouge, La. 923-2592 F.A.C.S. Terry Maples PLANT MANAGER M.M. Koenecke CORPORATE MEDICAL DIRECTOR Gilbert B. Meyers, M.D. Ethyl Medical Department 451 Florida Atreet Baton Rouge, La. 387-1838 (Home) O ASSOCIATE CORPORATE DIRECTOR PERSONNEL SUPERVISOR Henry DeCuir SAFETY SUPERVISOR B.J . Lentz INDUSTRIAL INSURANCE Earl H. Rachal Walter Hulon, M.D. Ethyl Medical Department 451 Florida Street Baton Rouge, La. 293-3353 (Home) ASSISTANT TO PLANT PHYSICIANS Wanda Spiers, R.N., 444 Frances Harriet Baton Rouge, La. 927-6076 COHN Dr. MEDICAL ADMINISTRATIVE ASSISTANT Charles W. Bruton 275-4993 E-06708 ETC 00145 Cardiology David W. Wall 3849 North Blvd. Phone: 387-0529 Perinatology Joe Tilley 8220 Goodwood Blvd. Phone: 923-1515 Charles Black 4550 North Boulevard Phone: 924-6256 Henry W. Jolly Carlton L. Carpenter I. J. Sherman 1415 Main Street Phone: 348-3194 Diseases of the Chest Thomas P. Thigpen Clay Waggenspack, Jr. 3849 North Blvd. Phone: 926-8128 James H. Lutschg 8415 Goodwood Blvd. Phone: 923-1515 Ear, Nose & Throat McHugh Simmons J. W. McLaurin 3888 Government Phone: 344-5239 Eye - Ophthalmologists R. C. Caffarel Kirk A. Patrick Paul L. Marks E. E. Afeman Albion B. Cross C. A. Fargason 5246 Brittany Dr. Phone: 766-7441 Neurosurgery William L. Fisher 3849 North Blvd. Phone: 387-4936 Edward S. Connolly 1515 Jefferson Highway New Orlans, LA Phone: 834-7070 Thomas B. Flynn 244 Peachtree Blvd. Phone: 387-0936 Neurology Sam L. Levert Suite 112 4560 North Blvd. Phone: 927-1495 Orthopedics Samuel Irwin Kenneth C. Cranor Jack F. Loupe John F. Loupe 3955 Government St. Phone: 387-0603 Moss M. Bannerman Thomas Campanella Alan C. Farries Joe A. Morgan 5630 Bankers' Ave. Phone: 927-0050 Plastic Surgery W. H. Kisner 606 Colonial Dr. Phone: 926-1710 Psychiatry F.A. Silva 625 Colonial Drive Phone: 927-1050 ETC 00146 PANEL OF CONSULTANTS - contd Radiology Dean W. Geheber Allie Woolfolk Thomas R. Jenkins, 3888 Government Phone: 344-3753 Jr. Surgery Millard E. Byrd, Jr. 3919 Convention St. Phone: 343-3467 Don R. Cowick Leo A. Farmer 3849 North Blvd. Phone: 383-0383 Hand Surgery Joe Morgan 5630 Bankers Ave. Phone: 927-0050 F-Oft?10 ETC 00147 Community Resources Baton Rouge General Hospital 3600 Florida Boulevard P. 0. Box 2511 Baton Rouge, Louisiana 70821 Phone: 387-7000 EMERGENCY ROOMS: 387-7600 Our Lady of The Lake Hospital 1600 Riverside North Baton Rouge, Louisiana 70802 Phone: 387-1131 Earl K. Long Memorial Hospital 5825 Airline Highway Baton Rouge, Louisiana 70805 Phone: 356-3361 MediCenter of America, Inc. 3888 North Boulevard Baton Rouge, Louisiana 70806 Phone: 387-2121 Doctors Memorial Hospital 2414 Bunker Hill Drive Baton Rouge, Louisiana Phone: 927-9050 Americare Hospital 3888 North Boulevard Baton Rouge, Louisiana Phone: 344-0571 70806 Lane Memorial Hospital 6300 Main Street Zachary, Louisiana 70791 Phone: 654-4511 East Louisiana State Hospital Jackson, Louisiana 70748 Phone: 634-2651 Dixon Memorial Hospital Highway 190 East Denham Springs, Louisiana Phone: 665-8211 * East Baton Rouge Parish Health Unit 353 North 12th Street P. 0. Box 3017 Baton Rouge, Louisiana 70821 Phone: 343-7411 Ambulance Service Co. of B.R. 3122 Main Street Baton Rouge, Louisiana Phone: 344-0566 Poison Control Center Charity Hospital 1532 Tulane Avenue ' New Orleans, Louisiana Phone: 899-3409 525-3618 524-3617 70140 Hypolite T. Landry, M.D. East Baton Rouge Parish Coroner Courthouse Phone: 389-3047 Baton Rouge Physical Therapy & Rehabilitation Center Suite 105 4560 North Boulevard Phone: 927-9170 BRGH Chemical Dependency Unit 4040 North Boulevard Baton Rouge, Louisiana Phone: 387-7970 F-06P11 ETC 00148 POLICY REGARDING MEDICAL PERSONNEL Dress Nurses and Medical Assistants are expected to wear uniforms and non-dress shoes. Registered Nurses and Medical Assistants to wear white, shift nurses (non-RN's) to wear navy blue. A new employee is authorized five uniforms initially and three per year, thereafter, to be paid for by the Company. Good grooming is essential and is required. Cosmetics and colognes are to be used in good taste. Em ployees are not to report for work with hair in rollers. Lab coats are to be worn by Medical Assistant. Uniforms will be laundered at Company expense. Nurses are to wear name badges and school of nursing pins. Medical assistants are to wear name badges. ETC 00150 0 MEDICAL CHARTS The following order should be maintained in handling and filing charts. Cooperation in this respect will make it easier on us all. The general order, beginning at the front, is as follows: A. Index card and death certificate. B. Blue cards numbered in red at the top of each blue card with the last number in front. C. History sheet (also initial pre-employment, medical questionnaire). D. Physical examination yellow cards and sheets. These are arranged with the most recent in the front and the earliest in the rear. E. Vinyl examinations, most recent in the front and t' j earliest in the rear. F. Miscellaneous, such as letters, slips, etc., in date order -- the most recent in the front and the earliest in the rear. All correspondence pertaining to a particular incident stapled in the same date order. G. EKG's, if more than one, the most recent in front and the others in date order with the earliest in the rear. H. Asbestos questionnaire. I. Pink laboratory card and, if more than one, again num bered in sequence in red at the top with the most recent in front. J. Immunization card. K. White lead cards and, if more than one, numbered serial- _ ly in red at the top and on the front of the card with the most recent in the rear. L. Disability wage cards, if more than one, numbered serial ly in red at the top and on the front of the card with the most recent in the rear. rV F-06214 ETC 00151 PROCEDURE FOR BLOCKING CHARTS The medical secretary will receive chart and order from plant physicians to block chart. The secretary blocks chart and tells clerk in Disability Wage Office, so that current Disability Wage Card will be blocked. CODES Brown m Blue Orange Diabetes Cardiovascular - Renal Modified Regular Work Block chart in upper right hand corner and on left upper side put small block, date, doctor and illness (on front of folder). ETC 00152 ORDERING by R.N. Day Nurse 1) Drugs Davis Wholesale Drug Company 212 S. 14th Phone 387-1436 Baton Rouge, Louisiana Call for Mr. Kemp or Ms. Neta Buttons and place order. Charge to purchase order No. 02524-P5. (To blanket P.O. for the year). When delivered, check items, sign package slip and give to delivery man. Kee^invoice, OK it and send to accounts payable. If invoice not correct, call Davis, then correct invoice before sending to accounts payable. 2) Sight Screener Record Cards American Optical Company Safety Products Division P.O. Box 13288 Houston, Texas 77019 3) Medical Supplies Bauman Surgical 3722 Convention Street Baton Rouge, Louisiana 70806 4) Wound closure instrument trays #61204 Made by Aerie United Corporation 155 Brookholiow Esplanade New Orleans, Louisiana 70123 5) X-ray film and EKG Paper Evangeline Medical and X-ray Distributor Box 64851 Baton Rouge, Louisiana 70806 6) Uniforms Nightingale Coat Company Georgiana, Alabama or Mary's Uniform Shop 3629 Florida Baton Rouge, Louisiana 70806 f-Oh;- 1 6 ETC 00153 ORDERING - by R.N. Day Nurse (Continued) 7) Laundry Highland Cleaners and Laundry Highland Road Baton Rouge, Louisiana Example: Write requisition as below for current year needed. To cover cost of laundry service to Medical Department from January 1, 1975 through December 31, 1975 - 8) Paper Cups Write requisition - do not put vendor - send to purchasing 9) Stationery From stationery supply room. 10) Hudson Disposable Oxygen Mask #1059 Vallen Corporation c/o Guardian Safety Equipment Company Box 66604 Baton Rouge, Louisiana 70806 11) Reece Orthopedic Shoe With Wooden Sole #175 Reece Wooden Sole Shoe Company Columbus, Nebraska Put 10 items on an order, must have different requisition and M-number if more than 10 items - write requisition for all orders except Davis Drug Company. Get M - Number from secretary - send requisition to purchasing. ETC 00154 -14- CONTROLLED DRUGS List of Controlled Drugs Used in Department Demerol Tablets, 50 mg Demerol ampules, 100 mg Darvon capsules, 32 mg Darvon capsules, 65 mg Donnatal tablets Lomotil tablets Morphine Sulfate ampules, lcc amps., %gr/cc Nembutal capsules, 1% gr. Sodium Luminal ampules, 2 gr. Paregoric Elixir Phenobarbital Tylenol tablets, #3 Valium tablets, 5 mg Quiagel PG - 1. Do not dispense without the written order of the Plant Physicians, except that in emergency situations upon oral prescription reduced promptly to writing. o Exception to the above---Quiagel PG and Darvon may be dispensed per standing orders in Policy and Procedure Manual but, Darvon must have order countersigned by Physician. 2. Record all controlled drugs dispensed in Control Drug Book. 3. In emergency situations, controlled drugs ordered per phone by outside physicians on personal illness may be dispensed but are to be countersigned by Plant Physician. ...j p-06?ia ETC 00155 POLICY AND PROCEDURE Medical Service for Non-Ethvl Employees on the Plant I. Mon-Ethyl employees on the plant are: a. Contractors' employees b. Vendors' employees c. Service and repair personnel d. Salesmen and other visitors II, Medical service will generally be limited to the following: a. Emergency service in cases of severe injuries while arrangements are being made by the injured person's employer to place the individual under care of a retained physician and transport injured to a hospital, b. Suddenly-developing illness where some immediate medical assistance is indicated. When immediate medical follow-up and/or hospitalization is indicated, the employer's availability and cooperation is expected. c. Exposure to Ethyl Chemicals In all cases, the employer's senior representative in charge on the plant will be expected to accompany the employee to the Plant Medical. In cases where the employee is not represented on the plant, as in the case of visiting salesmen, telephone repairmen, etc,, the Ethyl superintendent in charge or his designated alternate will be expected to accompany the non-Ethyl employee to the Plant Medical. Realistic exceptions may be made to afford assistance as may be occasionally required for: a. Guests, visitors, consultants, etc. v ETC 00156 b. Employees of an employer transiently on the plant whose members are few, and whose work is of such nature and/or duration as not ordinarily to justify the employer providing his own first aid facilities. The Ethyl construction coordinator or superintendent in charge is expected to be available as required for liaison with Plant Medical and the injured employee or personal physician in making such arrangements as may be required for moving the non-Ethyl employee off plant. Construction Coordinators -- Ext. 2728 David M. Foreman 0. D. Hollingsworth F-06PP0 ETC 00157 SPECIAL SAFETY PRECAUTIONS 130 Eve Protection 131 Contact Lens 131.01 Experience gathered over recent years has shown that there is no medical basis to prohibit the wearing of contact lenses in the plant provided that safety glasses or chemical goggles (depending upon the potential exposure) are worn with them in the plant areas. a. Contact lens shall not be worn by any person who normally works in any area outside the plant offices unless permission has been granted by the responsible area supervision. b. Anyone wearing contact lens must wear either safety glasses or chemical goggles (depending upon the potential exposure) in any plant area or any control or chemical laboratory. c. Contact lens are to be worn at the employee's risk and without liability to the Company. d. The SOFT type of contact lens cannot be worn on a regular basis or for extended periods of time in plant areas or chemical labora tories as soft lens can actually absorb chemicals. e. Wearing of contact lens with a respirator (any full face piece mask) shall not be allowed. 4/9/81 F-062C1 ETC 00158 DEATH ON COMPANY PROPERTY 1. Notify the Plant Medical Director. He will immediately notify the East Baton Rouge Parish Coroner. 2. Notify the employee's supervisor. The deceased employee's supervision will personally notify the family immediately. 3. Do not remove the deceased from the Medical Department until ordered to do so by the Plant Physician. F-06222 ETC 00159 DAY NURSE R.N. DUTIES 1. Responsible for timely ordering of supplies and equipment. a. Write requisitions b. Receive supplies, check supplies against invoice. 2. Checking bills on occupational cases and forwarding to Industrial Insurance. 3. Keep record of patients sent to outside M.D.'s on OCC cases and consultations. 4. Keep record of pending conditions and date letter received from Industrial Insurance and if made OCC or non OCC. a. Put information on blue card b. File letters in chart. 5. Received letters on OCC cases, send copy to Industrial Insurance and note on blue card. 6. Make appointment for patients with outside M.D.'s on OCC cases. 7. Review partial duty file once a week and call in deliquent patients. 8. Check controlled drugs. Inventory controlled drugs at least every three" (3) months. 9. Report the names of all patients referred to outside M.D. (for plant injury) to Industrial Insurance office. ID. Notify Plant Physicians of employees absent because of reported occupational illness or injury. 11. Give injections and vaccinations as ordered by plant physicians. 12. Assist physician as needed. 13. Check injury file monthly, final by record when indicated and call in deliquent patients. 14. Relieve in Lead Check office as needed. F-06>??3 ETC 00160 SHIFT NURSES' DUTIES A. General 1. Receive patients promptly at Dispensary desk. 2. Pull blue card (Dispensary record), attend patients, be courteous and polite. 3. Give treatments if qualified. 4. Get history and record if patient is to see a doctor. 5. Prepare for special procedures by having needed equipment and supplies at hand, assist doctor. 6. File cards back in charts when finished. 7. Responsible for cleanliness and good order of supplies and equipment. 8. Remove used supplies and straighten exam rooms between patients. 9. Replenish stock in Dispensary, emergency O.R. and treat'int rooms. 10. Change solutions in instrument trays and thermometers. 11. Set up new disposable mask and humidifier after use. Be sure C>2 is closed off after using in wards. 12. Clean top of treatment table in Dispensary with soap and water between patients. 13. Clean and defrost refrigerator as needed. 14. Sterilize supplies by autoclaving every six weeks. 15. Relieve in Lead Cheek office as needed. 16. Assist in Disability office as needed. 17.. Relieve in Medical Assistant's office as needed. Duties consist of: a. b. Take EKGs, audiograms, pulmonary functions. c. Operate sight screening apparatus. d. Perform tonometry. e. Process personnel for periodic and pre-placement exams. f. Collect and prepare specimens for transmittal to medical laboratory. g. Assist physicians in prepartation for examination of individuals. -06P74 TC 00161 NURSES' DUTIES--contd. 18. Fill in Shift Performance sheet. a. Record number of patients seen. b. Under sub-contractor, list names and badge numbers of people requesting excuse overtime shift and whether granted or not. c. List name and badge number of all possible TEL exposures. d. List every incident and every contact with plant physician. 1. Tine, badge number and name of patient. 2. Time, location, patient's name and badge number on ambulance run. e. List time and place of disasters, such as explosions, large fires, chlorine gas or other releases. 19. Fill in enployee Daily Log. 20. Type Daily Medical Breakdown a. Make five copies, staple one new injury and one retreat sheet together with the following names or locations on top comer. These will be picked up in the Dispensary in the A.M. on work days for distribution, after being checked by physician's assistant or medical supervisor. 1. Medical (original) 2. Safety 3. Manager of production 4. TEL (Operations 5. Maintenance 6. Sodium Operations F-062P5 ETC 00162 Nurses' Duties -- contd. D. Information put on / Breakdown 1. On New Injuries sheet--0ccupational injuries or Pending injuries (at bottom of page) Injuries of Non-Ethyl Employees on plant Off Plant injuries 1 } a. Shift and name of person typing b. List in red TEL exposures. Example: TEL exposure, foremans name. Time, Badge number, name, c. On Non-Ethyl Employees. Time, Name.Company, nature of injury, foreman. d. Off plant injuries. Badge number, Dept, name, nature of injury as stated on the 196 received from the Main Gate. 6 e. Occupational or.Pending Occupational injuries Time, badge number, sections where works, nature of injury, in parenthesis put foreman's name, if partial duty given put in red after foreman's name, place occurred, retreat date, if made pending or home comp, put in red in retreat column. 2. On Retreat sheet -- Occupational or pending occupational retreatments a. Shift and name of person typing b. Time, badge numb'er, section where works, patient's name, reported, redressed or retreat and indicate area of body involved, retreat date or if finaled. 1. Under nature of injury a. If you final injury, put "OK injury of" (date) b. If duty status changed, put as partial, full, modified regular work \, c. Reopened cases -- example: Reopen case of (date), retreat left knee. d. Patient placed on occupational absence or pending occ. abs. Example: Retreat left knee - ccc. abs. as of date, type in red, in retreat column occ. absence or pending occ. absence. e. Patient returned to work after occupational absence or Pending occ. Example: OK for partial or full duty after occ. absence as or (date). In retreat column, put date you told patient to report f._ r retreatment. ETC 00163 ETHYL CORPORATION INTER-OFFICE All Medical Department Personnel Address From F.M. Buckingham, M.D. - Address Subject "Off Plant Injury" Reporting Date f 5-83 Effective immediately, (1-6-83), all off plant injuries are to be listed on the Daily Medical Breakdown, at the bottom of the page. List the Badge Number, Department, Name and nature of injury as stated on the 196 received frcm the Main Gate. The 196's will be picked up at 7:00 A.M. ,each day and all re ported "Off Plant Injuries" are to be listed on the Daily Medical Breakdown prior to distribution. F-062P7 etc 00164 MEDICAL DIRECTIVES Medical Directives are written procedures, approved and signed by the physician responsible for the medical direction of the employee health program. Medical Directives serve as the medical authorization for the nurse in giving emergency care to employees for occupational and non-occupational injuries and illnesses. It would be impossible to include in this Manual all the types of illnesses and injuries encountered in industry for which procedures will be required. The procedures given are designed to help the nurse function with pro fessional ethics within the framework of established Company policies. The nurse should bear in mind at all times that she is legally required to perform duties assumed by her in carrying out the physician's order in a competent manner and that she may be personally responsible for wrongful acts of negligence even if performed under the authority of a physician. The occupational health nurse must strive constantly to retain the role of nurse and not to assume responsibility outside the range of her professional -training and experience. She must use judgment as to what she will undertake. If doubt exists, a physician should be consulted, an Ethyl physician for occu pational cases or for questions of Company policy, the patient's private physician for non-occupational conditions. ETC 00165 MEDICAL DIRECTIVES AID .TJRSINS PROCEDURES FOR EMERGENCY CARE OF OCCUPATIONAL AND NONOCCUPATIONAL II1JURIEG AND ILLNESSES NAME AND ADDRESS OF COMPANY ETHYL CORPORATION P. 0. Box 341, Baton Rouge, Louisiana 70821 NAME AND ADDRESS OF PHYSICIAN Carl B. Myers, M.D. P. 0. Box 341, Baton Rouge, Louisiana 70821 NAME OF NURSE IN CHARGE Wanda Spiers, R.N. , C.O.H..N. ' LJ- APPROVED: Date REVIEWED AND UP-DATED: ' / -' Date Date ' __________________ M.D. Signature Signature Signature M.D. M.D. F-06PP9 ETc 00166 MEDICAL DIRECTIVES AND NURSING PROCEDURES General Procedures 1. Observe the symptoms and determine the need for treat ment. 2. Record the presenting complaint, the pertinent medical history and the appearance of the patient. 3. Take temperature, pulse, respiration, and blood pres sure when indicated. 4. Repetitive treatment for non-occupational conditions should be discouraged. 5. When referring an employee (at his request) to a physi cian or dentist, always present more than one name and let the patient make his choice. 6. The Medical Department shall provide essential emergency care for non-occupational injuries and refer the employ ee to his personal physician for definitive treatment. 7. The nurse should be very careful not to be drawn into making remarks about the merits or demerits of any given diagnosis, plan of treatment or personal or pro fessional attributes of any physician. 8. Do not dispense medicine to a patient who is actually under the care of a physician for the condition concerned. 9. Dressings applied by an outside physician are not to be changed without the written request of the physician unless there is direct evidence of a pressing need for changing. If a dressing is changed, only a sterile, dry dressing with no medication is to be applied unless specifically instructed otherwise by a physician. 10. No narcotics, sedatives, antibiotics or other prescrip tion medicines are to be given to a patient without specific orders from an Ethyl physician. 11. Ordinarily a patient is not to remain at Medical longer than 30 minutes (one hour maximum). Should a patient be unable to return to work at the end of this period, he should be sent home or placed under other medical care. / F-06730 ETC 00167 General Procedures -- contd. 12. Injections will be given only by R.N's. 13. Properly label all drugs dispensed with name, date, directions, dispensed by, and stickers as appropri ate, such au: "For External Use Only," "POISON," "Shake Well." 14. Excusing personal illness for prearranged appoint ments : a. Employee to be excused by Day Nurse, Registered, or Assistant to Plant Physicians, if either is available. b. Medical certification will be forthcoming only if appointment cannot be arranged outside of working hours, and if for non-routine medical matter. 15. Injuries received while playing ball on Ethyl-sponsored teams are non-occupational and should be handled as such. 16. Injuries occurring on parking lots outside Ethyl gates are not occupational injuries unless employee is on a job and working outside gates. 17. Pending injuries: Safety is to be immediately called if case presents during regular hours. a. Injuries reported more than 3 days late. b. Back and knee conditions where no visible sign of injury is noted and/or when no accident occurred. c. When in doubt as to whether injury is plant connect ed. 18. Broken teeth sustained while eating -- make pending injury. 19. Do not dispense medicines such as Phemerol, Tincture Benzoin, tubes of Neosporin for employees to have on hand at work site or to take home. 20. X-ray and laboratory examinations requested by employees for non-occupational illness or injury will not be done at Plant Medical unless specifically ordered by Plant physicians. 21. Employees are not be be allowed to look at their rec ords. These records are for the use and guidance of the Medical staff and are not the property of the employees. This department will comply with the new OSHA Standard, 29CFR 1910.20, Employee's Right to access, in a timely, but orderly manner. See guidelines to be followed. E-06231 ETC 00168 General Procedures -- contd. 2 2. Foremen or other members of Supervision are to be told ONLY estimated date of return or date patient is ex pected to report to Medical on employees off on personal illness. 23. Do not discuss patients with other employees or with anyone outside the Medical Department. Supervision may be given the information recorded on the Injury Slip and information related to anticipated return to work, including restrictions if any, for occupational cases. 24. Confidential information, which may consist of results of examinations, laboratory work, and other procedures, or physician notes contained in the Medical record, must be kept absolutely private and confidential. If any doubt about the proper ethical handling of infor mation exists, refer the matter to a plant physician. 25. Do not dispense medicine to employees off from work due to personal illness. 26. Do not remove sutures unless ordered to do so by Plant Physician. If occupational, have patient report when the Plant Physician is in. If non-occupational, refer the patient to his personal physician. 27. Controlled drugs are not to be dispensed without specific order of a physician and, when so, to be entered in the Controlled Drug Record as well as on the blue card. 28. When necessary to call a physician on occupational ill ness or injury, call in the following order: Dr. Bucking ham, 923-2592; Dr. C. Myers 925-9317; Dr. ,W. Hulsn 293-3353 ; Dr.G. Meyers 924-8060 '. Note that Drs. Gil Meyers and Hulon are to be called only if plant physicians are unavailable. 29. Do not call a plant physician regarding personal illness. Exception -- he is to be notified of deaths. 30. Do not.take the responsibility for a condition; if you are in doubt, call the doctor on all medical-related problems. 31. For administrative policy and procedure, contact Miss Spiers or Mr. Bruton. 32. Do not give diathermy treatment without written order from personal physician or specific order from an Ethyl physician. ETC 00169 General Procedures contd. 33. X-rays on occupational injuries or illnesses are to be ordered by the physician, only. 34. Returning to work after occupational illness or injury (occupational absence). a. Employee to be returned by Day Nurse, registered or Assistant to Plant Physicians. If comes at start of A shift, have wait for Day Nurse. b. If there are no return slips on patients chart or on spindle in Dispensary and no write-up on .Medical Treatment Report, saying patient can return, call physician on call for permission to return patient. 35. Personal drugs are not to be ordered through Davis Wholesale by employees. 36. Personal prescriptions for employees will not be filled in Dispensary. 37. Controlled Drugs may notbedispensed or administered without written.order of the Plant Physician, except that in emer gency situations, upon oral prescription reduced promptly to writing. Exception to the above, Quiagel PG, Parepectolin and Darvon may be dispensed per standing orders 38. Treatments, such as hot packs or whirlpool, are- to be given only one time daily and for no longer than 20 minutes. 39. The Registered Nurses will handle all Partial Duty recommendations and reviews when on duty. At other times, the nurses on duty may recommend Partial Duty for only the period of time not covered by the RNs. In most cases this should not be for more than one (1) day or a weekend. Employees will be instructed to come back for review during the RNs' working hours. Physicians will review all Partial Duty recommendations requiring more than one working week. Partial Duty will: 1. Specify clearly the reason 2. Be recorded with appropriate information on the Medical Progress Record. () Date () Time in. (c) Reason for. (d) Foreman notified. 3. Be recorded on the First Aid Performance sheet(under "Recommend No Overtime") for physician review each workday. F-06233 ETC 00170 ETHYL CORPORATION INTER-OFFICE To Site Medical Departments Address From G. B. Meyers SuBJ ECT Pseudofolliculitis Barbae Respirator Usage Address Date Baton Rouge November 17, 1982 The following states the policy we have jointly developed with Toxicology and Industrial Hygiene for people complaining of "shaving bumps". If you have any questions, please contact Corporate Medical. Pseudofolliculitis barbae of the beard (ingrown hairs) results when stiff hair tips penetrate into the skin provoking small pustules. The pustules are easily cut during shaving. An individual alleging pseudofolliculitis should repof^ to the Medical Department for a physician examination. If the diagnosis is confirmed, the company physician will inform the foreman in writing of the diagnosis. This will authorize the foreman to permit the individual to grow a beard no greater than a quarter of an inch in length. The beard may be trimmed with a pair of small scissors or special razor. The employee must then pass a respirator qualitative fit test administered by a person specially trained in respirator fitting. The result must show that the seal of the respirator is adequate to provide the protection needed. Quantitative fit testing is satisfactory at those locations where it is used instead of the qualitative test. Supervision must assure that the beard is kept trimmed not to exceed one quarter inch. GBM:es G. B. Meyers e_06?34 etc 00171 PLANT AMBULANCE Phone: 3118 - 2614 Location: Main Gate Security is responsible for maintance of ambulance and for driving on calls. Oxygen tanks in ambulance are replaced by Security. Calls for ambulance will be received in Medical. Ask caller for location at which ambulance is needed and ascertain nature of emergency. Call Main Gate for ambulance, give location needed. Get emergency bag from O.R. and wait outside. There should be someone waiting in the area to direct you to the patient. i Respiratory protection devices (masks) are kept in the ambulance for your use if going into area where needed. The guard will get the stretcher; the guard and men in the area will put the patient on stretcher and into ambulance under your direction. Be sure to check to see that stretcher is properely fastened with bracket on side. If you need additional help getting the patient out of the ambulance at Medical, have someone from the area come with you. Have the guard stay with you if assistance is needed in the Medical Dept. Medical approval for payment of outside ambulance bill will be given if it is necessary to transport patients to hospitals or physician's office. Oopy of bill is to be retained and given to C. Bruton or W. Spiers. C ~~ 0 p O c; ETC OO172 PLANT AMBULANCE - contd. 3d If necessary to send patient to hospital in ambulance: 1. Call for outside ambulance. 2. Notify Main Gate that ambulance will be coming in. 3. If medicine was given to patient, record with time given on tag and tie to shirt where it can easily be seen. Also, tell ambulance attendant. When guards are no longer needed, give them: 1. Patient's name, badge number and complaint. 2. Clean stretcher from Ward. 3. One Medical Service Slip if the patient is excused. Make write-up on blue dispensary card, record in detail: 1. Time of call and location. 2. Symptoms 3. Vital signs 4. Time and name of physician called. 5. Rx given. Record amublance run on Shift Performance Sheet (note time and location). F-06736 In some instances where speed in getting a patient to the hos pital is of utmost importance, the Plant amublance may be used to take the patient to the hospital. Always transport directly to hospital Emergency Room in Plant ambulance if CPR is being administered. If a situation is serious enough to require the Company ambulance to leave the Plant with a patient, a nurse, shift nurse or M.D. ordinarily should accompany the patient (unless other injured employeed, etc., make the presence of the nurse in the Medical Department seem to be the more prudent decision). ETC 00173 MEDICAL DIRECTIVES AND NURSING PROCEDURES Emergency Situations The nurse in industry must be able to function in any emergency situation. She is expected to have professional competence and skill and use good judgment at all times. General Principles Applicable in All Emergency Situations: 1. Think clearly. 2. Do first things first. 3. Do no more than is actually needed. General Procedures Applicable in Serious Emergency Situations: 1. Restore breathing and maintain open airway. 