Ch18_pg593-612.pdf

Occupational Health and the Chemical Surety Mission

Chapter 18

OCCUPATIONAL HEALTH AND THE

CHEMICAL SURETY MISSION

CLAUDIA L. HENEMYRE-HARRIS, P h D * ; MELANIE L. MURROW † ; THOMAS P. LOGAN, P h D ‡ ; BRENT R. GIBSON,

MD, MPH § ; a n d ROBERT GUM, DO, MPH ¥

INTRODUCTION

THE CHEMICAL AGENT WORKPLACE

MEDICAL SURVEILLANCE FOR CHEMICAL AGENT WORKERS

Preplacement Examination

Periodic Medical Examinations

Termination Examinations

Potential Exposure Evaluations

Respirator Clearances

Screening for Substance Abuse and Dependency

Heat Stress Physiologic Monitoring

TRAINING AND EDUCATION FOR CHEMICAL AGENT WORKERS

MEDICAL SUPPORT OF THE CHEMICAL PERSONNEL RELIABILITY PROGRAM

MEDICAL ASPECTS OF A CHEMICAL ACCIDENT OR INCIDENT RESPONSE

AND ASSISTANCE

DEMILITARIZATION OF CHEMICAL WARFARE AGENTS

SUMMARY

* Major, Medical Service Corps, US Army; US Army Medical Research Institute of Chemical Defense, Physiology and Immunology Branch, 3100 Ricketts

Point Road, Aberdeen Proving Ground, Maryland 21010-5400

† Safety and Occupational Specialist, Safety, Surety, and Security Office, Office of the Commander, US Army Medical Research Institute of Chemical

Defense, 3100 Ricketts Point Road, Building E3101, Room 104, Aberdeen Proving Ground, Maryland 21010-5400

‡ Chemist, Medical Diagnostics Branch, Analytical Toxicology Division, US Army Medical Research Institute of Chemical Defense, 3100 Ricketts Point

Road, Building E3081, Room 293, Aberdeen Proving Ground, Maryland 21010-5400

§ Captain, Medical Corps, US Army; Army Medical Department Center and School, 3151 Scott Road, Suite 3507, Fort Sam Houston, Texas 78234

¥ Chief of Bio Surety, Barquist Army Health Clinic, 1434 Porter Street, Fort Detrick, Maryland 21702

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Medical Aspects of Chemical Warfare

INTRODUCTION

Medical officers assigned to US Army arsenals, de-

pots, or other installations that store chemical warfare

agents face a number of unique challenges concerning

chemical surety. The clinics supporting these instal-

lations, although frequently staffed by occupational

medicine specialists, may still be managed by primary

care physicians or even general medical officers with

no specialty training. These providers must care for

both military and civilian workers as well as master

myriad additional duties unique to chemical weapons

storage sites, including managing complex medical

programs that support chemical surety and accident

or incident response. In addition, many installations

are actively demilitarizing chemical munitions. These

operations run parallel with, but independent of,

chemical surety operations. Chemical surety systems

manage chemical agents throughout their life cycles

while maintaining operational performance, which

adds other challenges to chemical surety medical sup-

port program directors (CSMSPDs)—one of many titles

physicians may earn as they provide medical support

to employees working on tasks from storage to the

final disposal of chemical agents. Providers must be

on orders from their medical commanders to perform

CSMSPD duties, as well as those duties outlined below,

in ways that ensure accountability and responsibility

for operations.

In this chapter, a chemical agent is defined as a

chemical substance intended for use in military opera-

tions to kill, seriously injure, or incapacitate a person

through its physiological effects. Riot control agents,

chemical herbicides, smoke, and flames are not offi-

cially defined as chemical agents, but installations with

chemical agents may contain varying amounts of these

substances. Chemical surety (a term that encompasses

both safety and security) operations employ a system

of controls, procedures, and actions that contribute to

the safe and secure storage, transportation, and de-

militarization of chemical agents and their associated

weapon systems. Chemical surety material is defined

in Army Regulation (AR) 50-6, Chemical Surety , as

“chemical agents and their associated weapon system,

or storage and shipping containers that are either ad-

opted or being considered for military use.” 1(p43)

Although the chemical agents discussed are unique

to the military, the hazards to employees are common

to many industries. Examples include acetylcholin-

esterase inhibitors (the operative mechanism of nerve

agents) used in pesticides and carbonyl chloride (phos-

gene) used in the production of foams and plastics.

Both are transported daily on the nation’s highways

and railways. In addition to these chemical threats,

chemical storage depots carry out other operations

that pose potential physical hazards similar to those

found in other industries (eg, excessive noise, heat

stress, and lifting). When they were being produced,

military chemical munitions had different intended

uses, packaging, and methods of storage than indus-

trial chemicals (and are typically more hazardous), so

they required different controls.

Military chemical agent workers can find infor-

mation on chemical surety operations in a variety of

resources, including ARs, which implement Army

laws, and Department of the Army pamphlets (DA

PAMs), which provide additional technical guidance.

The most useful documents for the CSMSPD are AR

50-6, Chemical Surety 1 ; DA PAM 50-6, Chemical Accident

or Incident Response and Assistance [ CAIRA ] Operations 2 ;

DA PAM 40-8, Occupational Health Guidelines for the

Evaluation and Control of Occupational Exposure to Nerve

Agents GA, GB, GD, and VX 3 ; and DA PAM 40-173,

Occupational Health Guidelines for the Evaluation and

Control of Occupational Exposure to Mustard Agents H,

HD, and HT . 4 Safety publications AR 385-61 5 and DA

PAM 385-61 6 also contain medical guidance. The instal-

lation medical authority (IMA) must be aware of any

interim or implementation guidance or Department of

Defense directives, instructions, or memoranda that

affect operations. The IMA should maintain a close

relationship with the installation and legal offices of

the supporting medical treatment facility.

Military installations are often physically iso-

lated and are located a considerable distance from

the medical center or medical department activity

responsible for providing support and consultation.

The preventive/occupational medicine physicians

at these hospitals are responsible for providing the

necessary support and are a source of information

and guidance. The level of chemical and occupa-

tional-specific medical expertise at the supporting

treatment facility varies; however, the depot-level

physician should be a subject-matter expert on the

treatment of chemical surety exposures and perhaps

even on occupational medicine. Assets and time are

seldom available to train a general medical officer in

the unique occupational setting