2. Control bleeding. 3. Prevent and treat for shock (see shock). 4. Call a physician. 5. Provide the physician with as much history and infor mation as possible about the injury or illness, including temperature, pulse, blood pressure, etc. Arrange for follow-up care and record all pertinent data. 6. Prevent infection and further injury. Additional Medical Directives Applicable in Emergency Situations: Hemorrhage: 1. Call the physician. 2. Expose the wound. 3. Remove loose, surface foreign matter. 4. Apply firm pressure over sterile gauze directly over bleeding. ETC 00174 MEDICAL DIRECTIVES AND NURSING PRCXIEDUEES E--nerne--cnc<v -Situ.a.t.i-o-n.s- site. Avoid use of a tourniquet if possible. If direct pressure does not control bleeding from an extremity, use a blood pressure cuff as a tourniquet. Remember: 1. A tourniquet must be released every 15 minutes. 2. No dressing should be applied which would conceal the tourniquet. 3. Any person assuming care of the patient should be informed of the presence of the tourniquet. Asphyxia: Cessation of breathing 1. Mouth - to - mouth resuscitation (12 - 15 inflations per minute) at once and maintained until breathing is restored or a physician directs otherwise. 2. Notify a physician. Shock: Symptoms of shock following injury are pallor, perspiration, rapid thready pulse. 1. Notify physician. 2. Remove cause for shock, if possible (control hemorrhage, relieve pain by medication as ordered by a physician for the specific case). 3. Keep patient i/arm, dry, on his back with head low. Unconsciousness: Fainting produces unconsciousness of short duration. Pallor, shallow breathing, slow and weak pulse are . usually present. 1. Keep lying down until fully recovered. ETC 00175 MEDICAL DIRECTIVES AND MJRSING PROCEDURES Emergency Situations 2. Loosen clothing. 3. Use ammonia inhalants. If other signs are present or if unconsciousness persist longer tlian a few minutes, call a physician. Do not leave patient unattended. Open airway. Give notiling by mouth to an unconscious patient. ETC 00176 Witnessed Cardiac Arrest Have Ethyl Physician notified 1. Open airway. 2. Check for carotid pulse. 3. Deliver a blow to mid sternun (within first 30 seconds). 4. Ventilate four times by mouth - to - mouth technique. 5. Recheck for pulse, if still absent, begin external cardiac compression at 60/minutes with two ventilations after each 15 compressions. If two people use 1 to 5 rate. 6. Continue resuscitation without interruption 7. Transport to nearest hospital as fast as possible in Company ambulance. DATASCOPE DEFIBRILLATOR TO BE USED BY PHYSICIANS ONLY! 3f F-06240 ETC 00177 MEDICAL DIRECTIVES AMD PURSING PROCEDURES Acute Abdominal Injur5.es Trauma to the external abdominal wall may result in injury to underlying organs, even with little evidence of damage. Until seen by a physician, obviously severe or suspected internal abdominal injuries should be cared for as follows: External Abdominal Injury 1. Keep employee flat and quiet. 2. Control bleeding and cover open wounds. 3. If internal organs are exposed, cover with sterile moist bandage to avoid contamination. 4. Do not remove penetrating object. 5. Give nothing by mouth. 6. Treat for phock and avoid unnecessary handling. 7. Contact the plant physician-if cannot contact, then any appropriate physician listed on consultant's list. 0. Arrange for emergency transportation. Possible Internal Abdominal Injury 1. Keep employee flat and quiet. 2. Give nothing by mouth. 3. Treat for shock and avoid unnecessary handling. 4. Contact the Plant Physician. If cannot contact, then any appropriate physician listed on consultant's list. 5. Arrange for emergency transportation. Additional Medical Directives and/or Specific Medications ETC 00178 (EPICAL DIRECTIVES AND NURSING PROCEDURES Severe Chest Pain 1. Absolute rest in a position of comfort. 2. Place in Emergency surgery room. 3. Check pulse, blood pressure and respiration. k . Make EKG. 5. Connect heart monitor. 6. Have Plant physician see patient. 7 . Start Oxygen. 8. Notify personal physician. 9. Arrange for ambulance. Sprains and Strains of Extremities 1. Obtain accurate history and record. 2. Elevate and apply Ice cap for 30 minutes. 3. Have physician see patient. 4. If x-ray needed ( Dr. order only) notify technician. 5. Apply ace wrap. 6. Give Aspirin tabs (dispense 8) signify two every four hrs. as needed for pain. Strain in Groin If occupational in origin: 1. Obtain an accurate and detailed history and record on Medical Treatment Report. 2. Have physician see patient. Non-occupational in origin: 1. Advise patient to see his personal physician. H ive s 1. Give Benadryl 25mg. caps (dispense 3) signify one t.i.d. 2. See private physician if symptoms persist or reoccur. 3. Warn patient of sedative side effect of medication. Immediate Gare of Major Burns 1. Remove clothing quickly. 2. Cover with burn sheet. 3. DO NOT IMMERSE OK AIFLY ICE WATER OVER BURN. COLD MAY INTENSIFY SHOCK. 4. Maintain airway and adminster oxygen. S Nothing by mouth. 6. Notify the Burn Ur.it at the Baton Rouge General Hospital prior to transfer. Phone number 337-7717. v F-0624? ETC 00179 Burns Record type, degree and extent (Use "Rule of Nines") 1. Immerse in cool water (50-60 F.) until pain ceases. 2. With sterile thumb forceps removed dead tissue from the burn surface. 3. Clean thoroughly with soap and water, pat dry with sterile gauze. 4. Shave surrounding area if indicated. 5. Apply Silvadene , adaptic and sterile dressing. 6. Advise to keep wound dry and to report daily for dressing change. . Additional Medical Directives and/or Specific Medications. Have physician see patient on all electrical burns, all third degree burns and all burns if large % of the body sur^ face involved. On shift, notify Plant Physician. Record evaluation of wound healing daily. Notify plant physician if wound appears infected. Eschar will be debrided by the plant physician. Evaluating Wound Healing Such evaluation depends on the answers to the following questions: SIZE Is the wound diminishing? Enlarging? Healing peripherally? DEPTH Is it flat? Indurated? ODOR Is there a necrotic odor? Exudate Is it purulent? Thin? Viscid? APPEARANCE____ Is the wound clean? Epithelizing? Crusting? F-0A243 ETC 00180 MEDICAL DIRECTIVES AND NURSING PROCEDURES Lacerations 1. Scrub the wound thoroughly with soap and water and shave area if necessary. 2. Clean and dry wound and surrounding area 3. Apply Tincture Phemeral and sterile dressing. Additional Medical Directives and/or Specific Medication. 1. If laceration is deep, have doctor see patient. 2. If excessive bleeding, apply sterile pressure dressing and have doctor see patient. 3. Some lacerations may be closed with Steri-Strip skin closures. Fractures 1. Treat for shock and avoid unnecessary handling. 2. Immobilize part. 3. Have physician see patient 5. Arrange'for transportation. Indigestion 1. -Di-Gelr~ta"blo~trs~sigiTify 1 or 2 tabl'eYs^chew-as-needed~ldispen.se , ft) rjnnal M urU <- ^ <-rp-*y"arirl /rvr gpf^vhHr- Medications 1. Creamalin tablets signify 2 tablets - chew or swallow with water as needed (dispense 8) 2. CitrocarDonate 1-2 teaspoons. Stir in glass of water, take while foaming. F-06F44 ETC 00181 MEDICAL DIRECTIVES AMD HURSIUG PROCEDURES Insect Bites or Stints 1. Use Sting - Kill swab Crush swab and immediately apply solution to affected area. Puib in with finger. 2. Apply cold compresses 20 minutes. 3. Give Chlortrimeton 4 mg. one tablet. 4. In case of acute reaction a. Non-occupational - call personal physician immediately. b. Occupational - call plant physician immediately. Chafing, "Jockey itch11. Prickly Heat 1. Instruct to clean and dry affected area. 2. Apply Caldesene powder, Desenex powder-- Jelly to affected areas twice daily. or Vaseline Petroleum Sunburn 1. Demiaplast spray - one time to affected area. 2. Refer to personal physician for further treatment. Additional Directives ]. Nupercainal ointment to affected area. Poison Ivy or Oak 1, Caladryl lotion- apply to the affected area three or four times daily. 2, Advise to consult personal physician if condition persists. F-06245 r> ' MEDICAL DIRECTIVES AIR) HUESIHG PROCEDURES Dysmenorrhea 1. Take a history with empliasis on frequency, duration, associated symptoms, medication used. 2. Give the patient a mild analgesic. 3. If cramps are severe, have the employee lie down with heat to the abdomen. 4. If the patient is not able to return to work in 30 minutes, she should be sent home. 5. Refer to private physician for any further treatment. Headache 1. Take history. If accompanied by dizziness, nausea, vomiting, stiff neck, history of recurrence, general malaise or other symptoms, advise to see personal physician. Be alert that headache may be caused by exposure to toxic substances on the job. 2. If no other symptoms other than simple headache, give two Aspirin, Bufferin, or APC tablets. 3. If severe and past history indicates ASA ineffective, give oarvon-65 tablets, one p.o. stat only. 4. If allergic to Aspirin - give tylenol tablets 11. Respiratory Irritation or Infection 1. Take history, temperature and pulse. 2. If condition, as far as nurse can determine, is mild, the following medications may be given: a. Common cold symptoms: Cold tabs #f-sigvl L.i.d. (dispense 12) or Dasin Capsules two stat, then one every 3-4 hours (dispense 8). b. Cough: Quatussin~y 'Cough Syrup one teaspoon every 3-4 hours as needed (dispense 2 oz.). c. Sore throat: Cepacol Lozenges (dispense 1-2 packages) or Chloraseptic spray (stat dose in Medical). 3. Counsel employee regarding rest, diet and fluids. 4. If temperature is over 100 F., send patient heme and advise to contact his private physician. E--O ?46 ETC 00183 MEDICAL DIRECTIVES AI'D tlURSIHG PROCEDURES Bite Wounds Animal Bites 1. Scrub the wound thoroughly with soap and water. 2. Rinse thoroughly with running water. 3. Sterile Dressing. 4. Determine tetanus immunization status. 5. Refer to private physician. Boils and Local Skin Infections 1. Check temperature. Note history of duration of infection. 2. If of minor nature: a. Apply hot soaks of epsom salts for twenty minutes b.i.d. b. If draining, Trlp;le. astibiotia/oint', dressing 3. Any infection near a joint and above the neck should be referred to private physician. Also if lesion is large or seems to be spreading or if several lesions are present or lesions appear frequently, should be referred to private physician. 4. Do Hot squeeze or open lesion. 5. Protect your own hands from direct contact with the lesion or the exudate contained therein. Diarrhea 1. Take history, temperature, and pulse. 2. If employee has a fever of 100 or over or a history of abdominal pain, refer him to personal physician. 3. If there is no elevation in temperature, give 30 cc. of Ps-repectalin. 4. Advise the patient to eat a bland diet and to eliminate coffee. Additional Medical Directives and/or Medications 1. .Quiagel 30 cc. initially, repeat 1-2 tablespoons after each loose bowel movement. ^'~<06p>4 7 ETC 00184 MEDICAL DIRECTIVES AND NURSING PROCEDURES Dry Skin 1. Nivea cream, apply small amount 2 or 3 times daily. Dispense small amount in round tin. Fever Blisters (Herpes Simplex) 1. Apply tincture of Benzoin with cotton applicator - do no dispense. Additional Medical Directives and/or Medications 1. Apply Triple ant'i^iocic ;o.int> - dispense small amount in round tin and instruct to apply several times a day. 2 . If blisters increase, persist, or reoccur frequently, advise to consult with personal physician. Sore Throat 1. Take temperature, if has fever and/or if exudate in posterior pharynx or on tonsils, refer to his personal physician. 2. When complaints do not indicate need for immediate medical attention: a. Give Cepacol lozenges, dispense 1-2 packages. b. Aspirin, gr X Sinus or Stopped-up Nose 1. Privine Nasal Spsay (stat dose in Medical) . 2. Give- Allerfrintablets, one t.i.d. (dispense 6 tablets). Influenza Complaints of generalized malaise, muscular aching, sore throat, if temperature is over 100 degrees F.: 1. Send home. 2. Refer to his personal physician. If temperature is less than 100 degrees: 1. Give Cold Tabs #1 sig (1) t.i.d. (dispense 12) : Earache If eardurm is not perforated: F_0624a .1. Instill warm Auralgan drops, plug loosely with cotton. 2 Advise patient to see his personal physician. 3. Do not issue drops to take out. ETC OOI85 MEDICAL DIRECTIVES AND NURSING PROCEDURES Ear Wax Do not irrigate if there is any evidence of infection or if known perforation in eardrum. Advise patient to consult.his private physician for this procedure. If neither abnormality present: 1.) Lavage with warm water, directing stream to side of canal, if pain is experienced or if wax will not come out, advise patient to consult his personal physician for removal. Furuncle in Ear Canal Advise patient to see his personal physician. Nausea and Vomiting 1) Give Emetrol, 30 cc. This may be repeated in 15 minutes, if needed. Never dilute Emetrol and instruct patient not to drink fluids immediately before or after taking a dose. Athletes Foot 1) Wash and dry infected areas morning and evening. 2) Give Desenex Powder and ointment. a) Dust powder liberally every day rubbing powder gently on the skin. b) Apply ointment to affected areas every night before retiring. Additional Medical Directives and/or Specific Medications 1) Lavender lotion - apply one time daily - dispense one oz. 2) If condition does not improve or if it becomes worse, discontinue use and consult personal physician. Hemorrhoids 1) Give one tube of Nupercainal ointment. Instruct not more than one tube should be applied in 24 hours and not for prolong use. 2) Advise hot sitz bath at home. 3) Instruct to consult personal physician if symptoms increase, persist, or reoccur frequently. F-06249 ETC 00186 MEDICAL DIRECTIVES AND NURSING PROCEDURES Conjunctivitis 1. Murine drops for "tired eyes" * squeeze two or more drops into each eye. 2. Bleph - 10 - if photophobia or exudate present, I or 2 drops into lower conjunctival sac every 2 to 3 hr. during the day for one day only. 3. Advise to see personal physician if symptoms persist. Arc Burn of Eyes Latent period between burn and onset of symptoms. 1. Pontocaine drops - one time only (explain depresses healing process). 2. Cold compresses. 3. Neodecadron drops every 2 hrs. during the day for one day only. 4. Aspirin tabs two for pain. Additional Medical Directives and/or Specific Medications 1. Bleph 10 - one or two drops every 2 hours during the day for one day only. Chemica 1 Irritations and Burns o f Eve 1. Pontocaine drops one or two. 2 . Irrigate 10 - 15 minutes with Saline 3. For severe burn irrigate 30 minutes. 4 . Get visual acuity test- 5. Stain with STuor-I-gtrip 6. Have physician see patie n t . Eve Abrasions 1 . Get vision acuity test. 2 . Pontocaine drops one or two. 3. Have physician see patie nt . Sudden Loss of Vision (Possible occu l s ion of 1. Get vision acuity test 2. Take accurate history and record 3. Have physician see patient'. E-06P50 ETC 00187 MEDICAL DIRECTIVES AND NURSING PROCEDURES Hordeolum (sty) 1. Hot compresses, 20 minutes q.i.d. 2. Bleph 10-signify one or two drops ever 3 hours during day. Blisters on Eyelids (cause unknown) 1. Break blister with applicator. Blunt Trauma to Eye 1. Keep patient still and quiet. 2. Refer immediately to opthalmologist. Chalzions (Granuloma of internal sebaceous glands of internal eyelid) 1. If inflamed-hot compresses, 20 minutes four times a day. 2. Advise patient to contact opthalmologist. Spontaneous Subconjunctival Hemorrhage No treatment necessary E-06>?51 49 Foreign Body of the EYE 1. Pontocaine drops one or two (if involuntary spasm of the patients eyelids makes examination difficult). 2. Both lids are everted and the entire conjunctiva and cornea are inspected with a binocular loupe. 3. Conjunctival or corneal FB's are flushed out with a stream of Dacriose Solution or wiped out with a sterile cotton applicator moistened with Dacriose Solution. 4. Following removal of the object, irrigate conjuctival sac with Dacriose. 5. If no FB is noted, stain eye with Fluor-I-Strip, wash excess out with Dacriose Solution, abrasions will stain green. 6. Do not attempt to remove an embedded corneal FB, have physician see patient. 7. If rust ring remains after removal of a corneal FB, have the physician see the patient. 8. Refer to patient's personal physician if embedded FB is not occupational in origin. 9. Make Medic la Treatment Report if alleged and no FB found, put on Daily Breakdown as new injury. Issue Safety and foreman's copies as for all new injuries. 10. DO NOT USE EYE SPUD. ~ Friction Blisters A. Alleged to be occupational 1. Obtain an accurate history, record on the Medical Treatment report and make "Pending" 2. If infection is present, have physician see the patient. 3. Cleanse with soap and water. 4. Apply tincture benzoin and sterile dressing. 5. If blister is broken, apply triple antibiotic ointment and sterile dressing. B. Non-occupational 1. Treat as above. 2. Advise to consult personal physician if appears to be infected. F-OA?5? ETC 00189 51 MEDICAL DIRECTIVES AND NURSING PROCEDURES Toothache 1. Give Aspirin or Darvon Compound tablets two stat. 2. If caused by cavity, apply oil of cloves to cavity with piece of cotton. 3. Refer to personal physician for any further treatment. Nose Bleed - Epistaxis 1. Have patient pinch nose firmly for 5 minutes, by the clock. 2. If bleeding persists, refer to personal physician. Back Injuries and Back Complaints Back injuries or complaints may not be occupational in orgin. If non-occupational, refer to personal physician for any substantial complaints. When a plant physician is not in, make all alleged injuries "Pending". Alleged Occupational Injuries A. When plant physician is in: 1. Obtain an accurate and detailed history. (As much as possible of the data should be recorded in the employee's own words.) 2. Put employee in exam room and have him undress. 3. Notify the doctor. Asthma Usually the employee will identify himself as an asthmatic 1. Do not treat. 2. Excuse P.I. to see personal physician. 3. If in immediate distress: a. Notify plant physician. b. Call his physician. c. Transport to hospital emergency room. P-06P53 ETC 00190 ^3 ON ALL ALLEGED ILLNESSES SAID BY PATIENT TO BE RELATED TO HEAT ON JOB, ISSUEINJURY SLIP. IF NOT SEEN- BY A PHYSICIAN, SLIP TO READ "POSSIBLE HEAT CRAMPS" OR "POSSIBLE HEAT EXHAUSTION." Heat Exhaustion Symptoms of heat exhaustion are cramps of abdomen or skeletal muscles, profuse perspiration, weakness, headache, dizziness, rapid heart rate, nausea and vomiting, and no significant elevation of body temperature. 1. Rest in ward. 2. Check ORAL TEMPERATURE , pulse, respiration and blood pressure. 3. One glass of Gatorade to sip slowly. Additional Medical Directives and/or Medications: 1. Give sips of cool salty water (one teaspoon to a glass of water). Heat Stroke Medical emergency requiring immediate recognition and vigorous treatment. Symptoms are markedly elevated temperature (usually 105-106), the skin is dry, pulse very rapid and shallow with hypotension, and rapid respiration. May exhibit either a deep coma or seizures. Diarrhea and vomiting may occur. 1. Check RECTAL temperature, pulse, respiration, blood pressure. 2. Restore normo thermia (ice caps, alcohol sponge of body) . v i* *' 0 - .* - \ 3. Administer oxygen. 4. Transfer to hospital emergency room as soon as pos sible . Heat Cramps Characterized by spasm of voluntary muscles. The spasm can be painful and usually involves the extremities and the abdomen. 1. Check oral temperature, pulse, respiration, blood pressure. 2. Oral administration of 1 glass of Gatorade to sip slowly. 3. Rest in ward. E-06R54 ETC 00191 55 Head Injuries 1. Stop bleeding 2. Have rest in bed with ice cap to head 30 minutes 3. Take blood pressure, pulse, and respiration 4. Record neurological observations a. Level of consciousness b. Pupillary reaction 5. Have physician see patient if indicated. Abrasions 1. Clean throughly with Be.tadine surgical scrub. 2. Apply Triple Antibiotic Ointment and sterile dressing. Tar Burns 1. Remove tar with mineral oil or degreaser. Cold soak until pain subsides. 2. Clean with soap and water. 3. Apply Triple antibiotic ointment, adaptic, and sterile dressing. Alloy Burn (lead-sodium alloy) 1. Wash thoroughly with soap and water. 2. Apply Triple antibiotic ointment and sterile dressing. Aluminum Alkyl Burns These compounds burn on contact with air, so they cause burns when they contact skin. Although these burns are almost always shallow, they are immediately painful and often the burned skin will turn white. These burns are never as bad as they first appear to be. 1. Wash with soap and water. 2. Apply cold water compresses until pain ceases. 3. Silvadene, adaptic and sterile dressing. -06?S5 ETC 00192 Permanganate Burn Permanganate solutions used on this plant usually cause very shallow burns and may only leave a brownish stain. 1. Wash with soap and water. 2. Apply Nivea cream 3. Tell patient stain will wear off in time. 51 Sodium Burn' Sodium burns when it contacts water and causes deep burns when it contacts the skin. 1. Remove any sodium from wound with forcep 2. Wash thoroughly with soap and water. 3. Apply cold compresses until pain ceases. 4. ~-N-eospori-n, adaptic, and sterile dressing. Sulfuric Acid (Battery Acid, Oil of Vitriol) Immediate and thorough washing with lots of water and soap. Sulfuric acid causes a chemical burn which (after thorough washing) is treated like any other burn. F-06P56 E?C 00193 Procedure for Suturin? 1. Have doctor see patient to determine if suturing necessary. 2. Shave skin. 3. Clean wound thoroughly with Betadine Surgical Scrub, rinse off with water and dry with sterile gauze. 4. Put Barrier drape on Mayo stand, empty onto stand with sterile technique, wound closure instrument tray, eye towel, pack of sterile 3x3 sponges, and suture of operator's choice. 5. Set sterile gloves -d- "--~s out for operator. 6. Have Xylocaine and syringe with needle out for operator. 7. Do not leave room during suturing unless so directed by physician. 8. Put dressing on according to operator's directions. Instruct to keep dry. 9. Have patient report following day for examination of repaired wound by physician. ETC 00194 MEDICAL DIRECTIVES AND NURSING PROCEDURES Possible Alcohol Intoxication If presented with an employee who is supposedly under the influence of alcohol, function only as an observer. 1. Record your observations of the actions of the employee and how he responds in ordinary conversation. 2. Do not' interpret your observations. 3. Do not state an opinion as to whether the individual is "drunk" or under the influence of alcohol. 4. Employee's supervisor is to determine whether or not the employee can do his work satisfactorily. 5. Do not excuse personal illness, this is a disciplinary problan to be handled by employee's supervisor. 6. If to be sent heme by supervisor, and you feel employee is unable to take himself home safely, advise the supervisor to arrange for transportation. 7. Do not draw a blood sample unless specifically ordered by Ethyl physician. 8. If Ethyl physician orders blood sample, liave patient sign permission request form. 9. Notify Ethyl pliysician of all such incidents. F~Vt>P58 ETC 00195 io INSTRUCTIONS FOR COLLECTING BLOOD FOR ALCOHOL 1. Disposable syringes and needles and grey-topped vacuum test tubes for collecting blood are on the 2nd shelf from top of sterile linen cabinet. 2. Before collecting blood rub site to be punctured with ether (do not use alcohol sponge) and let dry before touching needle to skin. 3. Draw 10 cc. of blood. 4. Insert needle through grey rubber stopper of test tube and allow vacuum in tube to pull blood frcm syringe. Do not allow air into tube by reroving the stopper before or after filling tube with blood. 5. Immediately mix blood with powder in tube by inverting test tube at least 10 times. Do not remove stopper. 6. On slip of paper write name, badge number, date and time. Wrap slip around blood tube and wrap rubber band around tightly to secure label r a 7. Put test tube in standing position in wooden block. 8. Put blood in your refrigerator and leave note for Laboratory that blood was collected for test. / V ETC 00196 (W Date: - I hereby request and give permission for blood to be dravrn so that a blood alcohol determination may be made on my blood. I *- fully understand this test is capable of indicating whether I am under the influence of alcohol. I further agree in giving my permission that the result and the interpretation of the result will be given both to me and to my supervision. TTTTNESS: F-06?60 ETC 00191 Ethyl Corporation v Corporate Medical Department Baton Rouge, Louisiana Applies to: E Corporate Activities El Domestic Field Sites E Domestic Affiliates 1 | International Medical Directive Number: 05-001 Subject: Emergency Cardiac Care Issued: December 1, 1977_______ _ Effective: December 1, 1977_______ PURPOSE AND PROCEDURE * CONTENTS c c To assist in the care of patients with cardiac emergencies. Site Physicians will be responsible for the procedure in their clinics. Sites without monitor-defibrillators will be limited to basic life support and drugs approved by the Site Physician. Note: This directive is not intended to be a complete treatise on the subject, but is to serve as an aid to help us with our forgetfulness and difficulty remembering details we will rarely use. Introduction and explanation of emergency cardiac care applicable to Ethyl Clinics. Emergency Cardiac Care by the Nurse. Emergency Cardiac Care by the Physician. Life Support Summary. Major Drugs Summary. Samples of Arrythmias. JAMA Standards for CPR as a reference book. Emergency Cardiac Care (under separ. cover) for Site Medical Departments ETC 00198 EMERGENCY CARDIAC CARE CORPORATE MEDICAL DEPARTMENT ETHYL CORPORATION INTRODUCTION About one million persons in the United States experience acute myocardial infarction each year. More than 650,000 die annually from ischemic heart disease. About 350,000 of these deaths occur outside the hospital, usually within two hours.after the onset of symptoms. A proportionate number of .Ethyl employees will have a heart attack on the job. It is our job to pre vent sudden death from heart attack where possible by prompt appropriate treatment. Emergency cardiac care includes: 1. Recognizing early warning signs of heart attacks, preventing com plications, reassuring and stabilizing the victim, and moving him to a hospital without delay. 2. Providing immediate basic life.support at the scene, as needed. 3. Providing advanced life support as quickly as possible, as needed. 4. Transferring the stabilized victim to a continued cardiac care facility. Emergency transportation alone, without life support, does not constitute emergency cardiac care. The victim must be stabilized at the scene and maintained during transportation to the site of continuing care. The de gree of treatment is determined by the patient's clinical state and may . range from simple reassurance to cardiac defibrillation. LIFE SUPPORT Basic Life Support Basic life support is an emergency first aid procedure that incorporates the ability to recognize respiratory and cardiac arrest and to apply adequate cardiopulmonary resuscitation. Basic life support must be instituted within seconds to prevent biologic death. Advanced Life Support Advanced life support includes basic life support plus cardiac monitoring, int ravenous infusions, use of airway adjuncts, drug administration, defibrillat ion, and establishment of such postresuscitative care as is deemed neces sary. Advanced life support requires medical direction and adequate facilities ETC 00199 SUDDEN DEATH Sudden death occurs abruptly and unexpectedly. There are two stages: 1. Clinical death: The cells of the brain metabolize aerobically. Should delivery of oxygen to the brain cease, as in absence of ef fective ventilation or circulation, the brain cells are irreversibly damaged within 4 to 6 minutes in the adult. (The brain cells of in fants and children are more resilient and may remain viable as long as 8 to 10 minutes in the absence of oxygen.) This 4 to 6 minute period after cessation of effective ventilation and circulation is referred to as clinical death. The individual appears dead, yet re versal of all morbid symptoms is possible, since brain cells can remain viable if delivery of oxygen is reinstituted. 2. Biological death: The second stage of death is irreversible and exists when such changes have taken place in the brain cells that their function cannot return. Other tissues in the body, such as heart, lungs, liver, and kidneys can metabolize anaerobically for 15 to 20 minutes after biologic death has occurred. With resuscitative efforts the heart and respiratory functions may return but not conscious, voluntary cerebral function. Following biologic death, the victim may survive for many days or months without hope of recovery. The physiology of sudden death and its treatment may be better understood by considering the sequela to ventilatory and circulatory failure. Failure of Ventilation When respirations cease, there is no exchange of gases between the lungs and the bloodstream. Carbon dioxide accumulates producing respiratory acidosis; oxygen is not supplied, the tissues become hypoxic, anaerobic metabolism com mences, and lactic acidosis results. Response to this loss of vital function is immediate. There is strong acti vation of the nervous system resulting in restlessness, increased pulse and respiration, and peripheral vascular constriction - all aimed at preserving the oxygen supply to the brain. When affected by hypoxia and acidosis, the heart is unable to function normally, resulting in arrhythmias, which reduce .effective blood circulation. Initially, arrhythmias may simply impair the pumping action of the heart, but if these persist or are severe enough, they can cause total cessation of cardiac action. Thus the ultimate result of ces sation of oxygen interchange in respiratory' or ventilatory arrest is cardiac arrest. Circulatory Failure Cessation of effective pumping action of the heart prevents adequate perfusio: of the tissues since cardiac output is reduced. If there is disruption of the heart's rhythmical, electrical activity (which precedes mechanical contractio: and a severe arrhythmia ensues, effective pumping action of the heart will be impaired or may' cease entirely, resulting in cardiac arrest. ^ F-06763 ( `'i r. -3- MECHANISMS OF CARDIAC ARREST Ventricular Standstill In ventricular standstill there is no electrical activity and, hence, no me chanical contraction. This is seen on an EKG by the absence of all but a straight, undisturbed line. Ventricular Fibrillation In ventricular fibrillation the depolarization, or electrical activity, in the ventricle is totally disorganized so that different areas of the ven tricular myocardium are depolarized at different times. Therefore, the me chanical ability is disturbed and contractions of the heart cannot occur. MANAGEMENT OF ARREST It is essential that the initial diagnosis of cessation of vital function be made promptly. An estimated 4 to 6 minutes are available before biologic death occurs. It is necessary, therefore, in adults, to institute resuscitative measures within 3 to 4 minutes; otherwise, effective restoration to re sponsible life may not be possible. Diagnosis Respiratory inadequacy may be caused by obstruction of the airway or respira tory failure. An obstructed airway can be recognized by noisy, labored breathing and excessive respiratory efforts. Respiratory failure is charac terized by minimal or absent respiratory effort, failure of the chest to move, and inability to detect air movement through nose or mouth. If only breathing is inadequate or absent, rescue breathing may be all that is necessary to re store the patient. Opening the airway and restoring breathing are the basic steps of artificial ventilation and should be applied initially in emergency resuscitation. Airway The first step in successful resuscitation is to open the airway. This is done easily and quickly by hyperextending the head as far as possible. The person is positioned on his/her back and the rescuer places one hand under the neck and the other on the person's forehead. The rescuer then lifts the neck and tilts the head backward. This hyperextension of the neck lifts the tongue away from the back of the throat, thus relieving this anatomic obstruction. The head should be maintained in this position at all times. Should there be obvious foreign material in the throat, remove this immediately with the fin gers or suction. The first ventilatory effort will determine whether or not further obstruction exists. If maximum extension cf the head fails to ade quately open the airway, forward displacement of the jaw may achieve the necessary patency. ETC 00201 F-06264 r r V, t. ' - 4- Breathing If after opening the airway the person does not resume spontaneous breathing, begin artificial ventilation by mouth-to-mouth or mouth-to-nose resuscita tion. Mouth-to-mouth resuscitation. Mouth-to-mouth artificial ventilation is an effective means of providing needed oxygen. The body only extracts about a quarter of the oxygen inhaled from the ambient air, which leaves about 16% oxygen content in exhaled air. When performing artificial ventilation, the rescuer takes a deep breath and may provide the victim with as much as 18% oxygen. This concentration of oxygen is entirely adequate. Make no attempt to remove firmly fitting dentures; they will help to provide an airtight seal. If dentures are loose, remove them. After achieving an airway with exaggerated neck extension, take a deep breath, make an airtight seal by pinching the victim's nose, place your mouth closely over the victim's mouth, and exhale deeply and quickly. If desired, a thin layer of gauze or a handkerchief may be used to cover the victim's mouth; this will not interfere with the oxygen input. Initially, give four deep breaths. In between breaths remove your mouth and allow the victim to ex hale passively. After the initial four breaths, give one ventilation every 5 seconds - approximately 12 times per minute - until spontaneous breathing resumes. Adequate ventilation is ensured by seeing the chest rise and fall, noting the resistance of the lungs as they expand, and hearing or feeling air escape dur ing exhalation. Stomach distension. Rescue breathing can cause stomach distension. This is frequently seen in children, but is not unusual in adults. It occurs most often when excessive pressures are used for inflation or if the airway is ob structed. Stomach distension can be dangerous because it may (1) reduce lung volume by elevating the diaphragm, (2) promote regurgitation, and (3) cause vagal tone which may result in bradyarrhythmias after resuscitation. Firm but gentle pressure should be instituted over the epigastrium with the pa tient's head turned to the side. Circulation . . Having established an airway and delivered four breaths, the next approach is to check circulation and heart action. This can be done by palpating for the carotid pulse. With the tips of the index and middle fingers of one hand, gently locate the patient's trachea and slide your fingers laterally into the groove between the trachea and the muscles at the side of the neck. If pre sent, the carotid will be felt. The pulse area should be "felt" rather than compressed. ETC 00202 F -0fe2feF> -5- The carotid is the pulse to be checked for several reasons. The peripheral circulation may not be adequate to produce a radial pulse; the femoral pulse is inaccessible except in the hospital situations since the person is usually dressed. The neck area of the carotid pulse is immediately accessible. The carotids are the first arteries to arise from the aorta and, therefore, they are more central and frequently will persist when other pulses are no longer palpable. The absence or questionable presence of a carotid pulse is an in dication for starting external cardiac compression. Precordial thump. This maneuver is recommended only when the arrest is wit nessed. It is not recommended for children* . A single, quick precordial thump is delivered by raising the fist 6 to 10 inches and delivering a blow to the midsternum. This may restore an effec tive rhythm in cases of heart block, ventricular tachycardia, or ventricular fibrillation of recent onset; i.e., within the first 30 to 60 seconds of cardiac arrest. In the resuscitative procedure the time'of delivery of the thump varies. 'In the monitored patient, it is the initial maneuver of life support; that is, it is delivered immediately when arrest is diagnosed. In the witnessed ar rest of an unmonitored patient, an airway is established, breathing commenced, absence of pulse determined, and then the precordial thump is delivered. No time should be lost assessing the effect of the precordial thump or in de livering repeated thumps. One is all that is recommended. External cardiac compression. External cardiac compression must always be accompanied by artificial ventilation. For external compression to be ef fective, the patient must be on a firm surface. The aim is to depress the sternum 1 1/2 to 2 inches so that the heart is compressed between the ster num and the spine. If the patient is in a bed, a wide board should be in serted under the chest, but compression should not be delayed while waiting for such a board. . Position yourself to one side of the patient in close contact. Place the long axis of the he$l of one hand parallel to and over the long axis of the lower half of the sternum. Great care must be taken not to place the hand over the tip 'of the sternum. Place the other hand on top of the first with the fingers interlaced. Then moving forward so that the shoulders are di rectly above the patient's sternum and keeping your arms straight, exert pressure almost vertically downward to move the lower sternum 1 1/2 to 2 inches in the adult. The compressions should be regular, smooth, and unin terrupted, with the moments of relaxation and compression being of equal duration. The hands should not be lifted form the chest during relaxation. ETC 00203 F-OfePfcfc -6- The present preferred compression rate is 60 per minute, which maintains blood flow and allows cardiac refill. With two rescuers, breaths should be interposed every 5 seconds without any interruption of the rhythm of compres sion. The ratio is five compressions to one breath. Nothing should interrupt external cardiac compression for longer than 5 seconds with two exceptions: (1) Endotracheal intubation should never require interruptions of longer than 15 seconds. (2) Interruptions of up to 15 seconds may be absolutely necessary when transporting the patient. A single rescuer must perform both artificial ventilation and compression using a 15 to 2 ratio. This consists of two very quick lung inflations after every fifteen compressions. Because of these interruptions to ventilate the patient, the rescuer must compress at a faster rate - at least 80 compres sions per minute - to achieve the actual compression rate of 60 per minute. ^ Pupils. Pupils should be checked every 5 minutes during cardiopulmonary re suscitation, since they can indicate that oxygenated blood is reachi;^ the patient's brain. Change in pupil size indicates adequate oxygenation. It * pupils remain fixed, either constricted or dilated (do not react to light), serious brain damage may have occurred or may be imminent. Ingestion or topical use of drugs or age can change normal pupillary reaction, for example, morphine can cause constriction, and atropine dilation, of the pupils. Checking pulses. The carotid pulse should be palpated periodically during compression to check effectiveness of compression. A pulse should be felt with each compression. Compression should be stopped very briefly after one minute to ascertain if spontaneous effective heartbeat has returned. This should be checked every 5 minutes after commencing compression. Complications. Complications can occur from improperly performed external cardiac compression. Even with correct technique, it is inevitable that rib fractures will occur in some patients. Other complications include frac ture of the sternum, pneumothorax, hemothorax, lung contusions, laceration of the liver, and fat emboli. However, complications can be minimized by careful observance of correct technique. Remember: 1. Never interrupt external cardiac compression for longer than 5 seconds, except for endotracheal insertion and transportation. 2. Never compress over the xiphoid process, since this can cause laceration of the liver. 3. The heel of the hand should remain in constant contact with the lower half of the sternum, and the rescuer's fingers should never touch the patient's ribs when compressing. it. Never use sudden or jerky movements to compress the chest. 5. Never compress the abdomen and chest simultaneously. ETC 00204 F-0fe?67 -7- A maximum sense of urgency should continue throughout the procedure.. In arrest the most important aspect in diagnosis is time. Delay in commencing resucitation is the single most disastrous factor. Arrest of vital func tion is an emergency with a time limit of approximately 3 minutes in which to commence resuscitation. Results are poor if the full 6 minutes have elapsed before beginning. Interruptions should be eliminated unless essen tial to resuscitation. This feeling of urgency should possess the rescuer until spontaneous breathing and a strong palpable pulse have been restored. Basic life support should be continued until the patient recovers or can be transferred, to a hospital or until the pupils have been fixed and dilated for 15 to 30 minutes and the victim has remained deeply unconscious with absence of spontaneous respiration and heartbeat. ADVANCED LIFE SUPPORT Action It is essential that the defibrillator be available and in perfect working order. Personnel should be entirely familiar with the machine. They should check it weekly for function and be certain that the necessary adjunctive equipment is present. If the patient arrests in the department and two rescuers are available, one establishes an airway and the other prepares to defibrillate immediately. The rationale: 75% of those who arrest are in ventricular fibrillation rather than standstill. The speed with which ventricular fibrillation is terminated has a distinct bearing upon the outcome. A prompt application of electrical shock to the fibrillating ventricle can return the patient to normal heartbeat within seconds, often precluding the need for any other cardiopulmonary resuscitative measures. Defibrillation Defibrillation is the treatment for ventricular fibrillation. When elec trodes are correctly placed on the chest and the machine is activated, there is an instantaneous discharge of a dense field of current through the heart. This momentarily stops all electrical activity in the heart. One hopes that when it starts again, a more acceptable pacemaker will be in control. Most tachyarrhythmias are believed to be self-perpetuating; thus interruption of their action stops them. .. ETC 00205 F-06P68 Procedure: 1. The diagnosis is determined by - an unconscious patient without a palpable pulse or a picture of ventricular fibrillation on the monitor. 2. The machine should not be synchronized since there is no R wave. Hence, the synchronizer switch must be off; otherwise, there will be no delivery of current. 3. Defibrillation should be carried out within 30 seconds, if possible. 4. Upon diagnosis, turn on the machine and charge it to 400 watt-seconds while moving to the patient's side. Position the defibrillator comfortably close to the patient. , 5. If electrode paste is used, prepare paddles by covering the face of them completely with a thin layer. It is not recommended to place paste on the chest since this can be messy or inadequate. 6. Dry the patient's chest to remove any perspiration. 7. The position of electrodes on the chest should be such that the heart is encompassed. The usual position for anterior paddles is just below the right clavicle to the right of the sternum and below the apex of the heart to the left of the mid-clavicular line. 8. A firm pressure on the paddles is used so that the skin is smoothed out, and skin burning and dissipation of electrical cur rent avoided. Once correct position is achieved, pause a moment to see that all is as it should be. 9. "Everyone stand away." This instruction should be given by the person delivering the charge, who should also take care not to touch the patient. Properly functioning equipment and a complete supply of drugs must be avail able. This must be checked frequently. The fundamentals of CPR must be thoroughly understood by all personnel. If the first "shock" does not convert the ventricular fibrillation, repeat twice; then go immediately to CPR. A frequent cause of failure to defibrillate, if the machinery is functioning, is acidosis. ETC 00206 E-0A269 Cardiac Monitoring The patient, if not already attached to a cardiac monitor, should have elec trocardiographic monitoring established as soon as possible. The patient who arrests is particularly vulnerable to cardiac electrical instability for several hours following arrest. Personnel performing advanced life support should know arrhythmia recognition and treatment. It is important that lethal or potentially lethal arrhythmias be terminated quickly. The recog nition and treatment of the early warning signs of such arrhythmias can prevent their occurrence. Cardiac monitoring is so desirable in the arrested person that a monitordefibrillator with EKG electrode-defibrillator paddles is recommended since, immediately upon contact with the chest, the paddles will detect the cardiac rhythm. Intravenous Therapy An intravenous route for administration of drugs should be established. This should be accomplished as soon as possible as a routine part of the procedure. The intravenous equipment should be firmly taped and capable of withstanding the other arrest procedures (e.g., defibrillation) and not become dislodged from the vein. Consequently, indwelling catheters are much preferred to needles for these infusions. The solution recommended is 5% dextrose and water, which is infused at a rate sufficient to keep the vein patent. All medications to be infused should be hung in tandem to this main line and controlled scrupulously. Essential Drugs Certain drugs are considered of critical importance. The essential drugs include: Oxygen, sodium bicarbonate, epinephrine, atropine sulfate, lidocaine, morphine sulfate, and calcium chloride. Sodium bicarbonate. Metabolic acidosis is the first problem demanding cor rection, and sodium bicarbonate should be given first. In the presence of acidosis, the myocardium responds poorly to catecholamines. The early and regular administration of sodium bicarbonate can return the pH to normal and enable the myocardium to respond to the circulating and administered catecholamines. The recommended dosage 1 mEq/kg of sodium bicarbonate from syringes containing 50 ml of a 7.5% solution (44.6 mEq) should be given immediately. This should be repeated in 10 minutes if the patient remains unresponsive. (Example: The patient who weighs 70 kg vrill receive approxi mately 75 ml of the above solution initially and again in 10 minutes.) In another 10 minutes give half the initial dose if patient is still unrespon sive. ETC 00207 E-06270 r \ '. - 10 - Epinephrine. Although epinephrine can produce lethal ventricular arrhythmias, it has been shown to be effective in the following: 1. Enhancing ventricular fibrillation and thus effectiveness of defibril lation 2. Restoring electrical activity in standstill 3. Improving contractility in electromechanical dissociation Epinephrine exerts a strongly positive inotropic effect on the heart, improves automaticity, and elevates perfusion pressure. Because of its dramatic ef fects, it should be handled with caution. A 1:1,000 solution (1 ml ampule) should be diluted to 1:10,000 by the addition of 9 to 10 ml of normal saline. Five milliliters of this solution should be given by direct intravenous in jection every 5 minutes during resuscitation. The intracardiac approach is not recommended, it is fraught with danger and, even if efficiently accom plished, is of questionable value. - ___ Atropine sulfate. One of the most valuable drugs available for treating slow rhythms or heart block, particularly when hypotension is present, is atropine. Slow rhythms are often caused by stimulation of the vagus nerve. Atropine blocks the action of the vagus nerve and acetylcholine at the cell level, thereby allowing greater sympathetic control and thus increasing the heart rate. A dose of 0.5 mg is given at 5 minute intervals to a total dose of 2 mg. If preferred, the entire 2 mg may be given initially. In cardiac arrest it is used to treat standstill and is given directly intra venously. Lidocaine. Lidocaine is a valuable antiarrhythmic agent, which reduces the automaticity of the ventricle by increasing the stimulation threshold of the ventricle. Its effect is immediate and of short duration. When given in therapeutic doses, it neither affects myocardial contractility nor produces hypotension to the same extent as other antiarrhythmic drugs. But it can cause central nervous system irritability and convulsions and may cause hypo tension in large doses. Lidocaine is particularly effective in controlling multifocal, premature, ventricular ectopic beats and ventricular tachycardia. It is of no value in standstill and should not be used. Because of its short duration, lidocaine is usually given intravenously as a bolus of 50 to 100 mg and may be repeated. This should be followed by intravenous infusion of up to 4 mg per minute while ventricular arrhythmias persist; this dosage is then reduced to 1 to 2 mg per minute for the 24 hours following arrest from ventricular fibrillation to prevent further ventricular irritability. ETC 00208 IT-06.771 - 11 - Morphine sulfate. Morphine is not indicated in the cardiopulmonary emer gency, but is of the first magnitude in treating pulmonary edema. It is also important for patients with myocardial infarction for the relief of pain. Morphine reduces venous return by vasodilation and reduces anxiety and respir atory rate, all desirable in the patient with pulmonary edema. Calcium chloride. Calcium increases myocardial contractility, prolongs systole, and increases ventricular automaticity. It is worth noting that sinus impulse formation can be suppressed and sudden death can occur in the fully digitalized patient following intravenous administration of calcium. In profound cardio vascular collapse and in standstill, it is useful. Calcium must not be administered together with sodium bicarbonate, since this mixture results in the precipitation of calcium carbonate. Large doeses of calcium, when repeated, may produce dangerous blood levels. Recommended doses are 5 ml of 10% calcium chloride intravenously at 10 minute intervals during standstill in the non- digitalized patient. (Calcium gluconate 10 ml of 10% solution Q.10. min) may,, be substituted for calcium chloride). Care must be taken that calcium does not extravasate since tissue sloughing. will result* Oxygen. Supplemental oxygen should be used as soon as available. Because of the intrapulmonary shunting and ventilation-perfusion abnormalities associated with low cardiac output, marked divergence occurs between alveolar and arterial oxygen tension; hypoxemia and thus metabolic acidosis ensue. These two conditions make resuscitation difficult, if not impossible. When to Stop Life Support Basic and advanced life support should be continued until the patient is re stored to responsible life or until cerebral death is evidenced by: 1. Deep unconsciousness 2. Widely dilated and fixed pupils for a period of 15-30 minutes. 3. Absence of spontaneous ventilation 4. -Myocardial death as evidenced by progressive widening and slowing of QRS complex Life support should not be begun if it is known for certain that arrest has been present for more than 10 minutes (except in cases of drowning or in the very.young). ETC 00209 : ( Reference: .. E-06?7? Sproul, C.W.; Mullanney, P.J.: Emergency Care Assessment and Intervention, St. Louis: C. V. Mosby Co., 1974, pp 315-331. EMERGENCY CARDIAC CARE BY THE NURSE Management of myocardial infarction by the nurse consists of: 1. Absolute rest in a position of comfort. 2. Blood pressure and pulse. 3. Electrocar.diogram if there is someone present to interpret it. 4. Oxygen by mask or nasal catheter (8 liters per minute), as needed. 5. a) Morphine sulfate 15 mg (1 ml) I.M. or Demerol, 100 mg (2 ml) l.M. for pain. b) Lidocaine I.M. 300 mg (3 ml) I.M. in deltoid for PVCs (premature ventricular contractions) more than six a minute, or in pairs c) Atropine sulfate 2 mg (4 ml) in deltoid for sinus bradycardia (pulse under 40) . d) Aramine 2-10 mg (0.2-1 cc) I.M. for maintaining diastolic 90-100 mm Hg. 6. Start I.V. with 5% dextrose in water If indicated. 7. Cardiopulmonary resuscitation. 8. Transportation to continued care facility. BASIC LIFE SUPPORT Basic Life Support consists of cardiopulmonary resuscitation'(CPR) i.e. opening and maintaining a patent airway, providing artificial ventilation by means of rescue breathing, and providing artificial circulation by means of external cardiac compression. Cardiopulmonary resuscitation is started as quickly as possible in the fol lowing order: 1. Immediately call for help. 00210 2. Tilt the head to open the airway and simultaneously palpate the carotid pulse. If the pulse is absent, give a precordial thump if indicated. f r V - 2- If'the victim is not breathing , give four quick, full lung inflations. If pulse and breathing are not immediately restored, begin CPR: One rescuer: 15 chest compressions (at 80/min) to 2 lung inflations. Two rescuers: 60 chest compressions (at 60/min) to 12 lung inflations. 3. The major emphasis of emergency cardiac care is life support through stabilization of the victim at the scene. Stabilization must be maintained during transport of the victim to the hospital. Precordial Thump It must be emphasized strongly that no time should be lost in waiting to assess the results of the precordial thump or to deliver repeated precordial thumps. Give only one precordial thump and begin CPR. In delivering the precordial thump: 1. Deliver a sharp, quick single blow over the mid-portion of the sternum, hitting with the bottom, fleshy portion of the fist struck from 8 to 10 inches over the chest. 2. Deliver the thump within the first minute after cardiac arrest. 3. If there is not immediate response, begin basic life support at once. ETC 002 F-06274 EMERGENCY CARDIAC CARE BY THE PHYSICIAN When a physician is in attendance, MI is treated as follows: 1. Absolute rest in a position of comfort. 2. Connect heart monitor. 3. Blood pressure, pulse, EKG. 4. Oxygen. 5. Start l.V. with 5% Dextrose in water. 6. For pain Morphine sulfate 3-4.5 mg l.V. Q.5-30 prn (15 mg/ml diluted to 5 ml = 3 mg/ml) or Demerol 100-200 mg l.M. ARRHYTHMIAS I. PVC's (>6/min or in pairs) give lidocaine (Xylocaine 2% or 20 mg/ml) 50-100 mg l.V. bolus slowly. May repeat in 3-5 min. if necessary. Begin drip 250 mg in 250 D5W (1 mg/ml at 1 to 4 mg/min or 15-60 mm/min) 11. VENTRICULAR TACHYCARDIA (150-250) with good vital signs but in short bursts - handle as in PVC's. III. SINUS BRADYCARDIA (UNDER 40) Atropine sulfate 0.5 mg (1 ml of 1/120 gr/ml) l.V. bolus Q.5 min x 4 maximum until pulse = 60. IV. VENTRICULAR FIBRILLATION 1. Life threatening act quickly. 2. Signs: Unconscious, cyanotic, no pulse or respirations. Monitor - fine or coarse ( > 150 irregular) fibrillatory waves without identifiable QRS complexes. 3. Freoordial thump - once and hard. 4. Defibrillation. r V ETC 00212 E-06P75 2- 5. CPR a) Airway - clear and maintain b) Breathing mouth to mouth or ambu bag c 0 (12/min) c) Circulation - Feel for carotid pulse if absent begin external cardiac massage (60 compressions/min) Note: One rescuer 15 chest compressions at 80/min to 2 quick lung inflations 6. Drugs. 9) I.V. infusion D5W. b) Epinephrine - Dilute 1 ml (1:1000) adrenalin to 10 cc (1:10,000). Give 5 ml I.V. bolus every 5 min during resuscitation. c) Sodium bicarbonate 75 ml of 7.5% solution I.V. bolus immediately after defibrillation. Repeat 75 ml bicar bonate bolus in 10 min if effective circulation not restored. Repeat 35 ml bolus in another 10 min if still unresponsive. d) Calcium chloride 2.5-5 ml of 10% solution I.V.bolus Q.10.min x 3 maximum. Do not administer simultaneously with bicarbonate because mixture gives precipitate. Do not give to digitalized patients. e) Aramine (metaraminol) I.V. bolus 2-5 mg (0.2-0.5 ml) for hypotension followed by I.V. infusion 7.5-50 mg (0.75-5.0 ml) in 250 cc D5W. Maintain diastolic 90-100 mm Hg or A0 mm below usual pressure. 7. Stabilize and transfer to continued care facility. V. CARDIAC STANDSTILL . 1. Life threatening act quickly. 2. Signs: Unconscious, cyanotic, no pulse or respirations. Monitor - No electrical activity. Straight undisturbed line. 3. Precordial thump - once and hard. A. Defibrillation. ETC 0021 F-0677A r- -3- .5. CPR a) Airway - clear and maintain. b) Breathing mouth to mouth to ambu bag c 0 (12/min). c) Circulation - Feel for carotid pulse if absent begin external cardiac massage (60 compressions/rain). Note: One rescuer 15 chest compressions at 80/min to 2 quick lung inflations. 6. Drugs &) I.V. infusion D5W. b) Atropine 2 mg (4 ml) I.V. bolus stat. c) Epinephrine - Dilute 1 ml (1:1000) adrenalin to 10 cc (1:10,000). Give 5 ml I.V. bolus every 5 min during resuscitation. d) Sodium bicarbonate 75 ml of 7.5% solution I.V. bolus immediately after defibrillation. Repeat 75 ml bicar bonate bolus in 10 min if effective circulation not restored. Repeat 35 ml bolus in another 10 min if still unresponsive. e) Calcium chloride 2.5-5 ml of 10% solution I.V. bolus Q.10.min x 3 maximum. Do not administer simultaneously with bicarbonate because mixture gives precipitate.- Do not give to digitalized patients. f) Aramine (metaraminol) I.V. bolus 2-5 mg (0.2-0.5 ml) for hypotension followed by I.V. infusion 7.5-50 mg (0.75-5.0 ml) in 250 cc D5W. Maintain diastolic 90-100 mm Hg or 40 mm below usual pressure. 7. Stabilize and transfer to continued care facility. I ETC 00214 F-0fc?77 LIFE SUPPORT SUMMARY Basic Life Support: ABCs of Resuscitation 1. Diagnose cessation of ventilation. 2. Open and maintain airway by hyperextension of head and neck. 3. Ventilate with four quick, deep breaths. 4. Feel for carotid pulse. 5. If pulse is absent give one quick, precordial thump with the fleshy part of closed fist. 6. Check carotid pulse. 7. If pulse remains absent commence external cardiac compression. Find correct pressure point (lower one half of sternum) and place heel of hand on long axis of sternum. Do not lift hands during compression. Do not allow fingers to touch victim's chest. Give sixty compres sions per minute: Ratio with two rescuers: 5 compressions to 1 breati with one rescuer, 15 compressions to 2 breaths. Rate of compression with two rescuers: one compression per second. With one rescuer the rate is 80 compressions per minute to allow for time lost during venti lation. 8. Check pupils for reaction. 9. Do not interrupt external cardiac compression for longer than 5 seconds. 10. Check carotid pulse regularly for effectiveness. Advanced Life Support 1. Defibrillate as soon as possible. 2. Attach to cardiac monitor. 3. If defibrillation fails continue CPR (basic life support). 4. Obtain an intravenous lifeline. 5. Give sodium bicarbonate, calcium chloride, and epinephrine (separately, flushing between). ETC 00215 6. Check carotid pulse, monitor, and pupils. 7. Defibrillate as indicated. F-0627fi 8. Continue drug administration as indicated to correct acidosis and maintain adequate cardiac rhythm. 9. Continue to evaluate effectiveness by pupil and pulse checks until patient is restored. EMERGENCY CARDtAC CARE MAJOR DRUGS COMMONLY USED IN Ml AND CPR- ooo r-- xo. >> ,&3 ~ otco xt5o: -X t3o i3o Sc g> *5 O to --C 2to '5Q)>--^ E -O c to T 'J E X> b ooO --g> oE 2t "tToO T>O ~JC 5 cc 5> o > 3 C o Q_ c* . 23to L=3L i > . to " n II Si Qi 5 ~ tTTO ttoo pu IL O O2 u si Is X: cu cm H a^* o> E oo cr> E in re E^ D *q CD -E oj to o oE 3M TO "5 8 53 X> c 0 ^ --3 2> oE ll in tar C\J o x o> CC atr. o E3 o `a &c> T_ 3_ 0 6S c X3 O CO 5.. oE c in f hm* tEn to co *m? X c CM E 3<s ^o O CD 3 to 3 b cOo 2a CD d 5 in Q on E2 in E b Eo cm E <t3=o> n2* *Z3j OQ- CD TXO E x c E uo d 6 o ocoa; E CM _C2O o CD -V oTO IS to oiC^nM --E E in C9M C3O CoD E n co CT0CaLO)l T<ToT>ktCoOOOo-1 E in CM co to 2 oto in TO n Q E *v CD E o rCO 3E 5 Cow r.--. w tT3:O--O*32 cU*oO O CD O c o co (0 i; xcTjO --*i9 5 TO Or3 *T2O E O> UJ CM .Eoi: c to 2 tO fo 0 "T2O cQ) o> < o r- CM E o CD E E EE CM 6 o 9 *- o CO Or om H H H i--l 00 p +J tn in >! W c (0 c Mo*E-v. rarO wTO Xc) i> 3 TO = El E= tcToO ocsooSEp|twafo T3 TO>O, X3 TO ~ XcTO) a o> v c gVA >. X TO ID TO o CocO oTkO_ Co O iT_O O3 I. CkO. E E 'to 0) c CD. TO >aj t|o c- lBAa .2 CM TO to > ~6 EUa C in o > I- >" E. o CM 6 TO CL ETC 0021 oo TO Co 0) X5 D> 5 o c ToO t2; IOC 3SD Is OQ. qV..) C X) ID o^ 123 #in t2o ^ E5 U o 52 o <D oc -- _ cEHc2iJ2r 'CEET n2 2_ ^5 to o aiaP E i: ^ o -E 0 2 Oi . o> E TOoO oo o^ CM 2 2 *. >; 5 a c o^ 5" _E 2 0 ac> |o Q^> a E-06279 SAMPLES OF ARRHYTHMIAS Ventricular Flutter is produced by a single ventricular ectopic focus firing at a fate of 200-300/min. Notice the smooth sine wave appearance. True Ventricular Flutter almost invariably becomes Ventricular Fibrillation requiring cardio-pulmonary resuscitation and de-fibrillation. During Ven tricular Flutter the ventricles are contracting at about 300 per minute. There is no effective cardiac output. Ventricular Fibrillation results as-the many ventricular ectopic foci try to compensate. Reference: ETC 00217 Dubin, D: Rapid Interpretation of EKG's, Tampa: Cover Publishing Co., 1970, pp 114 and 115. F-06280 Paroxysmal Ventricular Tachycardia is initiated by a ventricular ectopic pacemaker. It has a characteristic pattern. Ventricular rate 150-250. Appears like run of PVC's. V v''-. l-V^V *: '-'h'V-V.`*ivv'. '-Vj' . v vTtl.V y*v; r,-*' -"''''"t*jt> '*2 VyA'"- *; iV/. ' ... - -l1-,-1* --(*, -. *' * ' .>' - ' * ' / v *; '. , \'Vs}v,. . ' v:\ -v'-' ,, ; V v-->.Runs' ^ovr - r ; w::y -v ?vi1^V.e n.t i* 8 c.u i arf.jCa c h vea r d i a -Vv"; /' . .-r. . - j. -^ ..-,.<; . ' "r Runs of Paroxysmal Ventricular Tachycardia may signify coronary artery disease. This rapid ventricular rate is really too fast for the heart to function effectively, so it should be treated quickly with Xylocaine. ETC 00218 r L Reference: Dubin, D: Rapid Interpretation of EKG's, Tampa: Cover Publishing Co., 1970, pp 309 and 111. ( Ventricular Fibrillation is created by stimuli from many ventricular ectopic foci causing a chaotic twitching of the ventricles. r- Ventricular fibrillation is easily recognized by its totally irregular appearance. If you do recognize any repetiton of pattern or regularity of deflections, you probably are not dealing with ventricular fibrillation. These three strips are a continuous tracing of the same patient's dying heart. Notice how the amplitudes of the de flections becomes less as the heart dies. ETC 00219 Reference: E-0628? Dubin, D: Rapid Interpretation of F.KC's, Tampa: Cover Publishing Co., 1970, pp 118 and 119. .fiS'J-' ETC 00220 F STERILIZATION PROCEDURES I. Cold Sterilization A. Chlorophenyl will be used as the disinfecting solution for metallic instruments. 1. Procedure: Instruments will be thoroughly cleansed with soap and water, will be free from blood and other debris before immersion into this solution. Common vegetative bacteria (except for tubercle bacilli) are destroyed in five minutes, but instru ments should be immersed for not less than fifteen minutes for adequate safety. B. Aqueous Zepherin 1:5000 to be used in thermometers and as dip solution for throat and nasal spray nozzles. II. Sterilization by Autoclaving A. General Rules 1. All articles to be sterilized must be cleaned and in good condition. 2. Articles to be autoclaved must be wrapped in autoclave paper, double muslin covers or placed in metal or glass container. 3. Packages and containers must be dated, labeled, and initialed after each autoclaving. B. Autoclave time -- 30 minutes. ETC 00221 P-06P84 DIRECTIONS FOR USE OF DIATHERMY Self-timing has simplified the diathermy treatment procedure -simple 10-step, push-button controls let you pre-select the output, and automatic tuning takes over to maintain the selected level. 1. Press minimum output Control Switch. 2. Turn on the Main Switch and allow at least 10 seconds for warm-up time. 3. Have patient remove all metallic objects and clothing from treatment area. 4. Place double thickness terry towel over area to be treated. 5. Apply the applicator. 6. Turn the Timer Switch to 10-15 minutes. 7. Press the Number 2 Button. The meter reading should increase. Advance to required dosage. 8. Advise patient that only a pleasant sensation of warmth should be felt during treatment, and that any burning or painful sen sations should be reported at once. Treatment may be contraindicated in the following conditions: 1. Acute inflammatory processes, such as cellulitis. 2. Where there may be a tendency to hemorrhage, as gastric ulcer. 3. Ischemic tissues. 4. Impaired circulation (peripheral vascular diseases). 5. Edematous tissues. 6. Pregnancy (through abdomen or lower back). 7. On patients with cardiac pacemakers. 8. Over adhesive tape. 9. Over known areas of metallic implants. ETC 0022 e"06285 INSTRUCTIONS FOR NEBULIZING A BRONCHIAL DILATOR DRUG (AEROLONE COMPOUND) IN CONJUNCTION WITH THE PNEOP.HORE 1. Must be ordered by Plant Physician. 2. Leave the cap off. 3. Put patient in upright position; mask in vertical position. 4. Instill 1/2 cc. of Aerolone Compound in nebulizer. 5. Check pulse rate. o 6. Turn nebulizer valve 160 counter-clockwise. 7. Check pulse rate occasionally. Normally the entire 1/2 cc. of solution can be nebulized and oxygen continued thereafter as may be indicated. 8. If pulse rate increases by 20 - STOP MEDICATION. NOTES: DO NOT use nebulizer in heart cases. ETc 00223 F-06P86 Directions for use of Manual Nebulizer 1. Must be ordered by Plant Physician. 2. Remove the cork from the mouthpiece, and pour a sufficient but small amount of medication into the nebulizer. 3. Insert the mouthpiece far enough into the mouth so that the mist reaches the throat with gentle force. 4. Inhale deeply through the mouth and, at the same time, press the hand bulb with the entire hand. 5. Breathe out and repeat the process until 6 to 10 inhalations have been taken. 6. Repeat the treatment every 15 minutes as necessary. ETC 00224 P-06287 Procedure to follow if necessary to change C>2 banks on shift 1. Turn off valves on empty bank at top of all three cylinders. 2. Turn off Service Valve (No. 2). 3. Turn Regulator Valve (No. 3) counter clockwise -- to take pressure off system. To cut on new bank 1. Open valves at top of all three cylinders. 2. Open Service Valve (No. 2). 3. Turn regulator valve clockwise to 28 or 30 lbs. of pressure. DIAGRAM SHOWING VALVE NUMBERS, ETC. r-' l t' rv .'C V, fi i/ '.jr ir r i c\ / 1` -* < t L.a Li' < r :. r; v ;i L * c. ,A pz c1 --7' Ci>L ) * ETC 002 F-OAP88 DIRECTIONS FOR USE OF ULTRASOUND I/**. Treatments may be given by Charge Nurse and shift nurses. 1. Turn generator on. 2. Position patient in a comfortable position. 3. Instruct that any feeling of burning or pain should be men tioned. 4. Apply gel by spreading generously over both, part to be treated and the sound head. 5. Move applicator in circular, overlapping strokes or by to- and-fro strokes. 6. Treatment will be ordered by Plant Physician and will be for 7 mintues, unless otherwise specified by M.D. Underwater Application Used when irregular areas of the body offer a poor surface for contact. 1. Part to be treated and the transducer are submerged in water. 2. Move transducer over the area, keeping the head approximately *5-1" away from the part. 3. Wipe air bubbles away as they appear so as to ensure proper transmission of energy to the tissues. ETC 00226 f-06?89 Directions for Use of Whirlpool 1. Temperature of the water should be 105 to 110. 2. Position jet nozzle to direct water directly onto the part being treated. 3. Duration of treatment 20 minutes To fill tank 1. Open main water valve. 2. Adjust mixing valve to proper temperature setting. Watch temperature gauge as the tank fills. 3. Fill tank to within five inches of the top. 4. Place patient in position. 5. Turn motor switch on NOTE: Never turn motor switch on to operate turbine ejector pump unless the pump is completely submerged in water. ETC 00227 Fr-O6?90 INSTRUCTIONS FOR USE OF HYDROCOLLATOR Operation 1. The unit is turned on and off with a Toggle Switch located on the control panel at the lower rear of the unit. 2. The thermostat has been preset at the factory to normal operating temperature. Do not adjust. Notify supervisor if adjustment is needed. 3. Only the front and rear sections of the steam pack rack can be adapted to contain the neck contour pad. 4. Submerge the pack into the water of the tank so that the rectangular sections are standing vertically and the loops are sticking above the water for easy removal. Always keep water level over top of pack. 5. Replace pack in tank after use -- do not allow to dry out. 6. Check water level daily. Safety Instructions 1. Never put your hands directly into the water. The tempera ture of the water is approximately 160 degrees Fahrenheit and can cause skin burns. 2. Be especially careful when inserting or removing the steam pack. Splashing or dripping of water 160 degrees could cause burns. 3. Always use the loops on corners of steam pack for inserting into and removing out of the water. Application of the Steam Pack Steam packs may be applied without an'order from a physician. 1. Place six layers of toweling on the area to be treated. 2. Never lay the patient on the steam pack. Always apply the pack to the patient. 3. Remove the steam pack and wrap it in one layer of toweling before placing it on the layers of towels. 4. Cover the steam pack with a layer of toweling to minimize heat loss. ETC 00228 F-06291 ts>4 J-> ...USE OF HYDROCOLLATOR - contd. 5. During treatment, check the condition of the patient on the treated area. 6. Always have patient inform you if pack is too hot. 7. Exercise caution when applying pack to thin skin or "bony areas." 8. Never lay one pack on top of another. 9. Do not use packs directly over cuts and abrasions. 10. Do not use packs in conjunction with skin balms and lina- ments. ETC 00229 ETC 00230 F-06793 Chemical Hazards 1. Obtain a complete history a. How long the possible exposure lasted? b. How long ago did it occur? c. Was there any coughing, choking, nausea or headache at the time of or shortly after exposure? d. Did an undue degree of lassitude come on- after exposure? e. What was the chemical? If employee doesn't know, get this information from his foreman. 2. Record signs and symptoms 3. Notify plant physician. etc 0023 f-06294 ANILINE Aniline is highly toxic. Immediate and thorough washing with lots of water and soap. It is important that no tiny spots of aniline remain on the, skin or scalp. Special atten tion should be given the areas around the fingernails and toe nails, using a brush if possible. Contaminated clothes should be washed before wearing again, or destroyed if badly contami nated. Shoes and gloves should be burned. Oxygen should be given if skin or lips are blue. Plant Medical Director is to be notified of all aniline exposures. Aniline changes hemoglobin to methemoglobin so the blood cannot carry enough oxygen. Moderate exposure may cause only a bluish or blackish discoloration of lips, cheeks, finger nails or ears. In more severe cases there may be headache, weakness, or irritability. If exposure continues, drowsiness, shortness of breath, unconsciousness or even death can occur. The symptoms described clear in a few hours if absorption is promptly stopped by thorough bathing and removal from odors. If the bathing is not absolutely thorough, the patient's condition will worsen for several hours. The patient must be warned to drink no alcohol and to take no headache pills except plain aspirin. ETC 0023 E-06P95 * BENZENE HEALTH HAZARDS: The principal hazard is from inhalation of vapors of benzene. CONTACT WITH SKIN AND KUCOUS MEMBRANES: Clothing contaminated with benzene should be removed immediately. CONTACT WITH THE EYES: If liquid benzene enters the eyes, flush thoroughly with plenty of water for at least 15 minutes. If irritation persists, secure medical attention. TAKEN INTERNALLY: There is no specific antidote for benzene poisoning. Do not induce vomiting. Call a physician. Keep patient warm ar^ quiet. INHALATION: In case of unusual exposure, call a physician immediately. To prevent collapse, the patient should lie down without a pillow and be kept quiet and warm. If patient is unconscious, and oxygen inhalation apparatus is available, oxygen' should be administered but only by a person authorized for such duty by a physician. ETC 00233 E-06296 HAZARDS: CAUSTIC POTASH U Marked corrosive action results from contact with all tissues of the body. GENERAL PLAN: Speed in removing caustic potash is of primary impor tance. Refer the injured persons to a physician even when the injury appears to be slight. Give the physician a detailed account of the accident. GENERAL FIRST AID: Irrigation and prolonged application of water to the affected areas should be continued for as long as one to two hours. If 5 per cent ammonium chloride or 5 per cent zinc chloride solutions are on hand, wash the affected areas promptly and thoroughly with these solutions. However, if they are not immediately available, no time should be lost awaiting them, but copious amounts of water should be used. No oil or ointment of any kind should be applied to burned areas within the first 24 hours after contact, and subsequently without the sanction of the attending physician. A physician should be called at the earliest possible moment. CONTACT WITH EYES: Eyes should be irrigated immediately with copious amounts of water for a minimum of 15 minutes. The eye lids should be held apart during the irrigation to ensure contact with the water with all the tissues of the surface of the eye and lids. A physician, preferably an eye specialist, should be called at the first possible moment. If a physician is not immediately available, the irrigation should be continued for a second period of 15 minutes. After the first 15 minute period of irrigation is completed, it is permissible as a first aid measure to instill 2 or 3 drops of an 0.5% pontocaine solution or an equally effective aqueous topical anaesthetic. No oils or oily ointments should be instilled unless ordered by the physician. TAKEN INTERNALLY: In gestion of caustic potash causes severe burns of the mucous membranes of the mouth, throat, esophagus and stomach. Here, chemical neutralization may be attempted. Dilute vinegar or a 5% solution of ammonium chloride may be administered freely if at hand. If they arc not immediately at hand, the patient should be encouraged to drink a large quantity of water without delay. After free caustic potarh has been diluted with water or chemicallv neutralized, whites of eggs or mineral oil may be administered. A stomach tube should not be inserted except by the attending physician. ETC 00234 MEDICAL DIRECTIVES AND NURSING PROCEDURES Chlorine Exposure Chlorine is a highly irritant gas, and combines readily with moisture to liberate nascent oxygen, and to form hydrochloric acid. Chlorine is so irritant that it may give rise to reflex spasm of the glottis, so that no further penetration of the lungs can take place. If it gains entry to the bronchi, it produces a necrossis of the bronchial epithelium. Inflammation of the eye, nose and throat, after exposure may be intense. If the bronchial tubes are involved, pain and a sense of constriction in the chest develop. Pulmonary edema will follow a heavy exposure. 1. Take history, pulse, and respiration. 2. Administer 0^ by I.P.P.B. with sterile water or saline (10-15 cc) in Nebulizer. a. Have patient sit directly in front of and facing the unit in a straight-backed chair. b. Instruct to breathe slowly and deeply during treatment. 3. If not improved in 30 minutes (or if clinically worse or in severe distress at an earlier time), notify Plant Physician. 4. If improved in 30 minutes: a. Give Orthoxicol cough syrup (dispense 2 oz.) instruct to take one teaspoon every 3-4 hours as needed for cough. b. Allow to return to work. ETC 00 9 *3 ^ c. Reassurance--Lots of this^especially if this is patient's first experience with chlorine. Stay calm and stay near the patient. He needs to know his condition will improve gradual ly. Call the doctor if you feel the patient is not doing well. F-06P98 MEDICAL DIRECTIVES AND NURSING PROCEDURES CHLORINE EXPOSURES Eronkosol will be available for you to administer by IPPB upon orders of the Ethyl physician. This should only be requested for other-than-mild exposures. Before requesting an order, ascertain any history of hyper tension, cardiac arrhythmias, hyperthyroidism or acute myocardial injury to relate to the Ethyl physician. The Ethyl physician will then decide what dose should be given. ETC 00236 l- _ f) f., q g 9 INSTRUCTIONS TO NURSES CYANIDE POISONING (Includes Acrylonitrile) ,4 Become thoroughly familiar with the attached instructions "First Aid for Cyanide Poisoning". These instructions have been made available to the workers in the cyanide areas. Cyanides are very rapid in their effects, killing instantly if pre sent in sufficient amounts. It is this speed of action, rather than the smallness of the fatal dose, which has given cyanide the reputa tion as' the most powerful common poison. On the other hand, in sublethal doses, cyanides are rapidly detoxified by the body. If a victim can be kept alive for a while after exposure, complete re covery may be expected. When the special alarm rings indicating a cyanide emergency, immediately gather your equipment and prepare to board the ambulance. At the scene of the emergency, make certain that the appropriate procedures as outlined in "First Aid For Cyanide Poisoning" are being properly carried out. Assume care of the patient(s) and continue necessary first aid as indicated as the patient is transported to Plant Medical. Any person who works with cyanide or is in the vicinity of a cyanide release and is suddenly taken ill should be managed as if poisoned by cyanide. This includes, for example, such a person if he has suffered a fall and is unconscious. V.. If a physician is not present at Plant Medical to assume direction of treatment, and such direction seems indicated, telephone the on-call physician and inform him of the nature of the emergency. If the physician is to come to Plant Medical, continue the appropriate treatment as outlined in "First Aid For Cyanide Poisoning" until he arrives, unless the physician specifically directs otherwise. If the patient is to be taken to' the hospital or the physician's office on an emergency basis, accompany the patient, continue first aid as indicated and be certain to carry a complete Cyanide Antidote Package (Eli Lilly) for ecah patient. Remain with the patient until the physician assumes his care. Be aware that a patient poisoned by cyanide may be conscious but confused, disoriented and agitated. Sufficient personnel should be made available to control such a patient. Do not keep persons needed to control the cyanide release from returning to their duties. Secure from elsewhere the assistance that might be needed to help restrain such a patient. The following guides may be of use: ETC 00237 Any person thought to have swallowed cyanide should be seen by a physician. v Any person who has been rendered unconscious by cyanide, even momen tarily, should be seen by a physician. F-06300 -2- f A physician should be contacted by telephone before releasing any patient who has had any symptoms possibly, related to cyanide exposure. Any person thought to have been exposed to cyanide should be kept under observation at Plant Medical for at least 2 hours. If no symptoms have been present, the patient may then be allowed to return to work. Acrylonitrile cannot be removed from leather and can cause skin burns - so remove and discard contaminated shoes. r ETC 00238 F-06301 FIRST AID FOR CYANIDE POISONING (including acrylonitrile) 7 V. Note: Administer emergency first aid immediately. Don't leave patient to seek help. You need that time to give first aid. Toxicity Poisoning can occur by breathing cyanide-contaminated air, by absorption of vapor and liquid cyanide through the skin and by swallowing cyanide. If a person works with cyanide or is in the vicinity of a cyanide release and is suddenly taken ill, cyanide poisoning should immediately be suspected. The earlier symptoms of cyanide poisoning may be weakness, dizziness, headache and occasionally nausea and vomiting. In more serious cases there is usually viol-- it breathing and weakness which may progress to unconsciousness, violent convulsions and paralysis. General Instruction for All Conditions A. Walk, carry or drag the patient to fresh air, upwind. B. Have the patient lie down; if clothing contaminated, deluge with large quantities of water, remove all clothing and wash the skin thoroughly. C. If amyl nitrite pearls are used, keep them away from you own nose and mouth. Otherwise you may inhale enough amyl nitrite to become dizzy and unable to give proper help to the patient. D. In every case of cyanide poisoning notify Plant Medical immediately for medical treatment. E. Never give liquids to an unconscious patient. F. Do not give mouth to mouth artificial respiration to a cyanide patient. First Aid of Cyanide Patients who are not Breathing F-Oh^o,- A. Start artificial respiration immediately using the bag and mask from the cyanide first aid locker. B. Crush an amyl nitrite pearl (from cyanide first aid locker) and put it in mask. Continue to inflate patient's lungs with bag for about 20 seconds, then remove (retain) pearl and continue artificial respiration for about 40 seconds, then repeat with same pearl in mask, etc. for a total of 5 minutes. The pearl is then exhausted and should be discarded. C. If the patient begins breathing on his own, place the amyl nitrite pearl in a cloth (as a handkerchief) and hold it lightly over his nose at the same intervals and for the same length of time as if giving artificial respiration. D. If the patient recovers consciousness, discontinue amyl nitrite. Resume amyl nitrite should the patient lapse back into unconscious ness. Continue to observe patient constantly. E. After the first amyl nitrite pearl is exhausted, if further amyl nitrite is needed (i.e., if patient still not conscious), crush ETC 00239 -2- another pearl, administering to patient for 20 seconds at 2 to 3 minute intervals therafter. This can be done for as long as 1/2 hour (using fresh pearls about every 5 minutes), by which time medical assistance should be available. Discontinue if patient recovers consciousness. First Aid for Cyanide Patients who are Breathing A. If the patient is conscious, do not give any medication. Keep patient under close observation, however. B. If patient is (or becomes) unconscious or has marked breathing difficulty, crush an amyl nitrite pearl (from cyanide first aid locker) in a cloth (as a handkerchief) and hold lightly over patient's nose for 20 seconds of every minute for 5 minutes. Give artificial respiration (as described in previous section) should the patient stop breathing. C. If the patient recovers consciousness and experiences relief from breathing difficulty, discontinue amyl nitrite but continue to observe patient constantly. D. Resume amyl nitrite if unconsciousness recurs, giving for 20 seconds every 2 to 3 minutes. Discontinue if patient again recovers consciousness. First Aid for Person Who Has Swallowed Cyanide A. If patient is conscious, give patient about one pint of 1% sodium thiosulfate solution (from cyanide first aid locker) by mouth. Repeat until vomit fluid is clear. B. Crush an amyl nitrite pearl (from cyanide first aid locker) in a cloth (as a handkerchief) and hold lightly over patient's nose for 20 seconds of every minute for 5 minutes. Pearl is exhausted and should be discarded after this. C. If patient is conscious after this, do not give more amyl nitrite. Continue to observe the patient constantly. D. If the patient lapses into unconsciousness again (or remains unconscious), crush another amyl nitrite pearl and administer as above for about 20 seconds every 2 to 3 minutes. Discontinue if patient recovers consciousness. ETC 00240 F-06303 Diazomethane R & D personnel may present with exposure to this material. Emergency treatment of respiratory symptoms is as for chlorine exposure. The physician on call should be contacted for further instructions. Skin exposure may result in a delayed severe skin irritation, so even minor exposures should be asked to return for repeat evaluation. PEA (Diethylaniline) DEA has an effect like aniline only it is less toxic. However, patient should be handled as for aniline, since it is always possible there may be some aniline in the DEA. DOWTHERM Dowtherm has strong odor. Is not especially poisonous but should be washed off with soap and water and clothes changed. ETC 0024] I F-06304 ETHYL CHLORIDE GENERAL: Ethyl chloride presents some hazard through inhalation because of its narcotic and anaesthetic action. It is slightly irritating to mucous membrane, - it may be absorbed to some extent through the skin, and may also have some local effect on the skin through its refrigerant effect, which under some conditions can produce frost bite. When inhaled it is rapidly absorbed, but is also rapidly eliminated. No form of chronic poisoning has been reported. When ethyl chloride is decomposed by heat, hydrochloric acid may be one of the decomposition products. This, if inhaled, is a very active irritant to the respiratory mucous membrane. FIRST AID: If the exposure has been extreme and extended, the victim is unconscious and breathing has stopped, artificial respiration should be started immediately. Call a physician at once. Oxygen should be administered. If ethyl chloride may have been decomposed by heat with the formation of hydrochloric acid, there may develop severe lung congestion. After such exposure inhalation of 10071 oxygen is indicated. ETC 00242 F-06305 ETHYLENE HEALTH HAZARD: The liquid nay be absorbed through the skin, causing systemic toxicity, CNS depression, kidney and liver damage. SKIN: Wash exposed areas. EYES: Flush with water. INGESTION: Induce vomiting. Call a physician. INHALATION: Remove patient to uncontaminated air at once. If breathing has stopped, administer artificial respiration. Call a physician. Can cause pulmonary oedema. ETC 00243 F-0A306 ETHYLENE D1BROMIDE \ \. HAZARDS: Causes irritation of all exposed tissues, respiratory tract, skin and eye. Death can occur from skin absorption. Acute toxicity equivalent to that of carbon tetrachloride or methyl bromide. May produce vcsiculation on skin contact and very probably if confined under any skin covering. FIRST AID: Exposed skin must be washed promptly with an abundance of soap and water. If cyanotic, administer oxygen. SPECIAL MEDICAL PROCEDURES: Keep patient under medical observation for at least 48 hours. Appreciable skin exposure may result in not only inflamed, sensitive areas, but considerable vcsiculation. A 48-hour medical observation period for delayed systemic or cutaneous effects is advised. NOTE: Shoes exposed to concentrations greater than 3.47. should be destroyed. ETC 0024 E-06307 ETHYLENE blCHLORIDE GENERAL: Mo st important in the c ase o f any poison ing is quick remova 1 from exposure. In the c ase of ethyl ene di chi or icie p oisoning, this means first removing th e pati from the con taminated atmospriere and, insofar as p ossibl reraov ing the ethylene dichloride from the patient' s resp tract , skin, or gastro-intestinal trac t. Keep the patient quiet and comfortably warm', Call a physician immediately. INHALATION: In case breathing has stopped, effective artificial respiration should be start.ed immediately. Oxygen should be administered. If the patient is conscious, hot tea or coffee may be given as a stimulant. SKIN: All contaminated clothing should be removed at once. All affected areas should be washed thoroughly with warm water and soap. After this an ointment containing lanolin should be applied in order to replace the natural skin oils. For serious or persistent cases of skin trouble, and for signs and symptoms of generalized poisoning, a physician should be consulted. CONTACT WITH EYES: If liquid ethylene dichloride has entered the eyes, they should be washed promptly with copious quantities of water for at least 15 minutes. Ethylene dichloride vapour can produce injury to the eyes if the exposure is intense or prolonged to higher concentrations. Eyes should be irrigated for vapour in the sane manner as for the liquid. Medical attention should be obtained in all these contacts with the eyes. x. INGESTION: If a person has swa 11 owe d ethylene dichloride, he should be induced to vomit, This procedure should be repeated at least three times and then foil owed by the administration of a tablespoon of epsom salt s. A physician should be called at once. ETC 00245 F"O6308 Ethyl Corporation Corporate Medical Department Baton Rouge, Louisiana Applies to: El IX 1 ia || Corporate Activities Domestic Field Sites Domestic Affiliates International PURPOSE RESPONSIBILITIES Toxicology and Industrial Hygiene Department Medical Department Local Management \ Guide Number: 03-007 Subject: Hydrofluoric Acid and Related Materia]s Issued: 1. Workers Medical Surveillance 2. Emergency Treatment October 17, 1979 Effective: October 17, 1979 . To establish guidelines to protect the health of employees exposed tr hydrofluoric acid and related materials Conduct periodic surveys of opera tions producing or handling hydrofluoric acid and related materials Report findings and recommendations to Plant Manager, Pla,.t Med real Department and Corporate Medical Department. Provide pre-placement and per ionic physical and laboratory c-xammatio.,on hydrofluoric acid and related materials workers - where indicated. Determine who qualifies for periodic-' medical surveillance examination. Provide for emergency treatment '--d employees who may have an acciden tal exposure. Identify employees with potential hydrofluoric acid and related materials exposure. Notify eligible employees to report for pre-placement and periodic examinations. ETC 00246 P-06309 RESPONSIBILITIES (continued) Local Management (continued) BACKGROUND -2 . Inform Medical Department and Toxicology and Industrial Hygiene Department of any contemplated or implemented change in handling, or processing hydrofluoric acid and related materials. . Maintain an emergency hydroflouric acid and related materials kits for first aid and medical personnel. . Arrange for more definitive care when indicated. . Hydrofluoric acid (HE) and related materials (act like or produce hydrofluoric acid) have the poten tial to produce severe and pa inf v.! skin burns and severe pulmonary edema. Skin contact with high concentrations will cause burns immediately and severe deep burns within hours because fluorides penetrate to seek bor.e. Inhalation of high concentrations will cause pulmonary edema immediately. Lev.' concentrations can cause severe skin injury within 24 hours if not treated early. Low concentration?; produce no immediate symptoms; therefore, it is important to remember `exposed skin that is wet should be treated as an HF exposure'. . Immediate and adequate treatment can reduce HF injury to a minimum. . Chronic exposure to excessive concentrations of fluoride over a period of years results in increased radiographic density of bone and eventually may causa crippling fluorosis (weakened bent due to deposition of fluoride). Fluorosis does not occur at the OSHA threshold limit standards for the workplace. ETC 00247 F-0631O SYMPTOMS OF EXPOSURE TREATMENT -3- 03-u07 . Burns may occur without symptoms when exposed skin is wet. Mild irritation of the eyes, nose and respiratory tract. Stinging of exposed skin. . Mild to severe deep burns of the skin. Choking and coughing. . Shortness of breath and cyanosis (blue lips and nail beds). . Pulmonary edema (wet lungs). . A hydrofluoric acid and related materials first aid kit shall be maintained in the immediate work area for first aid and medical personnel. The label, instructions and contents are listed in Appendix A. . The HF Treatment Kit shall acccmrany an employee being sent to a physicia for HF exposure. Information for medical personnel is listed in Appendix B. o 0o ETC 00248 f-063]i LABEL FOR OUTSIDE OF FIRST AID KIT FOR HYDROFLUORIC ACID (KF) AND RELATED MATERIALS Contents: First Aid Instructions for Hydrofluoric Acid Information for Medical Personnel (Physician Use Only) Zephiran chloride 0.13% solution, aqueous - 2 gallons Zephiran chloride 0.13% solution is made by adding 1 ounce 17% stock solution to 1 gallon water Gauze pads, 20 4" x 4" Calcium gluconate 3% in petrolatum iCalcium gluconate USP .ampules, 10 ml, 10%_w/v, 4 ampules (Physician Use Only) Moisturized oxygen with mask.Location ____________________________ NOTICE IF. INDIVIDUAL-. IS TRANSPORTED TO MEDICAL PERSONNEL FOR TREATMENT, TAKE ALONG THE HYDROFLUORIC ACID TREATMENT KIT. For additional medical information, contact: Gilbert B. Meyers, M.D. Corporate Medical Director Ethyl Corporation 451 Florida Boulevard Baton Rouge, Louisiana 70801 Telephone - 504/388-7651 Home Telephone - 504/924-8060 or Walter C. Hulon, M.D. Assistant Medical Director Ethyl Corporation 451 Florida Boulevard Baton Rouge, Louisiana 70801 Telephone - 504/388-8175 Home Telephone - 504/275-6391 ETC 00249 F--0631p 1 FIRST AID INSTRUCTIONS FOR HYDROFLUORIC ACID (HF) AND RELATED MATERIALS CONTACT Skin Contact: 1. Remove from contaminated area. 2. Flush immediately with copious amounts of water for 15 minutes. 3. Remove contaminated clothing while under the shower, including shoes. 4. Cover contact areas with gauze dressings soaked with 0.13% zephiran solution from the first aid kit. 5. Transport patient to physician, continuously keeping the gauze soaked with zephiran solution. 6. Be sure to take the Hydrofluoric Acid Treatment Kit with patient to physician. NOTE: Skin contact with HF may not have any apparent evidence of exposure for several, hours. Therefore, it is imperative that first aid be administered for suspected exposure because a very weak solution of HF can cause severe burns if in contact with skin for a protracted period of time. 7. For superficial fume burns of exposed . skin, calcium gluco nate 3% in petrolatum can be applied. Eye Contact: 1. Significant HF contact with the eye will cause immediate symptoms of slight irritation to severe pain. 2. Remove employee from contaminated area. 3. Immediately begin eye irrigation with copious amount of plain water for at least 15 minutes. Use a gentle force to avoid injuring the eye. 4. The lids should be held opened by gently separating the eyelid with the fingers. 5. After irrigation for 15 minutes, apply compress wet with 0.13% zephiran solution to the closed eye. 6. Transport the employee to a physician as soon as possible while continuing the wet compresses. 7. Take the Hydrofluoric Acid Treatment Kit with the employee. F -06.31 3 ETC 0 0 2 5 0 2- Inhalation: 1. Inhalation of HF fumes of significant concentration v/ill cause respiratory irritation such as coughing, choking, shortness of breath and may cause pulmonary edema and possible death within hours. 2. Immediately remove employee from contaminated area. 3. If there is difficult breathing, coughing or choking, give moisturized oxygen by mask. 4. Wash face as soon as possible with 0.13% zephiran solution in order to prevent any latent facial burns. 5. Transport to a physician immediately. Ingestion: 1. Since HF is very irritating to the mucous membranes of the mouth and pharynx in small amounts, only minimal amounts are usually ingested. 2. Encourage employee to rinse the mouth with cold or ice water and to drink as much water as possible. 3. DO NOT ENCOURAGE VOMITING. 4. Milk or mineral oil may be given for a soothing effect. 5. Refer for medical treatment. ETC 0025 F-063 3 A NVIDISAHd TUIia UV3MX) asn 2oj Apeaa uoxqnxos unToxBD 'A* I aAEq pue unTopro wruas 5 SU&TS ps^TA JO^TUCUl - BTUip -Axre oexpaeo pe^g exqxssod iox BTUBoxBDodAq axqeqoTpaxdun aosAas (vsa %z<) 'asjy afiJBi (q) aqeuoonxD unrppBD %0I irto ujnq punare Bare (snoauBqnoqns pua XBurtapcx^uj) 'qoaCui *suoq atp* cq saqBjqauad uot apTjanpj (ul) xirans (b) gongueo up(S Z (amsodxa jaqje sjnoq 8-9) Buepe itrcucurfnd pafexsa uoTqepequi 'T sln3wcq .ozlndo jo aco-i JONiMuncH am, jd a&raw aa errcv DracmjaacKH qi aasodxa Naaa svh iwaLLVd sihe :tWIDISAHd ONICmLIV HOI DNINHVM ETC 00252 Appendix B INFORMATION FOR MEDICAL PERSONNEL Hydrofluoric acid (HF) and related materials have the potential to cause painful and severe burns of the skin, eyes, lungs and mucous membranes. The success in treatment of these burns is dependent on the speed of treatment. The trauma of the exposure can be reduced to a minimum if the correct treatment is given quickly. ZEPHIRAN CHLORIDE SOLUTION 1. Aqueous zephiran chloride solution can be obtained as a 0.13% solution in one-gallon bottles (Kinthrop). 2. Aqueous zephiran chloride solution 0.13% can also be made from 17% stock aqueous zephiran chloride solu tion by using one ounce of 17% zephiran to one gallon of water. SKIN The patient should arrive with 0.13% aqueous zephiran solution compresses on the affected area. Remove the com presses to assess the burn. If all the acid has not been neutralized, the skin will be marble-white. If all acid has been neutralized, the skin will be a pinkish color. However, treatment should continue for a minimum of 30 minutes after the skin becomes pinkish. If the affected area lends itself to immersion, then immerse the area in ice cold 0.13% aqueous zephiran solution 5 to 10 minutes, remove 3 to 5 minutes and immerse again. (This is to prevent injury due to the cold solution.) For areas that cannot be immersed, use compresses soaked in ice cold 0.13% zephiran solution and irrigate frequently. In most cases, this process will relieve pain and reduce the burn trauma to a minimum. Again, caution is to be used to prevent harm to skin or tissues due to the cold solution. Calcium Gluconate Infiltration If the burns appear to be deep, or if there is exquisite pain, the painful areas should be cautiously injected with 10% calcium gluconate. The calcium gluconate injections should be in small quantities in order not to distend the tissues and be injected through a 30-gauge needle. The calcium gluconate is infiltrated directly into the affected dermis and subcutaneous tissue through use of a technique similar to the infiltration of a local anesthetic agent. Approximately 0.5 ml of calcium gluconate/cm of burned surface area is a rough guide to the ETC 00253 2- - usual effective dose. The infiltration in carried 0.5 cm away from the margin of the obviously injured tissue into the surrounding, apparently uninjured, area. Local Anesthesia Block anesthesia can be used if necessary. If anesthesia is not used, the patient's pain may be used as a monitor for the smallest effective amount of calcium gluconate. Further more, the patient can accurately localize the areas requiring treatment. Debridement HF burns that develop over a period of time, 24 hours plus or minus 2 hours, are usually accompanied by purulent, tense blisters which are generally quite painful. In such cases, the physician should debride the blisters. After the calcium gluconate injection, the burnt area of patients with severe burns may be carefully debrided. The physician should not hesitate to remove the fingernail if there is any question of serious subungual exposure. Aftercare If an extensive debridement is performed, the patient should probably be hospitalized. The hand should be dressed in a soft, bulky dressing, elevated and observed carefully for the next 48 hours. If the pain recurs, additional calcium gluconate injections should be given. EYES The patient should have had his eyes flushed with water before his arrival. If there is pain, Pontocaine 0.5% ophthalmic drops can be instilled in order to evaluate the trauma. The eyes should be irrigated again with the eyes open for a minimum of 15 minutes. The patient should be referred immediately to an ophthalmologist. Zephiran chloride solution 0.05% can be used to irrigate the eye in order to neutralize the acid. (A 0.05% solution can be made by using 1/2 ounce 17% stock solution in one gallon of water, or by diluting the 0.13% solution with equal amount of water.) LUNGS Patients that have inhaled moderate amounts of hydrofluoric acid are at a high risk of developing either immediate or delayed pulmonary edema. The patient should have moisturized ETC 00254 F'-063] 7 -3oxygen continued as long as necessary. Close observation should be continued for 24-43 hours. The patient should be treated as an acute adult respiratory distress syndrome if pulmonary edema develops. MOUTH AND GI SYSTEM If ingestion has occurred, it will usually be only a minimal amount because of the highly irritating effect of HF. The patient should drink large amounts of water. Milk or mineral oil may be given for a soothing effect. Try to avoid having the patient vomit. ETC 00255 F 16 DRUGS USED FOR HF EXPOSURE Zephiran chloride (Winthrop) (benzakonium chloride) supplied as: 1. Aqueous solution,of 0.13% zephiran chloride in pint and gallon bottles 2. Aqueous stock -solution of 17% zephiran chloride used to make the 0.13%-and 0.05% solution 3% calcium gluconate in petrolatum 10% calcium gluconate for injection Pontacaine 0.5% ophthalmic drops Mineral oil References: Chemical Hazards of the Workplace, Nick H. Proctor, Ph.D. and James P. Hughes, M.D., J. B. Lippincott Company, 1978, pp. 290-293. Hydrofluoric Acid Burn Management, Medical Series Bulletin No. 17-70, Industrial Hygiene Foundation of America, Pittsburgh, Pennsylvania. ETC 00256 F-06319 MEDICAL DIRECT WES AMD NURSING PROCEDURES Contact with Fluoride or Hydrofluoric Acid 1. Area personnel have instructions for immediate first aid procedures. These include the following: a. Immediately put under a shower of water and remove clothing. b. Notify Medical. c. Immerse part in iced solution of Magnesium Sulfate if Torso involved, compresses should be applied. d. Remove to Medical. e. If the eyes are involved, either by hydrofluoric acid or concentrations of vapor - irrigate immediately with copious amount of water for 15 minutes. f. If exposed to gaseous hydrofluoric acid, carry at once into uncontaminated atmosphere. Do Not allow to walk. If breathing has stopped, apply artificial respiration and call for ambulance. 2. Check to see if area personnel did immediate first aid procedures and if done adequately. 3. Skin contact - continue immersing or compresses of iced or saturated solution of Magnesium Sulfate for 30 minutes. *4. Call Plant Physician. 5. Eye involvement - instill ophthetic drops and irrigate with water for 15 minutes. 6. Gaseous exposure - Oxygen by resuscitator if necessary.7. Have calcium gluconate, 10% ready for physician should he elect to use, together with a 10 cc syringe and a 21 gaune needle. ETC 00257 F~OS3?o HYDROCHLORIC ACID, AQUEOUS HYDROGEN CHLORIDE, ANHYDROUS VV GENERAL: Speed'in removing hydrochloric acid from Che skin or eyes is of primary imporcance in all cases of contact with hydrochloric acid in any form. SKIN CONTACT: It is essential that all affected body surfaces be washed with copious quantities of running water for a sufficient time to remove all hydrochloric acid. No attempt should be made to neutralize the acid with alkaline solutions. It should be borne in mind that in cases of severe or extensive burns, shock symptoms may occur at any time. CONTACT WITH EYES: Even minute quantities of hydrochloric acid should be immediately irrigated with copious quantities of running water for at least 15 minutes. A physician, preferably an eye specialist, should be called at the first possible moment. If a physician is not immediately available, the eye irriga tion should be continued for a second period of 15 minutes. After the first period of irrigation is completed, it is f permissible as a first aid measure to instill into the eye 2 or 3 drops of an 0.57, solution of pontocaine or other equally effective aqueous topical anaesthetic. No oils or oily ointments should be instilled unless ordered by the physician. INHALATION: In the rare event that a worker is overcome by hydrogen chloride, as from a sudden leak, oxygen should be administered, along with artificial respiration if breathing has stopped. INGESTION: Immediately give copious amounts of lime water or milk of magnesia. Use plain water if these are not readily available. Do not use sodium bicarbonate. The patient may be expected to vomit spontaneously, but no attempt should be made to induce vomiting. Do not attempt to use a stomach tube. Summon a physician at once. ( ETC 00258 F-063?1 HYDROGEN SULFIDE Extremely toxic substance (rotten-egg odor). Signs and Symptoms: Eye, throat and lung irritation with possible pulmonary edema, cough, frothy sputum, cyanosis, nausea, abdominal cramps, .head ache, nervousness, sweating, elevated blood pressure, and irra tional and combative behavior. Inhalation 1. Artificial respiration if breathing has stopped. 2. Oxygen inhalation 3. Notify Plant Physician Eye Contact 1. Instill Dorsacaine drops and irrigate with Saline solution for 15 minutes. 2. Notify Plant Physician. ETC 00259 f-063?? METHYL CHLORIDE HAZARDS'. Methyl chloride seldomcauses any local irritation, but when inhaled may cause dizziness, staggering gait, drowsiness and, in severe exposures, unconsciousness and death. Repeated exposures which do not at once cause serious symptoms may be followed after a few days by more severe effects. If not fatal, recovery is usually slow. GENERAL PRINCIPLES FOR ACUTE EXPOSURES: Give oxygen. If respiration has stopped, start artificial respiration at once. If the patient is conscious, hot tea or coffee may be given as a stimulant. Adrenalin should not be given in a case of methyl chloride poisoning. A physician should be called immediately. SUGGESTIONS FOR MEDICAL TREATMENT: Some cases of methyl chloride poisoning are drowsy, depressed or even unconscious. Use of adrenalin as a stimulant is not advisable in such cases. Other patients may show excitement and even convulsion. Chloral or chloroform as a sedative is contraindicated in methyl chloride cases. V. ETC 00260 F-06323 TREATMENT Background Emergency Treatment of Poisoning by First Aid Personnel Symptoms of Poisoning -3- Organophosphates are permanent inhibitors of acetylcholinesterase. They are rapidly absorbed into the body by ingestion, through skin including the eye (even more rapidly through cuts, abrasions, areas of dermatitis, etc.), and by inhalation. Organophosphates may be direct or delayed enzyme inhibi tors depending on whether the com pound itself is active or whether it must be metabolized to another compound to become active. (1) Diagnosis of organophosphate poisoning may also be confirmed by a therapeutic trial with atropine, which is specific and effective. Marked improvement after a single dose of pralidoxime chloride (2-PAM chloride) (Protopam Chloride) is also diagnostic of poisoning. (1) Onset of symptoms more than 12 hours after the termination of exposure excludes the diagnosis of organo phosphate poisoning. (1) Chronic exposure to some organo phosphates may cause peripheral neuropathy. An emergency organophosphate poisoning antidote kit for first aid personnel should be maintained in the immediate work area. Earliest symptoms usually include: . Weakness . Unsteadiness . Blurred vision . Headache . Nausea . Feeling of tightness in chest . Constriction of throat These may be quickly followed by: . Vomiting . Abdominal cramps . Diarrhea . Profuse perspiration . Salivation . Watering of eyes . Difficulty in breathing ETC 00261 P-OA324 TREATMENT (continued) Emergency Treatment of Poisoning by First Aid Personnel (continued) Symptoms of Poisoning (continued) Imm> ediate Treatment Termination of Exposure Contaminated Clothing Eye Contact Skin Contact Ingestion -4- By this time, the pupils of the eyes are usually pinpoint and nonreactive, and there is evidence of accumulation of secretions in the respiratory passages. In severe cases, coma and convulsions may follow. . Terminate the exposure. . Support respiration. . Administer atropine. (See Below) . Notify the Medical Department if it is open. If possible, victim should be taken to the Medical Department. If the Medical Depart ment is closed, summon ambulance and call hospital to tell them poisoning case is on the way. . The rescuer should take precautions against self-contamination by wearing rubber gloves. . Remove patient to an area where further exposure is impossible. . Remove contaminated clothing from patient. Place in plastic bag. . If chemical comes in contact with eye, the eye should be irrigated immediately to prevent absorption. ,yj.J-GS bliUUiU JJC HC1U Upcu aiiku. water poured directly onto eyeball. . As soon as possible, the patient should be bathed with copious amounts of water and soap. Scrub under the nails well and wash the hair if contaminated. (2) . If the victim is conscious, immediately have him drink several glasses of water or milk and induce vomiting by having him place his finger down his throat. ETC 00262 TREATMENT (continued) Emergency Treatment of Poisoning by First Aid Personnel (continued) Inhalation Supporting Respiration Administration of Atropine E-0632A Support respiration. Removal of bronchial and salivary secretions .may be necessary. Place patient in prone position with head to one side. Elevate foot of stretcher. If airway obstruction occurs, loosen collar, elevate jaw, pull tongue forward and clear mucus with gauze-covered fingers, or, if possible, by suction. Give oxygen as needed. If patient is not breathing, arti ficial respiration must be becun at once and continued until he breathes or until he reaches one hospital and is turned over to hospital personnel. . An injection of 2 mg of atropine (one Auto-Injector) should be given intramuscularly as soon.as it is believed that insecticide poisoning has occurred. IF CY.ANOSIS (BLUISH LIPS OR FINGERNAIL BEDS) IS PRESENT, DO NOT GIVE ATROPINE UNTIL THIS HAS CLEARED. Give oxygen. Remember that giving this 2 mg of of atropine unnecessarily is not dangerous, but to delay if it is needed could be fatal. Note: Usually AtroPen Auto-Injectors are available. Each is a self-contained unit for the automatic administra tion of 2 mg atropine sulfate. if the Auto-Injector is not available, 2 mg is equivalent to three 1/100 gr or five 1/150 gr atropine sulfate tablets. ETC 00263 If signs of recovery or symptoms of atropir.ization (see be lev:) have not occurred within 10 minutes, a second injection of 2 mg atropine -6- H TREATMENT (continued) Emergency Treatment of Poisoning by First Aid Personnel (continued) Symptoms of Atropinization (Mild) Physician Treatment of Poisoning Antidote Kit Contaminated Clothing Supporting Respiration Dryness of mouth and throat. Slight flushing of skin. Slight difficulty in swallowing Rapid pulse. Pupils of eyes slightly dilated. (With full atropinization, will be widely dilated.) . May be mild drowsiness. May be slowness of memory and recall. May be blurring of near vision. An emergency organophosphate poisoning antidote kit for medical personnel should be maintained in the Medical Department. Remove clothing and any contamination. Dispose of contaminated clothing in plastic bags. Institute resuscitation by mouth to mouth or other acceptable pro cedures, if indicated. Remove bronchial secretions from airways. Give oxygen as needed. Give pralidoxime chloride (2-PAM or Protopam Chloride), 2.5 gm in 100 cc of sterilized water, intra venously, slowly in from 15 to 30 minutes or by deep intramuscular injection of 1 gram in 3 cc of dis tilled water. Repeat every half hour if respiration weakens or muscle fasciculation or convulsions occur. DO NOT GIVE ATROPINE IN THE PRESENCE OF CYANOSIS AS THIS MAY PRECIPITATE VENTRICULAR FIBRILLATION. Administer atropine, 2 mg intra muscularly or intravenously. Repeat dose every three to ci ;ht minutes until signs of atropiniza tion occur. E-06327 ETC 00264 7- TRE.hTMENT (continued) Physician Treatment of Poisoning (continued) Convulsions Hospitalization {' V Hospital Kit . If intractable convulsions (unresponsive to antidotes) occur in severe poisoning, causes unrelated to direct organophosphate action may be responsible: head trauma, cerebral anoxia, mixed poisoning. Although not thoroughly tested in these circumstances, DIAZEPAM (Valium) (5-10 mg for adults) is probably a safe and reliable anticonvulsant. (2) CAUTION: \ Be prepared to assist pulmonary ventilation mechanically if respira tion is depressed, and to counteract hypotensive reactions. (2) . ANY PATIENT ILL ENOUGH TO RECEIVE EVEN ONE DOSE OF ATROPINE SHOULD BE PLACED UNDER HOSPITAL OBSERVATION FOR AT LEAST 24 HOURS. . An emergency organophosphate poisoning antidote kit containing Protopam Chloride vials and instruc tions for its use should accompany the employee to the hospital when feasible. REFERENCES (1) Diagnosis and Treatment of Poisoning by Pesticides. U.S. EPA Office of Pesticide Programs, Washington, D.C. 20460. 1973, pp. 2-3. (2) Recognition and Management of Pesticide Poisonings. U.S. EPA Office of Pesticide Programs, Washington, D.C. 20460. Aug., 1977, pp. 4-8. VENDORS Survival Technology, Inc., 7801 Woodmont Avenue, Bethesda, Maryland 20014, ATTN: Mr. E. Bartner, phone - 301/654-2303. Atropine Auto-Injectors are available in a kit called "Insecticide Kit" containing 5 auto-injectors + 1 trainer, 2 mg atropine each, $35.00 per ( kit, prescription must accompany purchase order. ETC 00265 V- o 0 o F-063F8 ORGANOPHOSPHATES (DECTP and DKCTP) ;1 Signs and Symptoms Constriction of pupils, headache, vertigo, blurred vision, lacrimation, salivation, sweating, muscular weakness, ataxia, dyspnea, diarrhea, vomiting, pulmonary edema and loss of consciousness. Skin Remove all contaminated clothing and shower 5 minutes. Additional shower for 15 minutes after comes to Medical. Eyes Irrigate with normal Saline 15 minutes. Ingestion Give 1 02. Syrup of Ipecac followed by massive ingestion of water to induce vomiting. Inhalation If breathing has stopped administer artificial respiration. Call a physician. For Massive Exposures 1. Transport in Plant ambulance, accompanied by nurse, to hospital emergency room along with treatment kit. 2. Notify Plant Physician on call. A qualitative (screening) blood test kit is available. Six units of this test will be kept with other emergency supplies at all times (storage area of Surgery Room). A demonstration test will be run by the Medical Assistant for all nursing personnel. This test is intended to be used at Plant Medical when ordered by a Plant Physi cian in order to provide a (qualitative) confirmation of exposure in questionable cases. It will not be used for cases in which the nature and extent of an exposure already have been confirmed. ETC 00266 F-063P9 ORGANOPHOSPHATES DR-2 PROJECT A Pilot Plant project is now unde:- way where the compound DR-2 is being purified for a customer. Employees probably will present themselves stating they've been exposed to DR-2. DR-2 is a mild organophosphate. The symptoms and treatment for organophosphates (cholinesterase inhibitors) are outlined in the nursing guideline. Probably no treatment will be necessary other than a follow up blood test for RBC and plasma cholinesterase levels. We do not anticipate problems with poisoning or acute toxici ty but, the employees are very apprehensive and anxious about their well being and should be reassured. The whole group has been counseled and informad by Len Guretsky. Tommy Roberts and me. They will be, and are, very knowledge able now about exposures, toxicity, symptoms, what to expect and watch for and treatment. They have been told to especially watch the pupils of the eyes -- real pinpoint pupils are a positive sign of intoxication, requiring Atropine antidote. Be certain you know how to use the auto injectors of pre-measured doses of Atropine which are available. If Atropine is required, give it immediately, then call the Ethyl physician. As usual, if there are any questions, call the Ethyl physician. ETC 002 E-06330 PHENOL (CARBOLIC AC3 D) HEALTH HAZARDS: Phenol is highly hazardous and exerts a local corrosive effect. It is readily absorbed through the skin, mucous membranes, gastrointestinal and respiratory tracts. Death may occur in a short time after skin contact to solutions containing high concentrations. GENERAL PRINCIPLES: In case of skin or eye exposure, the chemical must be removed immediately or severe injury may result. CONTACT WITH SKIN Time is of the utmost importance Quart containers of decontamination solvent are located in the Medical Dept, emergency room. 1. Treat immediately with decontamination solvent(contains two parts polyethylene glycol 300 and one part 95% ethanol) Pour solvent onto contaminated area and swab with clean towel. Repeat at least twice or until area is clean. 2. Above to be followed by routine treatment as for any chemical burn. CONTACT WITH THE EYES: If phenol in either the solid, liquid or vapour form enters the eyes, they should be irrigated immediately and copiously with water for at least 15 minutes. The eye lids should be held apart during the irrigation to ensure the removal of the chemical from all the tissues of the eye surfaces and lids. A physician, preferably an eye specialist should be called at the first possible moment. If a physician is not immediately available, the irrigation should be continued for a further 15 minute interval. After the first 15 minute period of irrigation and if pain is still present, it is permissible as a first aid measure to instill 2 or 3 drops of a 0.5% pontocaine solution or an equally effective aqueous topical anaesthetic. No oils or oily ointments should be instilled unless ordered by a physician. TAKEN INTERNALLY: If a person has swallowed phenol, the injury that occurs will be due to corrosive action on the mouth, esophagus and stomach and to its systemic toxicity. The patient should instantly drink large quantities of water in order to reduce the concentration of the chemical. If vomiting does not occur spontaneously, induee. vomiting. If the patient is in shock, has severe pain or is unconscious, vomiting should not be induced. ETC 00268 Call a physician imrr.eci i a t c-1 y . INHALATION: F-06331 Exposed persons should he removed from contamination imme d: a t ciy and a physician called. If breathing has ceased, u i t i i i >- i a i iespirat;on should be initiated at once and oxj _n administered. Phosphonitrilic Chloride "Pinkie" PNCI2 Vapor exposure Eye and respiratory irritation No residual effects No dermal absorption Contact with Eyes Eye irritant which has a severe -initial effect on the cornea and the conjunctiva with the latter being the more persistent Dermal Contact Dermal irritation - erythema with possibility of skin slough later. Treatment First Aid Exposed skin must be washed promptly with an abundance of L. soap and water. Eyes Wash immediately with saline solution for 15 minutes. a physician. Call r ETC 0026 F-0633? TREATMENT OF PHOSPHORUS BURNS First Aid Treatment Medical Treatment Phosphorus burns, which are classifi as either second or third degree bur should be given first aid treatment appropriate to the type of phosphoru. contact. Skin Contact . Immediately place the patient unde a cool water shower, flush eyes thoroughly with plenty of water, and remove contaminated clothing. . Keep burned area wet by immersing . in cold water, or by applying cold water compresses. . Apply a saturated solution of sodium bicarbonate to the burned skin area either by compress or by soaking, or . Apply a dressing with "Vaseline" or an approved ointment if the burned area is small and pain subsides. . Get medical assistance. Eye Contact . Flush the eye immediately with plain water. Continue the procedure until the patient can be examined by a physician. Employerdesignated medical facilities should examine and treat all cases of phosphorus burns. Debride the burned area of phosphorus particles and dirt by surgical techniques when such debridement is indicated. Clean the skin with cold water con taining an antiseptic such as hexachlorophene (pHisoHex). Soak burned area with saturated sodium bicarbonate solution for at least 3u minutes. Apply saturated sodium bicarbonate in lanolin on Csl U E- -06333 / I /Medical Treatment I (continued) 2- - sterile dressing. Leave dressing in place for 24 hours. If preferred, apply a 3% hydrogen peroxide solution. Keep the solution in contact with the burn for at least 20 minutes to oxidize the phosphorus. Apply a sterile "Vaseline" or anti biotic dressing after pain subsides. Provide follow-up treatment, as needed, under the attending physician's direction. o0o ETC 00271 F"06334 ORGANIC LEAD EXPOSURES 1. Record on Medical Treatment Report all basic information. Follow procedure as listed on the Lead Exposure Report form, using it as a guide. 2. Ensure that all information is accurate and complete. 3. Copies of Medical Treatment Report will be distributed as marked (Safety and Superviosr's Form). Place Medical copy on Medical Director's desk. 4. List badge number and name on Shift Performance sheet. 5. Type on Daily Breakdown on New Injuries sheet (on shift that exposure occurred) in red as follows: "The following had possible organic lead exposure:". Badge Number and Name Call the Plant Physician if: 1. Respiratory exposure ( no mask) for longer than 15 minutes. 2. Respiratory exposure of any duration if elevated temperature (stA , fire, etc.) involved. 3. Skin (any amount) WETTED BY LIQUID TEL or. TML or sludge for more than 15 minutes. 4. Skin area of greater than 20% (use "rule of 9s," as for burns) wetted by liquid TEL or TML, sludge or contaminated water for any length of time. 5. Contaminated material in eye (follow emergency treatment outlined below). 6. Contaminated material in mouth, whether or not thought to have swallowed (if swallowed, follow emergency treatment outlined below). 7. Contaminated material in wound (follow emergency treatment ETC 00272 outlined below). E-06335 Organic Lead Exposure - contd. 8. Patient has symptoms claimed due to, and/or with'recent his tory of, unusual exposure. 9. Any exposure with peculiar or unusual circumstances. Emergency Treatment by Nurse: Eye -- Lavage as for caustic material. Call Plant Physicians to see if any special additional treatment or instructions are indicated. Ingestion -- Induce vomiting by giving 15 ml Syrup of Ipecac by mouth. After vomiting, give 30 ml activated charcoal by mouth. Call Plant Physician for further instructions. Contaminated Wound -- Immediately and thoroughly wash and scurb wound with kerosene, followed by thorough scrubbing with soapy water (if severity or location of wound seems to be contraindica tion, withhold this treatment pending advice from Plant Physician -- immediately life-threatening circumstances as severe bleeding, airway obstruction, shock, take precedence and should be controlled first). Call Plant Physician regarding further treatment. ETC 00273 f-06336 TEL EXPOSURES Beside the accuracy of obtaining a history of the accident (blown disc, fired or no fire, etc.), it is equally impor tant to record accurately the type of personal protective equipment worn at the time of the alleged exposure. Not only is it important to know if respiratory protective equipment was worn and how long the exposure prior to put ting on the protective equipment, it is also important to know the type, i.e.: 1. Face mask -- double or single cannister? 2. or 3. or 4. How long since filter changed? Full-face, fresh-air mask? Protective clothing -- gloves, boots, slickers? Please record the above information accurately. "Wore respirator" in response to the question is not an adequate history. When an industrial hygienist is requested by Supervision at the scene of an accident, please follow the procedure below: FIRST CALL Mr. Tommy Roberts -- home phone 357-4174. Mr. Roberts will notify a technician, if necessary. However, if Mr. Roberts is unavailable, then notify either Mr. M.aples or Mr. Kennedy, one of whom will be available at all times. Again, Mr. Roberts gets first call. ETC 00274 F-06337 TEL Exposures contd. TEL Employees Involved in Clean-up 1. If wearing cannister mask, report TEL exposure in the usual manner. 2. If wearing fresh-air mask, boots, slicker, and gloves, do not report as TEL exposure. ETC 0027 F-06338 Report on Lead Exposure Employee's Name ; Badge Number _; Home Address______ Telephone Number _______________ If no telephone, how can be contacted: H i Date and Time Exposure Reported <a.m.; p.m. Date and Time Exposure Occurred,a.m.; p.m. / Site (in plant) of Exposure __________________________________________________ Name of Foreman or Other Member of Supervision Having Knowledge of Exposure Circumstances: Material(s) To Which Exposed: Liquid TEL Liquid TML Liquid, Mixed or Unknown (Specify) Vapor ("smell") Disc Blow Material (Disc Blow fired, did not fire, unknown) Sludge Contaminated Water Other (Specify) Describe Incident ------------------------------------------------------------------------------------------ ETC 00276 F-06339 Report on Lead Exposure Respiratory Exposure Duration, Without Mask _____________________________ Duration, With Mask (air supply or other - Specify) Skin Exposure Duration (Time Before Washed Off) Area of Skin (Describe portion of Body Involved and Estimated % of Total Body Involved [use "rule of 9's" as for burns]): 2. Other Route of Exposure Ingestion (Estimate Anount) (Take Prescribed Emorgency Action) (Notify Plant Physician) ^__________________________ Decontamination Done Prior to Reporting to Medical (Describe) Symptoms: Physical Findings: ______________________________ . _____________ ETC 00277 F --06340 Report on Lead Exposure 3. Action Taken: ( ) Returned to work ( ) Sent home ( ) Sent to hospital ____________________ ________________________ Name of hospital ( ) Sent to outside M.D. Name of M.b. ( ) Plant Physician called ' Name of M.D. . Date and time called Signature of Nurse Disposition After Review by M.D.: ( ) No action needed ( ) Spot urine next scheduled lead check ( ) Call in for spot urine ( ) send routine ( ) send urgent ( ) Call in to see M.D. ( ) Other (Specify)_____________________________________________ Date Signature of M.D. ETC 00278 C-06341 SODIUM HYDROXIDE (CAUSTIC SODA) HAZARDS: This material is strongly corrosive to all body tissues. EYES: Wash with copious amounts of water for 15 minutes. Call a physician. SKIN: Speed in removing caustic from the skin is very important. If deep burn results, call a physician. INGESTION: Do NOT induce vomiting. Call a physician. Give diluted vinegar, lemon or orange juice. Also give demulcents: milk, olive oil or egg white. ETC 002 E-0634? TOLUENE Acute toxic symptoms generally are the result of inhalation of vapor and acute exposure may cause headache, nausea, giddiness and loss of consciousness. It causes local irrita tive effect upon nose, throat and eyes, and may also produce dermatitis on sustained or intermittent skin contact with liquid. FIRST AID Inhalation -- If the exposure has been extreme, the victim is unconscious and breathing has stopped, artificial respiration should be started immedi ately. Call a physician. Administer oxygen. Taken Internally -- Induce vomiting. Contact With Skin -- Causes temporary burning-stinging sensa tion. Remove contaminated clothing, shower immediately, apply Nivea cream. Contact With the Eyes -- May cause corneal burns. Irrigate with Saline Solution 15 minutes for vapor or for liquid. ETC 00280 TRICHLOROETHYLENE L/ May be harmful by inhalation, by prolonged or repeated contact with the skin or mucous membranes, or when taken by mouth. Essentially an anesthetic, also will cause irritation of skin or respiratory tract. INHALATION Symptoms -- irritation of eyes, nose throat, then dizzi ness, nausea, vomiting and gradual suppression of con sciousness. First Aid -- Remove from contaminated atmosphere. If breathing has ceased, start artificial respiration. Ad minister oxygen. Keep patient quiet and warm. Call physician. SKIN CONTACT -- drying effect. Remove contaminated clothing. Wash affected areas thoroughly with soap and water. Apply Nivea cream. EYE CONTACT Wash promptly with water for 15 minutes etc 00281 F --06344 VINYL CHLORIDE (CHLOROETHYLENE) -/ Primary health hazard is assocaited with excessive respira tory exposure. Acute over exposure effects central nervous system pro ducing intoxication and dulling of visual and auditory re sponses (light-headedness, some nausea). FIRST AID Inhalation -- Remove to fresh air. If not breathing, give artificial respiration. If breathing is difficult, give oxygen. Call physician. Skin Contact -- Immediately wash with soap and water. Clothing, including shoes, should not be worn again until dry. Eye Contact -- Immediate irrigation for 15 minutes with water. ETC 00282 F-06345 /- v V. - Allergy Injections Vi Allergy injections will be administered, by R.N. day nurse to employees if they bring a written request from their private physician including medication and directions. 1. Be familiar with directions that come with vaccine. 2. Inject as prescribed - if in doubt about dose - ask. 3. Inject so that there is enough room above site to place tourniquet. 4. Reactions to watch for: a. Dyspnea, prostration. b. Immediate swelling and erythema at injection site. c. Wheal and flare. 5. Call plant physician for emergency Rx 6. Record all reactions. 7. Know where these are kept a. Adrenalin b. Tourniquet c. Airway d. Decadron for injection e. Oxygen Injections and Treatments F-06347 'r- v R.N, on A Shift is to administer all injections to employees that are requested by their private physician. They must bring a written request and medication. Diathermy and whirlpool treatments for non-occupational conditions will ETC 00284 be given if employee brings a written request from his'personal physician. IMMUNIZATIONS Immunizations will be provided to employees who by reason of tdieir occupation or job assignments, may be exposed to significant hazards. Also to employees for vacation travel on request. Immunizations are not to \>c given without a plant physician order. Yellow fever vaccine is given at the Public Health Unit. Yellow fever vaccine and smallpox vaccine must be given on the same day or one month apart. Snallpox, cholera and yellow fever vaccinations must bear an approved stamp frem the health unit. After immunization certificate has been completed and signed by the physician, tell employee to take it to East Baton Rouge Parish Health Unit, 353 North 12th Street, to be stamped. Employees must be familiar with the package inserts prior to use or application of the medication involved. Information concerning official immunization requirements for international travel may be obtained from East Baton Parish Health Unit. Phone: 343-7411. Tetanus 1. Active - Primary immunization consists of three 0.5 ml injections of tetanus toxoid absorbed given I.M. The initial, repeated four to six weeks later, and the last, one year later. Routine 0.5 ml boosters should be given ever)'' 10 years. Eor significant "tetanuiT- pro*/e" wounds, repetition of a booster is the safest course. 2. Passive Required in absence of active immunization in a wound where the danger of tetanus is great - give tetanus immune globulin human 250 units intramuscular. L Snallpox E-06348 1. Site of preference is regiqa^^f^insertion of deltoid muscle. ETC 00285 .; ' ^ - '; A, -A :*&* fe-v. y - -, ; >v.' W-Kite;~&>$2ltefks" . ''' . ;; . ..v- , yV.r,...u .... I V .**?. .*J' -- - ~ '"V '5?.r.' 'X - v,'--:- .-r ' f. ,;i ^ -- til- - Xlly" >, , . -Va'*,: ! j ETC 00286 F 06349 MEDICAL TREATMENT REPORT To be filled out for any injury or illness alleged or sustain ed by employees or non-employees on Company property. 1. Impression -- Both listed impressions on form to be filled in and to be the same. If a physician sees the patient, the 2nd impression on report is to be filled in by him. If nurse only sees patient, fill in both impressions. Shift nurses and R.N.s can record their impressions which are tantamount to an M.D. diagnosis. 2. Physical findings: Descriptive. Give the: a. anatomical location b. size c. appearance d. motion e. restriction of movement, etc. 3. When a physician sees a patient, be sure he is given the chart to record his orders and comments. 4. Do not list allergies on Medical Treatment Report. These are to be listed on outside of charts. 5. Returned Consultation Report is to be clipped to Medical Treat ment Report in order received. 6. When Medical Treatments Reports are made on sub-contractor personnel, advise the patient that if he has further difficulty, he should contact his Supervision for possible referral to his Company Physician. Note the fact that he has been notified of this in the remarks section of the Medical Treatment Report. ETC 00287 F-06350 Ethyl Corporation ..-'orporate Medical Department Baton Rouge, Louisiana Applies to: [X!} Corporate Activities S Domestic Field Sites (X! I Domestic Affiliates 1 1 International PURPOSE ACKGROUND Medical Treatment Report Guide Number: 04-001 Subject: 1. Medical Treatment Report 2. Outpatient Consultation Report Is'sued: December 15, 1977 Effective: January 1, 1977 . To provide a uniform means of recording and reporting injuries or illnesses which are occupational, pending occupational, or potential liability cases. . To provide a uniform means of referring patients for consultation at Company expense. Any injury or illness arising out of or during the course of employment may be an occupational injury or ill ness. The Industrial Insurance Office decides if the Company is financially responsible for the cost of care. The Medical Treatment Report provides a record of essential information on every occupational, pending occupational or potential . liability case that is Reported to a Site Medical Department. The quality of each Medical Treatment Report is of utmost importance because .it is the permanent legal record of the case. The Medical Treatment Report informs site safety, foreman/supervisor and Industrial Insurance Office (when required) that there has been an incident. Any injury or illness alleged or sus tained by a non-employee on Company property may be the basis for a liability claim against the Company . It is, therefore, imperative that the facts be recorded accurately on a Medical Treatment Report. F-06351 ETC 00288 2- - ^ACKGROUND Continued) Outpatient Consultation Report The Outpatient Consultation Report is a practical, two-way written communication between the Site Medical Department and a consultant. It maintains Medical Department control of initial and follow-up consultations, provides chronological consultation reports and serves as an audit for consultant fees for service. FORMS Medical Treatment Report Outpatient Consultation Report ORIGINATING OFFICE Site Medical Departments PROCEDURE - MEDICAL TREATMENT REPORT Preparation Case Number * Distribution of Copies Employee Cases E-0635? Prepare in triplicate for all cases reporting occupational, pending occupational or potential liability conditions. Complete all information requested on form. Ask patient to sign his first per son statement. If patient refuses, write "Refused to sign" in place for signature. Assign case number when lost time, outside expense or permanent dis ability is involved. Case numbers are provided by Industrial Insurance Office. Original to site employee medical file. First carbon to Site Safety Department. Second carbon to Supervisor/Foreman of employee. Machine copy of original to Indus trial Insurance Office when required, i.e. lost time, outside expense, and/or permanent disability. ETC 00289 -3- "''ROCEDURE - MEDICAL TREATMENT .- REPORT (continued) Contractor Cases Other Non-employee Cases Progress Notes Discharge Date PROCEDURE - OUTPATIENT CONSULTATION REPORT Preparation r . Original for Site Medical Department file. . . First carbon to Site Safety Depart ment when a contractor employee is seen for first aid. . Machine copy to contractor. . Second carbon destroyed. . Original for Site Medical Department file. . First carbon to Site Safety Depart ment in non-employee cases other than contractor ones. . Machine copy to Industrial Insurance Office. . Second carbon destroyed. . Enter progress notes on the reverse side of the original. . Machine copy for Industrial Insurance Office as necessary to keep them posted of case status. . Record date of discharge from treat ment. . Send machine copy of discharge summary to Industrial Insurance Office if a copy of the original has been sent to them. . Prepare in triplicate for each visit to a consultant whether for an occupational, pending occupa tional or non-occupational case at Company expense. . Enter case number where applicable. ETC 00290 F-06353 PF.OCEDURE - OUTPATIENT ^CONSULTATION REPORT -"^(continued) Distribution of Copies -4- . Original and two carbons to the consultant. . Consultant retains one carbon and . returns original and one carbon to Medical. . Original to site employee medical file. Carbon to Industrial Insurance Office in occupational or pending occupa tional cases. . Carbon destroyed in non-occupational outpatient consultations. o0o w t ETC 00291 F~06354 b I HYL UUHPUhA I WN MEDICAL DEPARTMENT MEDICAL TREATMENT REPORT S-S. on EMPLOYEE NUMBER OCCUPATION CASE NO. department EXTENSION HOME ADDRESS AGE SEX MALE Q FEMALE MARITAL STATUS 0 SINGLE 0 MARRIED 0 WIDOWED ONSET LOCATION (BUILDING, FLOOR, SECTION, ETC.) DATE TIME DISPOSITION fl REGULAR WORK MODIFIED 0 REGULAR WORK Q RESTRICTED DUTY 0 HOME IF OTHER THAN REGULAR WORK, EXPLAIN: 0 DIVORCED HOME TELEPHONE REPORTED TO MEDICAL DATE TIME 0 CONSULTANT 0 HOSPITAL 0 OTHER IF REFERRED TO CONSULTANT OR HOSPITAL, PLEASE RECORD NAME AND ADDRESS: IMPRESSION: RETURN FOR ADDITIONAL TREATMENT 0 NO 0 YES DATE SIGNATURE OF MEDICAL ATTENDANT HISTORY OF COMPLAINTS (IN PATIENTS OWN WORDS WHAT, HOW, WHY) 0 FIRST AID DISCHARGE DATE ETHYL D PHYSICIAN 0 PENDING __ LOST 0 time OATES COPIES SENT TO INDUSTRIAL INSURANCE OFFICE 0 OTVER J PHYSICAL FINOlNGS: IMPRESSION: TREATMENT: . .REMARKS: EMPLOYEE'S SIGNATURE , - --' X-RAY DATES -- INJECTION . TETANUS m human 0 TOXOID LJ GLOBULIN _ ----------! o ! i SIGNATURE OF MEDICAL ATTENDANT MEDICAL DEPARTMENT COPY ETC 00292 Er-0fe3?>5 ETHYL CORPORATION MEDICAL DEPARTMENT OUTPATIENT CONSULTATION REPORT TO. . > i Cn r E s i RE: OUR EMPLOYEE IS REFERRED TO YOU FOR | | DIAGNOSIS ONLY | | DIAGNOSIS AND TREATMENT FOR COMPLAINTS REFERABLE TO:___________________________ S.S. OR EMPLOYEE NUMBER CONSULTANT: IN ADDITION TO A COMPLETE REPORT PLEASE RENDER THIS SUMMARY REPORT BELOW IMMEDIATELY. HISTORY M. D. FINDINGS DIAGNOSIS TREATMENT RECOMMENDATIONS (CHECK WHERE APPLICABLE--DETAILS UNDER REMARKS) | | X-RAYS TO BE TAKEN AT ETHYL CORPORATION WHEN POSSIBLE (SPECIFY) I | PHYSIOTHERAPY TO BE GIVEN AT ETHYL CORPORATION WHEN POSSIBLE (SPECIFY) | | TO RETURN TO ETHYL CORPORATION FOR FURTHER CARE I | TO RETURN TO MY (OFFICE) (HOSPITAL) FOR FURTHER CARE DA DISPOSITION | | MAY RETURN TO REGULAR WORK | | MAY RETURN TO LIMITED WORK (SPECIFY) I | HOME UNTII(APPROXIMATE DATE) I | ADMITTED TO | | OTHER (EXPLAIN) -(HOSPITAL) REMARKS: M. D. NOTE: fr-0f>35> Ethyl will be responsible for paymem only when each outpatient visit is authorized by this lorm. You may retain the third copy of tins report - please return me l;rst two copies with the patient. II Ihe patient is sent home or hospitalized please return ihe first two copies to us by mail and telephone the Medical Department. Reporis and bills should be submitted m duplicate to the Etnyi Meoicul Dcpartmeni ETC 00293 MEDICAL PROGRESS RECORD 1. Do not put "See Lead Card," or list work-related injuries on Medical Progress Record. 2. . Skip one line when recording on Medical Progress Record if patient has been returned after P.I. (line is to be used for recording certification). E--06357 ETC 00294 Ethyl Corporsti. lorporate Medica^ Department Baton Rouge, Louisiana Applies to: j Corporate Activities |><'| Domestic Field Sites |><^] Domestic Affiliates f I International Guide Number: 04-002 Subject: Medical Progress Record Issued: January 5, 1978 Effective: January 15, 1978 PURPOSE BACKGROUND FORMS ORIGINATING OFFICE PREPARATION DISTRIBUTION To provide a uniform permanent .indi vidual employee record on nonoccupational clinic visits, absences due to illness and other pertinent medical information. Separation of non-occupational personal medical information helps preserve the individual employee's right to privacy for personal medical matters. Medical Progress Record Site Medical Departments An entry should be made by the medical attendant for each visit to the Medical Department which is not recorded on an Occupational Treatment Report. Each entry should be made in ink or typed and signed with attendant's initials and last name. One copy only in employee's individual medical file. o0o F 6358 ETC 00295 M onWIDTH! NUMB8R .. c . ' V- . .- F~06359 ETC 00296 MEDICAL DIRECTIVES AND NURSING PROCEDURES /OS Employee reported off with occupational or pending occupational injury: a. Guard will bring 196 from Main Gate b. Notify plant physician. c. Make entry on Medical Treatment Report - "196 received from Main Gate," reported Home Comp (or Pending Home Comp.) as of date and shift. Leave retreat column open. d. Attach 196 to Medical Treatment Report and leave for R.N. day morse. e. Do not put on breakdown. ABSENT EMPLOYEE REPORT I CALL OR NOTICE RECEIVED ! DATE: BAOOE NUMBER SECTION AM PM RHONE NO. Perscnol Illness Off-the-lob Injury X On-the-job Injury FIR1T SCHEDULED SHIFT YOU EXPECT TO MISS SHIFT: DATE: REASON GIVEN FOR ABSENCE ATTENOINO PHYSICIAN NAME OP DECEASED RELATIONSHIP Deoth In Fomily Illness in Fomily FUNERAL HOMS NAME OF PERSON ILL BURtAL PLACC (CITY * TATt> RELATIONSHIP T1HE AM PM D Perscnol Business* Jury Duty O Union Business Q Witness E-06360 Election Commissioner Other* NAME OF FOREMAfi/ SUPERVISOR I .MAIN CATE NOTIFIED BY FOREMAN OR SUPERVISOR NCTiF.EO i time i SIONATURE CF PERSON PREPARINO REPORT Full Information not Available AM PM BR.iSSA r.LY. 7/ S3 BLUE--Med red ^INK.--Employee Benefits WHITE--for cine ETC 00297 Excusing for Personal Illness '* V Procedure to follow when employee is excused for persoanl illness regard less if working regular shift or overtime shift: 1. Record on blue dispensary card a. Symptoms - reason for excusing b. Vital signs c. Private physician, if patient plans to see one d. Give a date to report to Plant Medical if not back to work (use your judgment, take into consideration severity of illness, sheduled days off, etc.). 2. Make three Medical Service Slips a. One you keep and attach to blue card. b. Give two to patient with instructions to give one to his foreman and one to the guard as he leaves. 3. Tell to make absentee at gate. 4. Ask if he needs transportation and if so a. Call Main Gate and request they take employee home - give name, badge number and address. b. Have employee report to Gate for tansportation if able - if not, have guard pick him up at Medical. 5. If employee is acutely ill a. Call private physician. b. If to be sent to hospital, ask what mode of transportation. c. If to go to hospital via ambulance 1. Call ambulance service. 2. Notify Main Gate ambulance is coming in. F - 0 fi 3 6 ! 3. Notify foreman, ask him to send someone to get employee's street clothes. 4. Make calls for employee regarding getting his car home - guards are not allowed to take employee's car home. ETC 00298 Excusing For Personal Illness Y; d. If can go in car to hospital or doctor's office 1. Call Main Cate for car 2. Instruct employee he will be left by guard and must arrange his own transportation frcrn there. DUTY RELEASE/RETURN This certificate to be presented to Foreman/Supervisor by employee AME RELEASE FROM DUTY RETURN TO DUTY REMARKS DATE TIME S.S OR EMPLOYEE no SENT TO HOME HOSPITAL AM PERSONAL PHYSICIAN PM -- SUPERVISOR NOTIFIED -- (NAME) OATE | | OCCUPATIONAL Q^F^SONAL * 'ILInESS INJURY | | FIT FOR REGULAR WORK ,__ . MOOTED L_J REGULAR WORK r~] RESTRICTED DUTY UNTII............ L--1 ....................... ................. .... DATE TEMPORARY DUTIES SHOULD NOT INCLUDE THE FOLLOWING CLIMBING STAIRS OR LADDERS Q WORK ABOVE FLOOR OR GROUND LEVEL | | WORK AROUND MOVING MACHINERY | | DRIVE COMPANY VEHICLE Q LIFT. PUSH. PULLOVER | | SHIFT WORK LBS. f~) OVER TIME Q COLD EXPOSURE TO Q VCM Q HEAT Q SOLVENTS | | WATER Q NOISE | | DAMPNESS LEAD Q DUST/FUMES Q OTHER .WALKING OR STANDING OVER ________ % OF TIME Q KNEELING OVER _____OF TIME Q BENDING ... _ % OF TIME | | EYE HAZARDOUS WORK m USE OF 1__ 1 -- .. .. _____ ....... ____ ...... ............... -............. -- - - OTHER Employee on temporary work assignment should return fo Medical tor further classification when specified time has elapsed. FIRST DAY DISABILITY 'T> 'c , uhf L_ , ). 1 Ji. U* ! first day able to resume duties SHIFT - CM 7903 SIGNATURE 0> 3 (S ? ETC 00299 -PROCEDURE FOR HANDLING RETURN TO WORK After Personal Illness 1. Check list in dispensary of patients not to be returned without seeing plant physician - if on this list, do not return patient to work - hold for doctor; if on weekend, tell patient to report when doctor is in. 2. Do not issue a return to work slip in advance. Must be issued during shift employee is working on the day he returns. May be any time during that shift, but is preferred that he get it at the start of the shift. 3. Do not issue return to work slip if patient is back to work and forgot to get slip on day he returned, but leave note in disability wage box in dispensary with the following information: a. Name b. Badge Number c. Nature of Illness d. If private physician was seen, give name. e. Date and shift he returned. 4. Only issue return to work slips for personal illness, NOT illness in family, personal business, etc. 5. Employee must appear in person to get return to work slip - do not send through the mail. 6. Procedure to follow in issuing slip a. Obtain badge number ' b. c. Check Medical Progress Record & Medical Treatment Report for duty status. Make two medical service slips, one for the patient to take to his foreman and one for disability wage box in dispensary with the following information stapled to it on a separate piece of paper. 1. Date 2. Time In 3. Badge Number 4. Patient's Name ETC 00300 Procedure for handling return to work - (continued) 5. Nature of personal illness, question throughly. 6. If private physician was seen, give name. 7 Your name. 7. If employee has been off personal illness with a heart condition, surgery or long term illness or if questionable as to ability to work, hold for Plant Physician or doctors assistant. If on shift, call Plant Physician DUTY RELEASE/RETURN This certificate to be presented to Foreman/Supervisor by employee IAME RELEASE FROM DUTY RETURN TO OUTY DATE TIME S.S OR EMPLOYEE NO SENT TO HOME hospital AM PERSONAL PHYSICIAN PM SUPERVISOR NOTIFIED " {NAME) DATE 0 OCCUPATIONAL p<PERSONAt 1--1 0^fLLNESS | | INJURY Q^FIT FOR REGULAR WORK MOOIFIED 1__ ) REGULAR WORK 0 RESTRICTED DUTY UNTIl____ DATE TEMPORARY DUTIES SHOULD NOT INCLUDE THE FOLLOWING O climbing stairs or ladders WORK ABOVE FLOOR OR GROUND LEVEL WORK AROUND MOVING MACHINERY DRIVE COMPANY VEHIGLE LIFT. PUSH. PULLOVER IBS SHIFT WORK OVER TIME EXPOSURE TO D C0LD D HEAT 0 VCM SOLVENTS WATER Q NOISE Q DAMPNESS 0 LEAD 0 DUST,FUMES 0 OTHER | | WALKING OR STANDING OVER . 0 KNEELING OVER .......... S OF TIME 0 9ENDING ............% OF TIME 0 EYE HAZARDOUS WORK 0 USE OF __________________ OTHER Employee on temporary work assignment should return to Medical for further classification when specified time has elapsed. first day Disability first day able to resume outies shift V fr~063F>4 ETC 00301 Excusing from Overtime If employee has a valid medical reason vr 1. Write on blue card requested to be excused overtime shift today, reason and granted. 2. Make one Medical Service Slip and give to employee to take to his foreman with date and time. Under explanation, put "No overtime today only." Check under duty status column "other" and put advisory. 3. Put on shift performance sheet under "Subcontractor, " badge number, name and granted. If employee does not have a valid medical reason, follow same procedure as above. EXCEPT 1. Tell him you cannot excuse him. 2. Write on blue card reason not granted. 3. Make Medical Service Slip and give to employee for foreman. Under explanation put, "Insufficient medical evidence to advise against overtime." 4. Put on shift performance sheet, "Refused." Employee is to be excused from overtime prior to overtime shift only. DECISION ON EXCUSING FROM OVERTIME TO BE MADE BY PLANT PHYSICIANS ONLY. etc 00302 DUTY BEL^ASE/RETURN This certificate to be presented to Foreman/Supervisor by employee "EASE iOM DUTY RETURN TO DUTY DATE S S OR EMPLOYEE NO SENT TO | | NOME Q HOSPITAL AM Q PERSONAL PHYSICIAN PM SUPERVISOR NOTIFIED (NAME) OATE j | OCCUPATIONAL PERSONAL 0 ILLNESS Q INJURY FIT FOR REGULAR WORK __ MOOIFIEO LJ REGULAR WORK RESTRICTED DUTY UNTIL ... TEMPORARY DUTIES SHOULD NOT INCLUDE THE FOLLOWING Q CLIMBING STAIRS OR LADDERS | | WORK ABOVE FLOOR OR GROUND LEVEL | | WORK AROUND MOVING MACHINERY | | DRIVE COMPANY VEHICLE | | LIFT. PUSH. PULLOVER LBS Q SHIFT WORK Q OVER TIME EXPOSURE TO Q COLD Q VCM Q HEAT Q SOLVENTS 0 WATER 0 NOISE 0 DAMPNESS 0 DUST/FUMES 0 LEAD 0 OTHER | | WALKING OR STANDING OvER 0 KNEELING OVER _ % OF TIME 0 BENDING .. . . % OF TIME [ | EYE HAZARDOUS WORK 0 USE OF . . _________ . . . 0 OTHER _ ._ . -a OF TIME ____ _ Employee on temporary work assignment should return to Medical for further classification when specified time has elapsed FIRST DAY DISABILITY FIRST DAY ABLE TO RESUME DUTIES SHIFT iX '7*7 ^ RELEASE FROM DUTY RETURN TO DUTY SIGNATURE DUTY RELEASE/RETURN This certificate to be presented to Foreman/Supervisor by employee DATE S S. OR EMPLOYEE NO SENT TO 0 HOME 0 HOSPITAL AM 0 PERSONAL PHYSICIAN PM SUPERVISOR NOTIFIED (NAME) DATE f`2 C` J l <-rKL<1. 0 OCCUPATIONAL 0 PERSONAL j | ILLNESS 0 INJURY FIT FOR REGULAR WORK __ MODIFIED I 1 REGULAR WORK RESTRICTED DU TV UNTIL DATE TEMPORARY DUTIES SHOULD NOT INCLUDE THE FOLLOWING | | CLIMSING STAIRS OR LADDERS Q] WORK ABOVE FLOOR OR GROUND lEVEL I | WORK AROUND MOVING MACHINERY Q DRIVE COMPANY VEHICLE | | LIFT. PUSH. PULLOVER [ | SHIFT WORK LBS EXPOSURE TO COLD HEAT WATER 0 VCM 0 SOLVENTS 0 NOISE DAMPNESS LEAD | | DUST/FUMES 0 OTHER | | WALKING OR STANDING OVER j | KNEELING OVER . _ sa OF TIME 0 8EN0ING % OF TIME 0 EYE HAZARDOUS WORK 0 USE OF . | | OVER TIME OTHER Employee on temporary work assignment should return to Medical for further classification when specified time has elapsed first day Disability first day able to resume duties Shift i tvo 1) etc 00303 PROCEDURE TO FOLLOW IF NECESSARY TO SEND EMPLOYEE WITH OCC INJURY TO A PHYSICIAN IN TOWN ON SHIFT //> 1) Call plant physician, 2) Call Main Gate for car - if patient will be gone for a short time, have guard wait for him; if it's going to be longer, have guards return and tell patient to call Medical when he is ready to return. 3) Give Outpatient Consultation Report to patient for doctor. 4) On MTR* write up and on shift performance sheet put doctor contacted and time, time and place sent and how sent. 5) Be sure to note on MTR*if consult report . was salt to doctor and if patient returns with Consult Report filled in by doctor, attach with paper clip to MTR* and leave in tray for Charge Nurse. 6) If patient is admitted to hospital or told by doctor not to return to work notify plant physician and patient's foreman. Have patient report off occ. at gate. If admitted to hospital, tell him .to notify plant medical when discharged. Be sure he understands that fee will be paid by Industrial Insurance except for extr as telephone, television or other personal items and to deliver all bills forwarded to him to Plant Medical. If prescription is given patient, have him fill it at drug store and bill to Ethyl or pay for it and he will be reimbursed - Bring bill to Plant Medical. *MTR -- Medical Treatment Report F-06367 ETC 00304 Partial Duty When plant physician is in Medical Department assignment or approval of assignment shall be exercised by the physician. On "A" shift reviewing shall be done by registered nurses only. At all other times, the decision may be made by the nurse on duty. The record should always specify clearly the reason for the partial duty and the stipulations of such duty should be itemized separately - as example: Recommend the following Partial Duty 1. No heavy lifting - 50 lbs. maximum 2. No climbing other than ordinary stairs 3. Review (date ) On every occasion that an employee with partial duty is seen in the dispensary, check review date. On each case, determine that the partial duty restrictions are necessary, are desired by the employee and are no more restrictive and of no longer duration than absolutely necessary. Do not issue partial duty to an employee requesting per mission to shower early for medical reasons, even though he may have a written request from his personal physician. Refer him to his supervision. E O 3 Ri J-s ETC 00305 RETURNING TO PARTIAL DUTY AFTER PERSONAL ILLNESS Find out what partial duty needed and for how Long. Call shift foreman, outline partial duty needed and time required. If partial duty available Make three Duty Release/Return slips. Example: OK for partial duty after personal illness 1) Limited use right hand 2) Review date (tell employee to be sure and report for review on date listed). Duty Release/Return slips go to the following.: 1) Patient (to take to his foreman). 2) Overtime clerks box in dispensary. 3) Wage Disability box in dispensary. On Med. Progress record record condition requiring; partial duty, name of foreman called and can use on the following partial duty. Example: OK for partial duty after personal illness. 1) List restrictions 2) Review date Stamp with partial duty red stamp Return card to active partial duty file. If no partial duty available 1. Have patient return home 2. Tell him date to report to Plant Medical 3. Make note and put in disability wage box - time in, condition requiring ETC 00306 partial duty, what shift suppose to work, if private physician was seen, foreman called (his name) and could not use on the following partial duty, list restrictions requested and date told to report. DUTY RELEASE/RETURN This certificate to be presented to Foreman/Supervisor by employee RELEASE FROM DUTY RETURN TO DUTY S S OR EMPLOYEE NO SENT TO Q HOME Q HOSPITAL n PERSONAL PHYSICIAN ^_____________ SUPERVISOR NOTIFIED (NAME) DATE OCCUPATIONAL pT| PERSONAL ILLNESS | | INJURY FIT FOR REGULAR WORK IFIED REGULAR WORK S3 RESTRICTED DUTY UNTlU TEMPORARY DUTIES SHOULD ROT INCLUDE THE FOLLOWING CLIMBING STAIRS OR LADDERS WORK ABOVE FLOOR OR GROUND LEVEL WORK AROUND MOVING MACHINERY DRIVE COMPANY VEHICLE t IFT PUSH PIJ11 OVER '1 -j IBS o SHIFT WORK OVER TIME COLD EXPOSURE TO Q VCM Q HEAT Q SOLVENTS WATER Q NOISE | | DAMPNESS Qj DUST,FUMES | | LEAD Q OTHER { | WALKING OR STANDING OVER_______ % of time | | KNEELING OVER________ % OF TIME |--[ BENDING________ X OF TIME j~~[ EYE HAZARDOUS WORK USE OF_________________________________ OTHER . Employee on temporary work assignment should return to Medical tor further classification when specified time has elapsed. FIRST DAY DISABILITY FIRST DAY ABLE TO RESUME OUTIES SHIFT F-06370 ETC 00307 RETURNING TO DUTY AFTER WORK-RELATED ABSENCE If there are no slips on patient's chart or on spindle in dispensary and no write-up on Medical Treatment Report saying patient can return, call physician on call for permission to return patient. 1) If medical service slips are on chart or spindle - give one to patient, one in disability wage box and one in overtime clerks box if on partial duty. 2) On Medical Treatment Report put date and time returned list OK for full duty after Occ. Abs. as of date and shift (tell patient) and put date to report in. 3) File Medical Treatment Report in active file if retreat date is given. If injury is finaled at same time, OK injury of date, final and file back in patient's chart. WHEN NOT TO ISSUE EXCUSE PERSONAL ILLNESS SLIP 1) If patient comes in at start of shift and has not started on job (even though he may have changed to work clothes and requests to be excused for personal illness - DO NOT ISSUE EXCUSE SLIP. a) First explain to him he does not need slip since he has not started work, even though he may have clocked in already. b) Pull MPR. Record request to be excused, why not necessary to issue slips - nature of illness, if plans to (continued next page) E ~0(~>37 \ ETC 00308 see M.D., tell and record date to report in, file back in chart. c) Tell patient to report of personal illness at gate, d) Make note for disability office and put in box in dispensary with sane information you put on blue card as tine, date, shift expect ed to miss, nature of illness, M.D., date to report to Plant Medical. 2. If an employee has worked 24 consecutive hours and is unable to work his regularly scheduled shift because of fatigue, do not excuse personal illness. He is to be excused, if he so desires, by his foreman (Code 90). F-0637 7 ETC 00309 Appointment with outside physician for occupational injury during working hours - 1) Patient is to notify R.N. day nurse and foreman in advance. 2) Tell foreman to carry his time as visit to Plant Medical. 3) Provide transportation if needed (may use his car if he wishes). 4) Issue one Medical Service slip for guard "allow to pass". 5) Have patient report to Medical when he returns. Consultations Plant physician will order consultation. Day nurse R.N. will make appointment and fill out consult form and give to patient. Explain to patient fee will be paid by Plant Medical for consultation only - not treatment. Records Control Drugs Record in book in dispensary all control drugs dispensed. Crutches. Canes Record in book in dispensary - may be issued for occupational and non-occupational conditions. Treatments of Construction Workers, Visitors, etc. Record in book in dispensary: Name, time in, condition, treatment given. Fill out a Medical Treatment Reportany injury or illness alleged or sustained by a non-employee on Company property. F-06373 ETC 00310 // Rules for Non-Occupational Disability For the proper administration of the Accident and Sickness Benefit Plan, employees must comply with the following rules in order to be considered for benefits. 1. Report absence to the Main Gate as soon as is known will not be at work on next regularly scheduled shift. 2. If employee becomes ill at work, must check out through Medical and report absence to the Main Gate. 3. Report in person to Plant Medical the first day disability does not confine you to home or hospital unless otherwise instructed by Plant Medical. Reporting days are Monday through Friday, excluding Holidays, between the hours of 7:30 a.m. and 4:00 p.m. 4. Report any change of address during your disability to Plant Medical. 5. Notify Plant Medical of admittance to hospital. 6. Report to Plant Medical and receive a l^ack-to-work slip on day you return to work. 7. If you are absent due to. disability and are able to re turn to work, you must report in person to Plant Medical for a return to work slip before going on vacation, jury duty, etc. 8. Prearranged appointments for non-routine medical treat ments, surgical procedures, emergency dental work and diagnostic procedures where actual disability does not exist must be scheduled outside of working hours. Dis ability benefits are not paid for routine, previously arranged medical and dental appointments. Vw E-06374 ETC 00311 Instructions to Nurses 1. Employees who must be returned by Physician or Assistant to Physician-put time in, name and badge number on Form 1332 (Disability Daily Sheet) and have employee wait in waiting room if they report before disability office is open. 2. Do not take information if employee reports to Medical on weekends, holidays, or when disability office is closed. Instruct them to report at the proper time. 3. When employees off on disability report to dispensary des*; on "A" shift during week days, question if off on personal illness or occupational. If personal illness, refer to disability wage office. If clerk is not in the office, pull card and record time on daily sheet and place card in door box. 4. Information on the Disability Wage Cards must be kept strictly confidential. Foremen or other members of supervision are to be given only the estimated date of return or date patient is expected to report to Medical. F-0A375 ETC 00312 D is a b ility wage O ffic e F-06376 ETC 00313 V J- ; ru I Work Schedule for Disibility Wage Office. 1. Pick up from Dispensary first thing each morning the following: A. Medical Service Slips (Return to Work Slips) B. Slips marked O.K. from Occupational Condition - These are sent to the Industrial Insurance office. C. Dispensary Cards (Blue Cards) of employees who were excused because of Personal Illness. D. Name sheet for employees waiting to see Disability Wage interviewer. E. Pull "Daily Breakdown Report" from bulletin board. 2. In Disability Wage Office: A. Pull Employee Disability card (White Card) who1s name appears on name sheet and process for Disability Wage Interviewer to see. B. Check Form 196 (Absence Report). All reports on manage ment and confidentia employees are set aside to be pick up by Personnel after absence is typed on Employee Disa bility card. C. Match up Form 196 with Employee Disability Card and re turn to work slip and Dispensary Record Card; then the Return to Work Slip with the Employee Disability Card from the active file. (1) On Employee Disability card taken from active file type in RED: (a) Current date. (b) In caps: RETURN TO (the appropriate date (ie: FULL DUTY, PARTIAL DUTY or MODIFIED REGULAR WORK) and the date patient returned to work. Then any note from Dispensary, giving reason for being off. Make note of any com ment made by patient's personal phy sician if he saw one. Then enter the initials of the person who initiated the Return to Work Slip followed by your initials in the right hand mar gin of the Disability Card. (All this is typed in red.) (c) If Disability Wage Interviewer returns an employee to work this shift, this report is typed in black, noting the date, time in, followed by the report, followed on the same line in RED caps: RETURN TO (appropriate duty) as checked If duty is Partial Duty issue slip to P Dispensary for entry on patient's Dis_ '^77 pensary card. ETC 00314 Work Schedule for Disibility Wage Office (continued) fcrcac 3. After all returns have been typed, go to master board and block out square in orange denoting that patient has re turned to work and make a check mark opposite the day of the month returned. On the right side of the sheet, put the number of days missed. (This is applicable only to the current working month.) 4. File the Disability Wage cards back in the inactive file. (In badge number order) 5. Match up new 196's with the Disability Cards which have been pulled from the inactive files. Check address, phone number, work section and update the white card as indicated. A. Skip one line between last illness. Type in RED - the current date and: ABS. REPT, date, FDD, date, Dr's name and notified by whom. If in hospital, so note and which one. B. Place on Master board under section employee works; earliest FDD first. Then file all white cards in active file. . 6. As patient reports to see the Disability Wage Interviewer, pull white card from active file, enter on Name Sheet and process for Interviewer. After Interviewer sees patient, type the write-up in black and if patient is given a slip to return to work at this time, notify the appropriate supervision of this fact. F-06378 etc 00315  ... /V- tf-itC:' : 7; +- L*-*' -,:7 vi -' F-06379 ETC 00316 MEDICAL ASSISTANT'S DUTIES 1. Collection and recording of certain information and collection of sample associated with lead check procedure. 2. 3. Operate electrocardiograph and take EKG. 4. Operate audiometer and take audiograms. 5. Operate sight screening apparatus. 6. Perform tonometry. 7. Assist in Disability Wage Office. 8. Process personnel for periodic or pre-placement examinations. 9. Collect and prepare specimens for transmittal to medical laboratory. 10. Assist physicians in the preparation for examination of' individuals. 11. Calibrate audiometer once a week. F-06380 etc 00311 INSTRUCTIONS TO MEDICAL ASSISTANT PREPLACEMEHT AND PERIODIC EXAMINATIONS W1 Height - to be recorded to nearest one-half inch. Height for men recorded with shoes on. Women wearing high heeled shoes should remove the shoes before height is taken. Weight - to be recorded to nearest pound. Weight is taken with usual indoor clothing (including shoes); men remove coat. Temperature - to be recorded in degrees Fahrenheit to nearest one-tenth degree. Thermometer under tongue for 3 minutes (use timer). Pulse - to be recorded in beats per minute. ' Blood Pressure - to be recorded in mm Hg. using mercury gravity manometer for determination. Patient to be supine with the forearm at heart level (if sitting or other position, so specify). Inflate cuff of sphygmomanometer to about 30 mm Hg. above point at which the radial pulse disappears, then release pressure at rate 2 - 3 mm Hg./sec (not faster or slower than this,'). The stethoscope head should be applied firmly (but without unnecessary pressure) to the antecubital space over the previously palpated brachial artery. The systolic pressure should be recorded as that level at which the initial tapping sound is heard through the stethoscope for at least two consecutive beats. The diastolic pressure should be recorded as that level at which distinct, abrupt muffling (or sudden dis appearance) of the sounds occur. Where a very wide range (greater than 5 mm Hg.) between muffling of sounds and disappearance of sounds, record both (e.g. sounds appear at 140, muffling at 90, disappearance at 40 - record B.P, as 140/90-40). Vision - to be tested by use of A-0 Sight Screener and Ishihara color plates (using Macbeth Easel Lamp for illumination). Vision without glasses is to be recorded in black, vision with glasses is to be recorded in red. Persons wearing contact lenses are to be tested with lenses in place (i.e., do not ask them to remove lenses for testing without correction). Hearing - is to be tested with subject in soundproof booth using Rudmose ARJ-4A Automatic Recording Audiometer. Audiometer must be calibrated once a week and calibration proof retained in file. Record nature, duration and time of last noise exposure on back of audiogram card. Intra-ocular pressure - is to be recorded in nm.Hg,, patient supine, using certified Schiots tonometer. Identify pressure in right eye by "O.D.", left eye "O.S.". F-063BI ETC 0031 ft Instructions to Medical Assistant (Continued) Electrocardiogram - standard 12-lead tracing to be made vdth patient supine. Urine analysis - dipstick for pH, protein, glucose, ketones, bilirubin and blood (Bili-Labstix), record results. Label specimen vdth date, badge number of subject and area ("25"), attach analysis slip (similarly marked plus check off "spot", vjrite "Routine" under "Remarks"), send to R D laboratory vdth specimens going from Lead office each day. Blood - one small purple-top (EBTA) tube (mix well; refrigerate) and one small red-top tube with at least 5 ml serum (obtain by collecting blood in a large red-top tube, let it clot, "ring" clot, spin down in centrifuge, draw off serum; refrigerate); each labelled vdth date, subject's name, "Ethyl Corp." - send to Pathology Laboratory with completed request slip. Also collect one large brown-top tube (mix well), label with date, badge number, area ("25") - attach analysis slip (marked as for urine except check off "Blood"), send to R D laboratory with specimens going from lead office each day. Chest X-ray - EPA of chest on 14 x 17 film at 72 inches distance. h-0638? ETC 00319 0 Records (By Medical Assistant) I. EKG book a. Date b. Employee's name c. Badge number d. EKG number II. LAB work request book a. Date b. Employee's name c. Badge number d. LAB work done-Ethyl Standard and other e. Whether repeat W hi. Periodic physical examination schedule a. Badge number b. Employee's name c. Section d. Time of appointment e. Check tests done f. If does not report - reason. ETC 00320 PERIODIC EXAMINATIONS A. Receive Schedule for next week's exams every Friday afternoon 1. Check eligibility for exam (date of last periodic -- at least three years service, at least three years since last exam and not examined since date current cycle began). 2. Notify master scheduler (Personnel) if ineligible, accept replacement for assigned slot if available from group scheduler that same day. B. Exam Sequence 1. Afternoon before pull all charts Pull audiogram master card Fill in all information available on forms, as patient's name, age, badge number Get blood tubes ready 1 - 20 ml Brown top - # Badge Number 1 - 10 ml Red top - #Badge Number 1 - 7 ml F,ed top - name, date, badge number 1 - 7 ml Purple top - name, date, badge number 2. Weight 3. Height 4. Temperature 5. Pulse 6. Blood Pressure ) > While temperature being taken 7. Eye test 8. Audiogram 9. EKG 10. Blood Sample - Fasting 11. Tonometry (ove.fi 40) 12. Chest X-ray 13. Urine sample 14. Have patient fill out questionnaire 15. Make M.D. appointment and give appointment slip 16. Mount EKG _ C 06384 ETC 00321 17. Process blood 18. Urine sample (dip stick and record) attach request slip and send to R & D for ^.3 19. Attach request slips to blood CE'A 20. Charts to H.D. for EKG reading (remove all EKG' from chart with most recent in front, attache to chart plus yellow sheet) C. When available 1. File reports in charts, stapled together in following order a. yellow physical sheet (put results of urine dip stick) b. X-ray report c. SMA d. Eye chart e. Audiogram f. CBC g. lead result 2. File questionnaire in chart (put after reports) 3. Refile charts in dispensary (if review within one week - keep charts in file in lab) D. Afternoon before M.D. appointment 1. Pull chart 2. Attach slip to folder showing date and time of appointment with M.D. E. Patient in for M.D. appointment 1. MALE - Put in examining room - have undress FEMALE - Remain dressed 2. Put chart in door box 3. Notify M.D. When SMA reports return if any abnormalities, make appointment for repeat. Egilibility for physical - must not have had any type physical, periodic, or preplacement since 1968. ETC 00322 Electrocardiograph Procedure 1. Have patient lie on table with shirt, shoes and watch removed. 2. Make certain patient is in a position of comfort with arms supported so total relaxation is possible. Mus cular tremor is not acceptable. 3. Make strips long enough for mounting, but not longer. 4. Mount EKGs and record required data on folder. 5. Make copies of all EKGs daily, send original plus consul tation order to Dr. David W. Wall, 3849 North Boulevard, for interpretation. 6. On yellow Medical Examination sheet record, in pencil, date and EKGs sent to Dr. Wall. 7. File copies in patient's chart. 8. When origianl is returned, record interpretation on Medical Exam sheet, erase penciled date sent, destroy copies and place original in patient's chart in proper order. Laboratory Procedure Two Hour Glucose Tolerance Test 1. Nothing to eat after midnight. 2. At 7:30 A.M. draw a fasting blood sample. 3. Instruct patient to empty his bladder. 4. Have patient drink a bottle of Glucola. Note the time. 5. Two hours later, draw blood sample for sugar and obtain a urine specimen. 6. The urine specimen is to be tested for glucose with dipstick and results recorded. 7. The blood specimen to be sent to Pathology Laboratory. f-0b3S7 ETC 00324 Cleaning Tonometer ii 1. Wash tip of tonometer in water after each time used and place in sterilizer. 2. At the end of the day, take weight off and clean each part separately in water and place in sterilizer. 3. Once a week take apart and clean with alcohol. ETC 00325 A natom ical ETC 00326 )crc?5S SIMPLIFIED GUIDE OF ANATOMICAL CHARTS The main objective of this guide is to assist the nurse in describing areas of injury or complaints in SIMPLIFIED, BRIEF, AND CONCISE terminology- Highly technical and detailed anatomical areas of the skeletal, musculature, and circulatory systems can be easily obtained from many available sources, and have been purposely emitted from this very basic guide. ETC 00327 Extent of Injury - 9 Per Cent Rule The area of one arm is 9 per cent, the area of one leg is 18 per cent, the area of the front of the torso is 18 per cent, the area of the back of the torso is 18 per cent, and the area of the head 9 per cent. The remaining one percent is assigned to the genitalia. F-0(S391 ETC 00328 Supraorbital C-Oft39? 2 ETC 00329 Cornea 5 EXTERNAL EYE J F-On,'!9 'i 3. ETC 00330 ETC 00331 VOLAR OR PALMAR REGION Volar - pertaining to the flexor surface of palm, wrist or forearm. 6. ETC 00332 Deltoid ETC 00333 Deltoid Lateral Area Arm1 Third,' Axilla --Medial Area Arm "Posterior Area Arm DORSAL OR POSTERIOR ARM 8. f ETC 00334 9. ANTERIOR AREA. LEX} ETC 00335 1 -----a *\ J h-0h399 POSTERIOR AREA LEG 10 ETC 00336 fcooodt DORSAL AREA FOOT (RIGHT) MEDIAL SID?: LATERAL SIDE' n. F-06400 ETC 00337 SIDE SIDE <f--Distal Phalanx tt Distal Interphalangeal Joint ` Middle Phalanx /Proximal N jlnterphalangea] V Joint "Proxiraal Phal. RIGHT %QS Metacarpophalangeal Joint MEDIAL SIDE LATERAL SIDS Body of Toenail Sub Ungual (under nail) Lunula Distal Phalanx 1 Matrix of) Interphalangeal Toenail Joint (nail bed^ Proximal Phalanx MEDIAL AREA FOOT Metacarpophalangeal Joint RIGHT GREAT TOE Lateral Area Ankle Medial Area Ankle endon Calcaneus Area of Heel Lateral Area Heel Posterior Area Heel POSTERIOR AREA FOOT y .12 F--06401 ETC 00338 AKTEHIuR CHI^ST - ABDOi':-~H ARrA E-0640X ETC 00339 14. ETC 00340 SPINAL COLUMN BACK 15. F-06404 ETC 00341 / feg"' Tshic of Eruption nnd Shedding Dotes Names and Number ofleith 4 Centre! Incisors 4 Lateral Incisors 4 First Molars 4 Cusp:-":, tcanir.es) 4 Second Molars Age of Child at Eruption 6 to 9 months 7 to 10 months 12 to 14 months 16 to IE months 20 to 28 months i : C-. -------- s r; * i. . i j rsffiv-', u . w w rC'- A-(-------------------------- . rji : r.'-r- ^rr.onii ?;v / * *s , :{/ (. ;v:::.i IV:.Id i> Age When Shad 6 to 7 years 7 to 8 years 9 to 11 years 11 to 12 years 9 to 11 years Tabls of Eruption Dates Names of Permanent Teeth First Molars 16 yr. molars) Centra! Incisors Lateral Incisors First Bicuspids Cuspids Second Bicuspids Second Molars Third Molars (wisdom teeth) Age at Eruption 5 Vi to 6 years 6 to 7 years 7 to 8 years 10 to 11 years 10 to 11 years 11 to 12 years 12 to 13 years 16 to 21 years F-06405 ETC 00342 D isaster Plan ETC 00343 DISASTER FIERI MEDIC'LL DEPAIliifLNT, BATON ROUGE PLANT I. DEFINITION: A mass casualty situation exists when the number oi patients gene rated by a plant incident exceeds the capabilities of the Plant. II. NOTJ "ICATION: III. MISSION: T/. RESPONSIBILITIES: A) Medical Department, open: Notification will be through the Plant general alarm system. B) Medical Deportment, closed: Tiie Plant Emergency .Area Coordinator will notify the Plant Medical Director, or the Plant Assistant Medical Director, vfiao wall, in turn, decide whether to initiate the Medical Department noti fication plan. (See Annex "A". During a mass casualty situation, the primary mission of the Plant Medical Department is to triage and evacuate patients. The Plant Medical Director, or his de signee, will be responsible for the over all medical operations. F-0A407 ETC 00344 DISASTER PLAN V. CONCEPT OF TRIAGE: VI. PATIENT LOCATION: -2- Triage is the sorting out and classi fication of injured persons to determine the priority of need end proper place for treatment. Triage will be perfor med by a physician if at all possible. The priorities are as follows: 1st -- Immediate. This includes abdominal wounds, partial amputations, hemorrhage, chest wounds, pulmonary edema, severe lacerations, severe head injuries and extensive burns. 2nd -- Delayed. This includes closed fractures, mild to moderate burns, (e.g., <30% 2nd deg.), non-hemmorrhaging lacerations. 3rd. -- Fatalities. A) Immediate -- Plant emergency room area. B) Delayed -- Plant ward area. C) Fatalities -- Medical proctology room. fr-064.08 ETC 00345 DISASTER PLAN VII. CONCEPT OF EXECUTION: -3A.) Medical Department, open: 1) Upon notification of a poten tial mass casualty situation, a nurse and ambulance will be dispatched to the scene. While preparing the first patient (s) for return to Plant Medical, the nurse will make a rapid assessment of the approximate numbers and types of casualties and return to the Plant Medical as promptly as possi ble. If warranted, outside ambulance ser vices will be immediately notified, as well as local emergency rocms. This may best be accomplished by use of the Baton Rouge Mutual Aid System plan. a) Call telephone number 343-4805 using the following form message: "Mutual Aid, this is, (your name) , of Ethyl Corporation Medical Depart ment requesting the following help, (give details), Mutual Aid." b) Give Mutual Aid the telephone number to call back for additional information. 2) While waiting for outside help, the physician(s) will initiate triage ETC 00346 CHEMICAL EXPOSURES EFFECTS AND TREATMENT F-0641O ETC 00347 ALLOY (lead-sodium alloy) is a powdered mixture of metallic lead (90%) and sodium (10%). Since it contains 10% sodium, it can produce skin burns, but more often produces mild skin irritation. Treatment of skin burns and irritations from alloy is washing'with lots of water and a soothing cream such as Nivea. ALUMINUM ALKYLS. These compounds burn on contact with air, so they cause burns when they contact skin. Although these burns are almost always shallow they are immediately painful and often the burned skin will turn white. Immediate and thorough washing with lots of cold water is important. Ice water compresses relieve the pain and lessen the seriousness of the burns. After this, the treatment is the same as for any other burn. These alkyls are not poisonous. The burns are never as bad as they first appear to be. ANILINE is highly toxic. Immediate and thorough washing with lots or water and soap. It is important that no tiny spots of aniline remain on the skin or scalp. Special attention should be given the areas around the fingernails and toenails, using a brush if possible. Contaminated clothes should be washed before wearing again, or de stroyed if badly contaminated. Shoes and gloves should be burned. Oxygen should be given if skin or lips are blue. Aniline changes hemoglobin to methemoglobin so the blood cannot carry enough oxygen. Moderate exposure may cause only a bluish or blackish discoloration of lips, cheeks, fingernails or ears. In more severe cases there may be headache, weakness, or irritability. If exposure continues, drowsiness, shortness of breath, unconscious ness or even death can occur. The symptoms described clear in a few hours if absorption is prompt ly stopped by thorough bathing and removal from odors. If the bathing is not absolutely thorough, the patient's condition will worsen for several hours. The patient must be warned to drink no alcohol and to take no head ache pills< "BATH" See caustic. (Bath is a weak caustic.) BENZENE has an anesthetic affect. The principal hazard is from inhalation of vapors. In case of unusual exposure, call a physician immediately. To prevent collapse, the patient should lie down with out a pillow and be kept quiet and warm. It is a mild skin irritant.Contaminated clothing, affected areas of body should be washed thoroughly with soap and water. If liquid benzene enters the eyes, they should be flushed with copious amounts of water. f-Oo4l1 ETC 00348 2- - CATALYST. Different substances are used as catalysts in different areas of the plant. Thoroughly wash all catalyst off, shower and change clothes. Find out from supervisor what the catalyst contains and call Plant Medi cal Director, if needed. A catalyst is a substance which serves to speed up, or slow down, a chemical reaction. Most of the ones used here are not extremely hazardous. CAUSTIC (Mostly sodium hydroxide or lye). Immediate and thorough washing with lots and lots of water. Eye burns are especially bad from caustic. Burns are sometimes deeper than they appear to be. After thorough washing, treat like any other burn. CHLORINE severe irritant of breathing passages. Have patient sit ~"Trp, give nothing by mouth. Oxygen in all cases that have breathing distress or cough. Start as soon as possible and give as long as it seems needed. Give at rate of 6 liters per minute. Reassurance -- lots of this. Stay calm and stay near the patient. He needs to know his condition will improve gradually. Call thedoctor if you feel he/she is not doing well. If breathing ceased, restore breathing -- artificial respiration immediately. Liquid chlorine very corrosive. If in eyes, flush with cold water for 15 minutes. If on skin, remove clothing, shower immediately. Never try to neutralize the chlorine with chemicals PEA (Diethylaniline) has an effect like aniline only it is less toxic. However, patient should be handled as for aniline, since it is always possible there may be some aniline in the DEA. DOWTHERM has strong odor. Is not expecially poisonous but should be washed off with water and soap and-clothes changed. Dowtherm can cause skin irritation and a temporary increase in blood pressure. ETHYL CHLORIDL presents some hazard through inhalation because of its narcotic and anaesthetic action. It may have some local effect on the skin through its refrigerant effect, under some conditions can produce frost bite. If someone is overcome he should be given artificial respiration until he can breathe alone. ETHYLENE. From a medical standpoint, this is like ethyl chloride. F-0641? ETC 00349 -3- ETHYLENE DIBROMIDE (EDB) is highly toxic. Immediate and thorough washing with lots of water and soap. All clothing must be thorough ly laundered. Shoes and gloves must be burned. This substance is absorbed through the skin or by breathing vapors. It is damaging to the lungs, brain, kidney and liver and it will blister the skin if not immediately washed off. Plant Medical Director should be notified if contact is large or prolonged. ETHYLENE DICHLORIDE (EDC) is much less poisonous than ethylene di bromide but must be handled the same way. Immediate and thorough washing with lots of.water and soap. All clothing must be laundered. Shoes and gloves must be burned. a^LOURIDE OR HYDROFLOURIC ACID. Strongly corrosive, causes serious and painful burns, may have delayed reaction. Remove from skin or eyes immediately by thorough irrigation with water. .Involved part should be immersed in iced solution of magnesium sulfate as soon as possible. If exposed to gaseous hydroflouric acid, carry at once into uncon taminated atmosphere. Do not allow to walk. If breathing has stopped, give artificial respiration and call for ambulance. HYDROCHLORIC ACID (Liquid) . Same effects and treatment as for sulfuric acid. HYDROGEN SULFIDE. Extremely toxic substance (rotten-egg odor). May cause eye, throat and lung irritation. Give artificial respi ration if breathing has stopped. Eye contact -- irrigate with water for 15 minutes. METHYL CHLORIDE. Seldom causes local irritation, but when inhaled may cause dizziness, staggering gait, drowsiness and, in severe exposures, unconsciousness. Give oxygen. If respiration has stopped, start artificial respiration at once. NITROGEN. An absolutely inert gas. Pure nitrogen is used to "blanket" certain substances on this plant so oxygen can't get to them. It is also used to "purge" certain tanks or "vessels" so there is no oxygen in them. Man can only live 3 to 5 minutes without oxygen, and nitrogen is only harmful when it displaces the oxygen found in air. Anyone overcome by nitrogen must be immediately moved into fresh air and given resuscitaiton. OLEFINS Not very toxic. Could put a person to sleep if he continued to breathe strong concentration. If a person is overcome he should be taken to fresh air and given artificial respiration if breathing has stopped. Fire and explosion are greater dangers from olefins than are their medical effects. Olefins on skin should be washed off and patient's clothes changed. F-0641o ETc 00350 -4- 'ORGANOPHOSPHATES. Rapidly absorbed into the body by ingestion, through skin, including the eyes and by inhalation. Pinpoint pupils are a positive sign of intoxication, requiring atropine antidote. Auto injectors of pre-measured doses of atropine are available at immediate work area. Patient will have weakness, blurred vision, difficulty breathing, accumulation of secretions in respiratory passages. Im mediate treatment. Terminate exposure, support respiration, adminis ter atropine, call ambulance. Skin Contact. Soap and water shower. Eye Contact. Irrigate with water immediately PERMANGANATE. The permanganate solutions used on this plant usually cause very shallow burns and may only leave a brownish stain. Wash with water and apply Nivea cream. Tell patient stain will wear off in time. PHENOL (Carbolic Acid) is highly toxic. Immediate and thorough washing with lots of water and soap. All clothing must be laundered. Shoes and gloves must be burned. This substance is absorbed through the skin or by breathing vapors. It is damaging to the brain, kidneys, liver, lungs and pancreas and it will burn the skin if not immediatley washed off. Plant Medical Director should be notified. "PINCKLE" (PNCl,, Phosphonitrilic Chloride). Causes eye, skin and respiratory irritation. Has a severe initial effect on the eye. Wash immediately with water for 15 minutes. Exposed skin must be washed promptly with soap and water. PITCH. See tar. PHOSPHORUS burns spontaneously when exposed to air and may cause severe burns. Vapors are irritating to the nose, throat, and lungs. Place under cool water shower and remove contaminated clothing. Keep burned area wet by immersing in cold water or apply cold water compresses. Medical to examine and treat' all cases of phosphorus burns. SODIUM. Sodium burns when it contacts water and it causes deep burns when it contacts the skin. These burns are always deeper than they appear to be and are slow to heal, especially if on feet or ankles. Immediate and thorough and repeated washing with lots and lots and lots of water. Then treat like any other burn. SULFURIC ACID (Battery Acid, Oil of Vitriol). Immediate and tho rough washing with lots of water and soap. Sulfuric acid causes a chemical burn which (after thorough washing) is treated like any other burn. TAR. Tar can often be removed with mineral oil and a gauze square. Handle carefully as there may be an underlying burn. f - 06.4 1 u ETC 00351 -5- TEL-TML. If ingested, induce vomiting. Immediate and thorough washing with kerosene, if available, followed by lots and lots of water and soap. Be sure hair, scalp and under nails are washed also. All clothing is to be destroyed (burned). These substances are absorbed through the skin and by breathing vapors. They irritate the brain and cause insomnia, headache, ner vousness and other symptoms. All exposed employees are to'see the nurse or doctor at the earliest convenient time. Keep accurate record of time and length exposed, how long before showered, type of exposure (respiratory, skin), material(s) to which exposed, where occurred, area of skin involved. Duration with or without mask. It is important to remember that the symptoms of TEL poisoning can also be caused by worry, fear or anger. '^TRICHLOROETHYLENE. Essentially an anesthetic, also will cause irri tation of skin or respiratory tract. If breathing has ceased, start artificial respiration. Keep patient quiet and warm. Skin Contact -- drying effect. Wash with soap and water. \VINYL CHLORIDE. Primary hazard is associated with excessive respira tory exposure. Affects the central nervous system producing intoxi cation and dulling of visual and auditory responses (light headedness, some nausea). If not breathing, give artificial respiratic- . ?emove to fresh air. Skin Contact -- Wash with soap and water. Cloth ing, including shoes, should not be worn again until dry. Vinyl chloride probably causes liver damage and possibly cancer in employees with large exposure for many years. F-06415 ETc 00352 DISASTER PLAN -4- VII. CCKCEPT OF EXECUTION (continued) and, along with nursing personnel, administer life saving measures to those in the "inmediate" category. 3) Upon arrival of outside help, patients in the "immediate" category will be evacuated, the most urgent first. 4) Following this, tliose in the "delayed" category may be evacuated, keeping in mind that all fractures must be immobilized prior to movement. 5) In the event of fatalities, the coroner will be notified at the earliest available moment, (See Annex "B" 6) At the earliest convenient moment, religious personnel of the appropriate faith should be notified - (See Annex "B" B) Medical Department closed: 1) Should a disaster occur when the Medical Department is closed, the Emergency Area Coordinator will noti the Plant Medical Director, or his Assistant, who, in turn, will decide v.hether to initiate the alert noti fication system for the Medical De partment. 2) It can bo assumed lh.it by Lb. F-0641A time an effective medical team can lx* assembled, plant supervisory personnel ETC 00353 VII. CONCEPT OF EXECUTION (continued) -5- will have initiated evacuation procedures. This icing the case, the medical team leader will re port to the Emergency Area Coordi nator for instructions. 3) Ml or part of the guidelines set forth under VII "A" may be followed depending on the circumstances. F--0A417 ETC 00354 6- ANNEX A ALERT NOTIFICATION PLAN Emergency Area Coordinator 4 4 4 Dr. Frank M. Buckingham 923-2592 4 4 4 Charles W. Bruton - 275-4993 C 4' Wanda Spiers 927-6076 4 4 4 Barbara Mitchell 924-6037 , - 4 Gaynell Duke 664-9073 4 4 4 4 4 Mabel Slaton 355-3609 4 4 4 Ernie Webb 926-1933 4 4 4 Eloise Strickland 261-8347 . C ETC 00355 ANNEX D CHAPLAIN CALL LIST CATHOLIC: Father Michael Collins or Father Bryan Gray St. Charles Catholic Church 356-2527 JEWISH: Rabbi Brahmes B'Nai Israel Temple Synagogue: 343-0111 Home: 766-5067 PROTESTENT: Brother Charles Matthews Weller Avenue Baptist Church Church: 355-4407 Home: 355-8349 8- ANNEX C CRITICAL PHONE NUMBERS Baton Rouge Mutual Aid System - 343-4805 Baton Rouge General Hospital Emergency Room - 387-7600 Our Lady of the Lake Emergency Room - 387-8826 East Baton Rouge Coroner's Office - 389-3047 F-06420 ETC 00357 yy Si- C -- _.* x y y X a ] ZZ S' 3 3 y r~ x. y aa >: 2 .3 y . p . ?5c -- __ y "5^ a! a; y : 1w y >. 1^S-2"3 x S,C aw 1 5o? i" N" - g.iJJ &r S "s = 2 d. -- & ,_' y ________ -5.a2_.,,2a_;_"5f.E* [- = 33; x= b> b3 5 ?tO -- =-y y --=- -3 S .= ft 5 P -P .= y j X 3yc 3 x 0.^5 C..J 3 s i i_ ^ -- 3 * .3 . 0 Ck. 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Ml -Nf*3 "y3 x a 3 - = 303 1.11-X y o : * yru; -yo* X"=a ' 15 x X ; X a-- -- a^ 33a- aa 3 >> a X 0 u 2= ^ y u A LCX -- Lo.2 2 = ,S>o 2 E I y s Z *3 = "= .5 yy c x x -g 0 a 10 -- c E to y 3X y a ^ >* 3, o : = 2 > 11 "2 ' r :y 1x p xx 3 y-. ^ x 'E* <*_ 3 'J U SPg 2 22 :r^ a-- Q y u- y yj a = * x 1 S'-s. : y y" JO *Ox y II : -- y U-3- y PS -3 x -3w y y. tils 1 H-s'32 --paE c = = ~ .yp^ -- -- o X> c3Z XA 'XSO.. 3l'a* f?9 -" 3 >> l'l^ x -- x fx a SO^ to^4" 10 -- pX o 3 x- -- 10 > yt/3 y wa aP >, si. O-- S > f 2 >- 2 ' -3 y 3 ^ X T io 'rr- y -3 ..2 -3 ? - a -Xx a y !-- a x ^3 x .2 " > !: l.' -a ayc. --ya y |3io- >y ^_--.*OL. . ; aa yf a S d' L > - yClm* >y j x -3 aX -- p-0^4?l ETc 00358 EVALUATION 1. Estimate the Injury A. History B. Body Surface Area C. Depth of Burn 2. History and Physical Examination A. Brief History should include: 1. Circumstances, force, location, etc. 2. Pre-accident health of patient 3. Pre-accident medications 4. Allergies 5. Tetanus immunization B. Physical Exam 3. Determination of Severity of Bum A. Body Surface Area B. Depth of Burn 1. Superficial Burn 2. Partial Thickness Burn 3. Full Thickness Burn 4. Types of Burns A. Contact-Tar Burn, Scald B. Flammable Liquid C. Fabric D. Burns Associated with Child Abuse E. Smoke Inhalation F. Carbon Monoxide G. Special Burns 1. Electrical Burns 2. Chemical Burns ETC 00359 COMPREHENSIVE CARE OF THE BURN PATIENT EVALUATION John A. Boswick, Jr., M.D. F.A.C.S. Evaluation or assessment of the patient with a burn injury is an important consideration in the overall managment. The evaluation should provide information as to the seriousness of the injury. This depends on the extent, depth and location of the wounds, as well as the patient's age, preexistent diseases, associated injuries, and mechanism or etiology. An evaluation of the patient should also determine what patients need to be hospitalized, require intravenous fluid replacement, early wound excision, antibiotics, topical drug therapy, and other aspects of care. The patient assessment should start with a detailed history that includes the time, location, and exact circumstances of the injury. This includes the etiology or burning agent, whether or not the accident was in a closed space where the heat and smoke might have been intense. The history should also include all information of the patient's past health status, information on allergies, medications, and status of tetanus immunization are especially important. A complete and detailed physical examination should be performed. No aspect of the physical should be omitted. Special emphasis should be placed on evaluating the extent and depth of the injury. The location and types of burns are important in children where child abuse might be a problem. The simplest and most expedient way to determine the extent of a burn injury is to use charts designed for this purpose. These charts should take into consideration the variation in body surface for different age groups. A reasonable estimate of depth of injury should be made. This can be determined by the history of injury and wound appearance. In some situations, the presence of sensibility may help distinguish between a deep partial and a superficial full thickness injury. If there is dirt, grease, smoke or other discoloring agents on the wound or on the patient, it is better to remove these agents before estimting the extent and depth of the injury. Grease and dirt can be confused with burned skin, or might be disleading as to depth. F-064?:i etc 00360 TRANSFER AND STABILIZATION 1. "Specific Optimal Criteria for Hospital Resources for Care of Patients with Bum Injury" 2. Consider for Transfer: A. Third Degree Burns Greater Than 10% BSA B. Second Degree Burns Greater Than 20% BSA in Adults and 10% in Children C. Serious Burns of the Face, Hands, or Feet D. Burns of the Perineal Area and the Genitalia E. Circumferential Burns of an Extremity F. Electrical Burns G. Inhalation Burns (AMPLIFY BY EXAMPLE ON THE ABOVE) 3. Stabilization of the Burn Patient Prior to Transfer A. Airway B. Lifeline C. Intravenous Fluids D. Urinary Output E. Medications Administer intravenously 4. Transfer information A. Utilize a Burn Diagram B. Utilize a Transfer Form C. Transfer Agreements 5. Transportation A. Stress Physician to Physician Contact B. Stress the Need for a Transport Team 1. Advantages: a. Provides Personnel Familiar with Acute Burn Care b. Provides Personnel Skilled in Stabilization of Airway and Fluid Resuscitation F-06424 ETC 00361 TRANSFER AND STABILIZATION OF THE SEVERELY BURNED PATIENT Alan R. Dimick, M.D., F.A.C.S, These comments will naturally be limited to the more severely burned patient with a greater extent of burn rather than small or minor burns. They will also apply to burn patients with complications in addition to their burn injury, such as inhalation injury, multiple fractures, and lacerations. A bench mark for burn care was the publication in 1976 by the American Burn Association of Specific Optimal Criteria for Hospital Resources for the care of patients with burn injury. Included in these criteria are categories of burn injury as well as categories of burn care facilities. One should be aware of these criteria because they concern stabilization, treatment and transfer of burn patients. Three categories of burn injury are listed: minor bums covering less than 15% of the body surface; moderate uncomplicated burns ranging from 15-25% of the body surface; and major complicated burn injuries which are greater than 25% of the body surface and which may also have electrical injuries, inhalation injuries and burns of strategic areas such as face, hands, feet, perineum and genitalia. Major burns also include patients with serious medical problems such as hypertension and diabetes. Depending on the level of burn care expertise at the receiving hospital, moderate uncomplicated burn injuries and/or major complicated injuries should be referred to a major burn care facility such as the Bum Unit or Burn Center. Obviously this depends on the local inventory and classification r.` burn care. It is imperative that a hospital which cannot care for all levels of burn injury have transfer agreements with bum care facilities. Transfer agreements are recommended by the Joint Commission on Accreditation of Hospitals because they provide established protocols for these critically ill patients. Such an agreement is between two hospitals and is usually signed by the chief of the medical staff and hospital administrator. Therefore when the burn patient arrives, initial stabilization occurs and transfer is initiated to the level of care which is appropriate for the severity of the bum injury. One cannot emphasize how important it is to have these transfer agreements in place so that delay in transferring the acutely burned patient is minimized, because the initial care and especially the early care in the initial phases of burn injury are so important for later results in the bum patient. These considerations for transfer should be well thought out in advance and included in the transfer agreement. In general, the guidelines of the ABA Specific Optimal Criteria state major bum injuries should be referred to a burn unit or burn center. Depending on the level of burn care expertise at the given hospital, the patient may either be admitted to that hospital or referred to a hospital that can treat the moderate uncomplicated burn injuries. The patient should be stabilized before transfer either from the emergency department into the same hospital or from the emergency department to the burn center. Four major concerns are: 1. Airway must be maintained and oxygen administered. Burn patients are usually hypoxic during the initial 24-46 hours and should always receive at least nasal oxygen therapy. 2. Dry sterile dressings should be applied and the patient should be covered with a blanket for insulatin to conserve and maintain his body temperature. One should not cool the burn, or apply ice to the burn, because there is not normal sensation in this area and frostbite can very quickly occur. Also, hypothermia will occur dropping the body temperature causing cardiac arrest if the patient is cooled too rapidly. Therefore, because of these complications, it is best not to try to cool a major burn, but rather wrap the patient in a dry sterile dressing, cover with a blanket and transfer him. If the patient is being referred to another hospital, it is best to simply apply a dry sterile dressing to the burn wound and send the patient. The rationale here is that if any kind of cream or ointment is applied to the burn surface, it will have to be removed when the patient arrives at the receiving facility. Therefore, it is best not to apply cream or ointments if the patient is going to be transferred withn the next hour or two. F-0A4?5 etc 00362 AIRWAY 1. Pathophysiology A. Airway Thermal Injury B. Inhalation Injury 2. Clinical Manifestations A. Signs of Airway Injury Facial Burns B. Signs of Smoke Inhalation Injury Carbonaceous Deposits C. Physical Signs of Smoke Inhalation Injury 3. Radiologic Manifestations 4. Laboratory Manifestations A. Arterial Blood Gas Manifestations B. Ventilation Profusion Relationships 5. Measures of Support A. Bronchoscopic Evaluation B. Bronchoscopic Therapeutic Measures C. Respiratory Support with Mechanical Ventilation ETC 00363 AIRWAY Glenn D. Warden, M.D. Successful management of respiratory problems may be life saving following thermal injury. While the possibility of respiratory injury exists with all burns, likelihood is increased in the following associations; burned in a close space, unconscious during the fire, burns of the head, neck and oral pharynx, singed nasal hairs, presence of a productive cough and presence of carbonatious sputum. Respiratory injuries are best diagnosed by maintaining a high index of suspicion and treating expectedly. Respiratory injuries may be divided into four major classifications -- asphyxia/carbon monoxide, upper airway obstruction, tracheobronchial injury, and inhalation injury. Asphyxia/Carbon Monoxide--These entities can kill a burn patient without producing any damage what-so-ever to the respiratory tract. Both are common causes of the '`dead-on-arrival" burn patient. Symptoms of carbon monoxide intoxication include headache, confusion, somnolence or coma. Frequently symptoms correlate poorly with carboxy-hemoglobin concentrations. Also, burn patients often do not exhibit the so called cherry-red cyanosis of carbon monoxide poisoning. Asphyxia may present as an agitative combative or somnulent patient. Treatment of both disorders should be empiric when suspected and should not await blood gas results. High flow oxygen alleviates asphyxia and speeds the clearance of carbon monoxide to the blood stream. Carboxy-hemoglobin levels should be determined as soon as possible and followed subsequently until normal. Long term, permanent neurological sequelae are common following asphyxia or carbon monoxide exposure. Upper Airway Obstruction--Upper airway obstruction may be due to oral pharyngeal burns, laryngeal spasm, or obstruction from massive upper airway edema. Upper airway obstruction may occur in the absence of airway injury, perse. Burn patients are at risk from upper airway obstruction from the time of burn injury until the point of maximum edema formation which occurs at 18 to 24 hours post-injury. Elective nasal-gastric intubation can be performed if the obstruction appears progressive or imminent. Tracheobronchial Injury--Damage to the upper respiratory tract resulting in a tracheobronchitis occurs from products of incomplete combustion including aldehydes, acids, cyanide and carbonacious particles. In addition, super heated steam may also cause direct damage to the trachea. These products may damage any part of the tracheobronchial tree or the pulmonary parenchyma itself. Injury to the upper respiratory tract and large airways is manifested by hoarseness, a dry brassy cough, and a production of copious bronchial secretions. During the first 48 hours following injury, tracheobronchial injury develops progressive edema and sloughing of the bronchial mucosa. Such patients are also at risk from obstruction due to edema and inability to clear secretions. Treatment may necessitate intubation and aggressive pulmonary toilet. Such patients are also at risk from infection and should be followed with chest PT until completely healed. Pulmonary Inhalation Injury--The true inhalation injury involves the pulmonary parenchyma itself, and is generally thought to involve the bronchiolar size passages. In addition, there is generally a component of large airway injury. The pathophysiology is a direct toxic injury to the small bronchiolar passages and alveoli from combustion products and soot. Thus, inhalation injury can best be categorized as a chemical injury to the pulmonary parenchyma. This injury is often delayed in onset presenting 12 to 96 hours post-burn with interstitial infiltrates, hypoxemia, decreased pulmonary compliance and elevated shunt fractions--the typical picture of ARDS. Diagnosis is made by maintaining a high index of suspicion and by serial evaluation of blood gases and chest x-rays. The Xenon ventilation-perfusion scan is invaluable in detecting pulmonary injury and is positive prior to the onset of clinical symptoms. Bronchoscopy confirms the diagnosis of associated tracheobron chial injury. Treatment includes intubation and mechanical ventilatory support with PEEP. True inhalation injury strongly predisposes patients with major thermal injuries to pulmonary infection which frequently lead to the patients demise. Accordingly, vigorous chest physical therapy and meticulous pulmonary toilet are recommended. There is no evidence to support the use of steroids or antibiotics on such patients. f-ObA?7 ETC 00364 CASE REPORT -- AIRWAY A nineteen year old girl is admitted to the hospital following a laboratory explosion and fire. Alcohol was ignited by a Bunsen burner resulting in burns of the face, neck, chest and both arms. Physical examination revealed a restless patient complaining of pain in the throat and hands. There are burns of the face with singeing of the eyebrows and nares. Her laboratory garment is attached to the underlying burn skin. Burns of both hands and arms are full thickness. Her body weight is 60 kg. Initial stabilization is carried out with the insertion of two longdwell catheters and infusion of lactated ringers solution. The patient is recieving oxygen by mask at 6 L./min. Medical history obtained from the family indicates no allergies, sensitivities or significant medical illnesses. The patient is engaged and a wedding date had been set for three months from now. QUESTIONS TO THE PANEL 1. Is the airway threatened? What are the signs of airway injury? 2. What is the time interval between exposure to super heated air and obstruction? 3. What is the role of steroids? 4. What are the early laboratory manifestations of airway inhalation injury? 5. When to intubate? 6. If I intubate, do I need to ventilate? 7. Are upper airway injury and smoke injury the same clincial entity? E-0642S ETC 00365 FLUID RESUSCITATION 1. Physiologic Impact of Major Bums A. Cardiac Output B. Vascular Permeability C. Extracellular Fluid Loss Total Fluid Loss D. Crystalloid Fluid Loss E. Colloid 2. Resuscitation Guidelines A. Isotonic Resuscitation B. Hypertonic Resuscitation C. Colloid-hypertonic Resuscitation 0. Guidelines Utilizing the Baxter Formula 1. Day One 2. Day Two 3. Days Three - Ten 3. Electrical Injuries A. Voltage Effect B. Tissue Destruction -- "Tip of the Iceberg" C. Myoglobinuria Production of lactic acid and myoglobin precipation in the renal tubuls F-06429 ETC 00366 FLUID RESUSCITATION Charles R. Baxter, M.D., F.A.C.S. The guidelines for resuscitation of major burns have changed in the United States during the past decade. The changes have resulted from both research and the establishment of many new burn treatment facilities which have intensified the experience with thermal injuries. It is generally agreed that the principles governing optimal resuscitation are: 1) that in the initial 24-hour burn period an isotonic balanced salt solution (lactated Ringer's) replaces the immense losses of body fluids as effectively as colloid-containing solution and that no other solutions (neither colloid nor 5% D/W) are given in this time interval, 2) plasma expansion can be accomplished with colloid-containing solutions at approximately 24 hours post-burn and 3) that the total time required for resuscitation can be shortened by the rapid reconstitution of plasma volume as soon as leaky capillaries are sealed, i.e. between 24 and 32 hours post-burn. It is emphasized that lactated Ringer's or balanced salt solution is the sole fluid utilized in the first 24 hours, i.e., no 5% dextrose/water as well as no colloid-containing solutions, and that the calculated amount of plasma is given in the fourth eight-hour period, not spread over a period of 24 hours during the second day. Isotonic salt is not needed after 24 hours. The quantity of lactated Ringer's needed in the first 24 hours, may range between 2 and 5 cc/kg/% body burned in individual burn patients. An appropriate approach, in our opinion, is to first start fluid therapy on the basis of 4cc/kg/% burn and to adjust the rate by reduction or addition according to the patient's response. This latter method insures a more rapid alleviation of shock and does not result in administration of excessive fluids. This range of fluid requirements emphasizes that formula* for calculating burn resuscitation fluids are but guidelines and that clinical signs determine the quantity ' actually given to individual patients. The clinical parameter of urine volume, clear mental status, and an elimination of all signs of shock are used as the end points of resuscitation, altering the total quantity on the basis of the patients' response. More refined indices of optimal resuscitation are the return of the cardiac output to normal within eight to ten hours post-burn, and correction of the metabolic acidosis as determined by pH restoration to normal. The return of oxygen consumption to normal and normal core (rectal temperatures) are also good indices (if the ambient temperature was kept at 92 degrees F). After 24 hours, serial hematocrits are indicative of the plasma volume re expansion. The increased fluid requirements of the larger burns have been shown to result from the movement of Na# and HaO into cells in unburned tissue, most notably skeletal muscle cells. Transmembrane potentials (Tm) were measured using the Ling-Gerard electrode and serial muscle biopsies used to calculate the intra- to extracellular distribution of electrolytes and water. Burns less than 40% of the body surface (Group 1) had an initial depression of Tm which was transient and rapidly approached normal by 48 hours post-burn. The internal distribution of sodium is significantly different in the larger burns (Group 2). They had a depressed Tm and remained at a slightly sub-normal level forthe sevenday period of the study. The persistence of the high-intracellular Na+ and low-intracellular K+ is not totally explicable on the basis of the Nernst equation. The measured Tm's in the Group 2 burns were much lower than theTm predicted by the Nernst equation. Tm responses indicated an increase in the cell permeability to sodium which persists throughout the length of the study. Most major burns exhibited an increase in sodium permeability from a normal 0.01 to between 0.02-0.04. These studies suggest that initial defect in ATPase function rapidly returns to normal in the burns below 40% TBSA, but in larger burns the major difficulty lies in the slow channels of sodium transport. The clinical implications are that body weight does not reflect mobilized extracellular fluid which can readily be returned to normal by excessive excretion thereby negating measurements of body weight as indices of fluid mobilization while at the same time explaining why additional sodium and water may be needed for these patients after the initial resuscitation. F-Oft430 ETC 00367 CASE REPORT -- FLUID RESUSCITATION A nineteen year old girl is admitted to the hospital following a laboratory explosion and fire. Alcohol was ignited by a Bunsen burner resulting in burns of the face, neck, chest and both arms. Physical examination revealed a restless patient complaining of pain in the throat and hands. There are burns of the face with singeing of the eyebrows and nares. Her laboratory garment is attached to the underlying burn skin. Burns of both hands and arms are full thickness. Her body weight is 60 kg. Initial stabilization is carried out with the insertion of two longdwell catheters and infusion of lactated ringers solution. The patient is receiving oxygen by mask at 6 L./min. Medical history obtained from the family indicates no allergies, sensitivities or significant medical illnesses. The patient is engaged and a wedding date had been set for three months from now. QUESTIONS TO THE PANEL 1. Assuming this patient is 60 kg. and has a 40% body surface burn, outline your resuscitation guidelines. 2. Is hypertonic resuscitation indicated in this patient? 3. What about the new recommendations of albumin and hypertonic solutions? 4. This patient will receive 9,600 cc. of fluid in the first 24 hours. Isn't fluid overload a real possibility? 5. Do the fluid requirements including both fluid load and composition remain the same on post burn day two? 6. What about colloids and blood? 7. How do I calculate fluid requirement in electrical injuries? F:-0643 1 ETC 00368 BURN WOUND CARE 1. Debridement A. Tangential Excision B. Total Excision C. Enzymatic Debridement 2. Biologic Dressings 3. Homograft 4. Skin Substitutes 5. Skin Grafting 6. Criteria for Grafting A. Mesh vs Sheet Graft B. Grafting the Face C. Grafting the Hand D. Caring for the Graft F-0643? ETC 00369 BURN WOUND CARE WiHiam P. Curreri, M.D., F.A.C.S. Early debridement of the burn wound and timely closure of the wound with skin graft is highly desirable. Early closure of the wound not only prevents subsequent Infection, but decreases the hypermetabolic response to burn injury thus minimizing the nutritional requirements. In general the wound may be most rapidly readied for definitive grafting by employing either tangential excision, total excision of the bum tissue down to the level of investing fascia, or with the use of chemical or enzymes. The advantages and disadvantages of each will be discussed and the methods utilized described. In addition, it must be emphasized however, that with rapid debridement of the burn wound, there is a mandatory requirement for immediate closure. Several materials have been utilized to obtain closure of the burn wound including the use of bio logic dressings, synthetic skin substitutes, and definitive autograft. If possible the patient should be grafted with his own skin immediately, providing sufficient donor sites exist. In the case of tangential excision or enzymatic debridement, frequently the wounds can be temporarily closed with homograft or procine heterograft. The current state with regard to preparation of such skin substitutes as well as storage will be reviewed. In general, definitive autograft may be either applied as sheets, in which the best cosmetic appearance may be obtained, or the autograft may be meshed. The latter process allows for the expansion of the skin to cover large areas when there are limited donor sites and provides for drainage of fluid from under the graft which may, if excessive, prevent autograft adherence. In general, sheet graft is preferred over areas exposed to recurrent trauma such as the foot, the popliteal space, the anticubital space, and the neck. In addition, sheet graft is usually preferable on the face since it is associated with less scarring and a smoother appearance. The techniques for harvesting skin and caring for the graft will be reviewed. -06433 ETC 00370 AMBULATORY BURN CARE I, PRINCIPLES A, APPLICATION: MINOR AND MAJOR BURNS B, IMMEDIATE RESUSCITATION C, WOUND CARE DAILY CARE PERIODIC PHYSICIAN MONITORING II, IMMEDIATE RESUSCITATION A, REMOVE CLOTHING B. STOP BURNING PROCESS III, WOUND CARE A, DEBRIDEMENT SOAP, WATER AND SCRUB B. ANTIBIOTIC AND DRESSING SILVADENE IMPREGNATION ON GAUZE FLEXI NET DRESSING C. BIOLOGIC DRESSINGS PORCINE HOMOGRAFT SYNTHETICS HYDRON BIOBRANE D, DAILY CARE DAILY WOUND DRESSING PERIODIC PHYSICIAN EVALUATION E-06434 ETC 00371 AMBULATORY BURN CARE Robert W. Gillespie, M.D., F.A.C.S. Ambulatory burn care can be accomplished in the physician's office or in the hospital emergency department in an expeditious manner for the patient with minor burns and selectively for major burn patients. The goals of ambulatory burn care are to minimize infection, reduce complications and expedite healing. Ambulatory burn care can be accomplished by a team approach utilizing a member of the physician's office staff or the nursing staff in the emergency department to provide the daily burn care supplemented by periodic evaluation by the physician. The principles of ambulatory care are similar to those utilized in major burn management, namely, immediate treatment and definitive burn wound management. The principles of immediate treatment in the minor burn patient are to stop the burning process, eliminate contamination and control pain. The burning process may be arrested by removal of the clothing in the area of burn, immersion of the burn area in cool water and physical separation of the burn from the burning process. Contamination can be minimized be deferring the application of any topical dressing until the burn has been assessed and debridement has been initiated. Pain is readily controlled by isolating the burn from the injurious effects of the environment. Fluctuations in ari temperature and air currents are painful to the patient. Isolation of the burn by covering with a clean moistened cloth will effectively control pai.i. Thp . application of ice to the burn surface is contraindicated. Ice is vasoconstrictive and may result in the * transition of a partial thickness burn to a full thickness burn. Definitive burn wound care is based upon elimination of the eschar and promotion of epithelialization. Debridement can be easily accomplished daily by the gentle brushing of the burn wound or washing with a soap water and cloth application. Others have utilized enzymatic debridement with variable success. Following the daily process of debridement, antibiotic dressings are applied. Anti biotic dressings serve to reduce the bacterial flora. Our procedure is to impregnate fine mesh gauze with Silvadene and secure it with a flexinet dressing. The role of biological dressings and skin substitutes in the minor burn wound depends upon their availability and cost effectiveness. The utilization of these dressings in ambulatory care of the major burn has rather broad application particularly in the partial thickness burn. In these situations epithelialization appears to be accelerated and wound sepsis appears to be reduced. ETC 00372 m oci'i r vrioNAi. ni>h.\si:s 1UBI UXIKAI'HY Barber. H. 1934. H;ien)6nb;)yic nephritis and necrosis of ihc !nci fiom dioxane poisoning. Guy's Hosp. Rep. S4:267. Woeh-l.iueti. C., M. F. Argus, and J. C. Arcos. 1970. Induction oi e.ucinomas in the nasal cavity of rats by dioxnne. Br. J. Cancer 24-I M. Johnstone. R. T. 195V. Death due to dioxane0 Arch Ind. Health 2u*-i-Jr F.PICH l.OROHY DRI.\ DENOR1P I ION' CFLOCHCFLCI. cpichlorohydrin. is a colorless liquid with a chloro form-like odor. SYNONYMS 1 p i, chloropropylene oxide, l-chloro-2,3-epoxy propane. chloromeiiiyloxidrane. 2-epiehlorohydrin. potential occfpationm exp ISC RES Eptchlorohydrin is used in tl ; manufacuire of many elvceiol and giycidol derivatives am) epoxv rcsi is. as a stabilizer in chloiine-eu.niainin:: materials, as an inteimediate n the preparation o! eellulose c and ethers, paints, varnishes, nail entimels, and lacquers. and a, a cc- ment lor celluloid. A partial list of occupations in vvhicli exposure may oceir includes: Cellulose ether workers Lacquer makers Fpoxy re-in makers Nail enamel makers Glycerol derivative makers Organic chemical synthesizers GIveerophosphorie acid makers Paint makers Glyeidol derivative makeis Resin makers (.nun processors Solvent workers 1 aetpierers Varnish makers PERMISSIBLE L.XPOSLRE I INI ITS The Federal stamlaid is 5 pptn (id mg nr). NtOSH has recom mended ;i time-weighted average limit of 2 mg nr with a veiling con centration ot !0 mg nr based on a ! 5-minute sampling period RiU' it rii hn I KY Inhalation of v.gvii. percutaneous absorption of liquid It VK'-n t | j ;-/ R |.s . L:>. I.pichloiohvdrm is highly irritating to eyes. skin, and icspiratnrv Iract Skin contact may result in delayed blistering and deep sc.Ted pain. Allergic ee/eniatoti' contact dermatitis occurs oceasioituih. X v.v.i;:, - The e.Hiest >v mpumi-- of intoxication may be uivrahle lo tl;.- g;,-. tromteslm.il tract I nausea, vomiting, abdominal discomlor! ) or pain ir, ::'.e reeiiin of the liver, i a Pored breathing, cough, and evanoses niav f... w evident and die onset of client after exposure. Animals expo veloped lung, kidney, and !i\\ MEDICAL SURVEILLANCE Consider possible effects in preplacement or periodic e SPECIAL I I S I S None currently used. PERSONAL PROTECTIVE MET Goggles and rubber, pr chiorohydrin slowly penetrate should be thoroughly washed, concentrations. bibliography Hahn. J. D I97n. BoM-fust-cnia; epoxyprop;t.'i<4 \'.i tt/re 226 > ; .iwrencc, W ! I . M. Mahk. I. ! lile of cpichlorohydrin. J. Phi 9'ricU Chsnucal f nmpnny. !h72. Shell Chcni.c.iJ Company. K>;: ethylene oxide description H,COCTL, ethylene oxidt synonyms I,2-Fpoxycthane. oxirane POTENTIAL OCCUPATIONAL : Ethylene oxide is used to ethviene glycol, polyglycols, gl nitrile, plastics, and surface-act for foodstuffs and textiles, an especially for surgical instnime A partial list of occupatioAcrylonitrile makers Butyl cellosolve makers Detergent makers Disinfectant makers Ethanolamine makers Ethylene glycoj makers Exterminators Foodstuff fumigaU.rs Fumigant makers . 1- RNl INSlBf-i I.M'O-.LKE UM The Federal -landard i- CHKM1CAI. IIA/.\KI)S !Ti exidem and the onset of chemical pneumonitis may necur several hums alter exposiuc Animals exposed repeatedly to this chemical have de xeloped luim. kidney. anJ liver injury. Ml dh \t st xv; it I \NCT t .'tiMiicr " ilsle ellccD on the skin, eyes, limits. Iivci. and '-nine, in pi ej'laeenieni or periodic examinations. sl'l *, I \! I <L S ] S None currently vised. I'l-KswVAi l-ROtt-c I IVE ME"! Ill IDS ('entitles and rubber, protective clothing should be worn. I'.pi- eitlorohydrin slowly penetrates rubber, so all contaminated clothing should oe thoroughly washed. Respirators are required in areas of sapor concentrations. H11U I' .X MMI'i Halm. I '> ! -,?l I'osi-iO'llcul.u -in!ifertility clTeels of cpiehloinhv-a ui an.I .' : cT'\ k p-op.tiuil Ntiuit c '2t>: I awrtfi'.cc. W. \\ . M. Malik. .1. E. Turner, and J. AuMsn. !'*T2 l o\iJ<-N piv'* uW -M cj'uhiorohydritt. J. Pharm. Sci. 61:1712. Sh.Ti k nctrk.:! t ornpimy. W'2. I ptchlorohjdrin -- Industrial IKviicik- H- llcim shpli lu'iniv.il C ompany. N'cu York. FI fl) !.F\F ox IDF. m s; K1 i> I i< >N II OX'ii . ethylene oxide. is a colorless gas with a sweetish .*loi. 'A '.i 'X .MS : ' 1 povActhaae. oxn.uu. dimelhvlcnc oxide, anprnlenc , | S i I \i . li (, t !".\ I li \! I XI'ONDKES I-;i'.\tene oxide is med a- an intermediate in oru.mic s\iuIic- edtylene glycol. polyglvcoi-.. giveol ethers esters, ethanol,unines. a nitrile, piasi.es. and surface-active agents. It is also used a- a tun for foodstutls and textiles, an agricultural fungicide, and for xterih/ espccialh lor stiigical instruments. -\ partial list of occupations in which exposure may occur uv rules \er\ ionit: lie makers Fungicide workers l'.uh I c.Tosolvo makeis Gasoline sweeteners Itc.crgcm makers Oomicci.in! makers Grain elevator winkers Organic chemical syiuhc'-i/c I ! h.mo!.mime makers Polyglvcol makers l ii'Aiciie gixcoi makers I'olyoxirane makers : ` slei minators Rocket fuel handlers 1 oodstuti luimgrar- Surfactant makers i uuue.in! makers Textile fornicators i t NMt'sXiU! ! i \IMSI Kl. 1 1MI ! S Use 1 ederai si.ukl.tid o 5t) ppm (90 mg in ). E-06437 ETC 00374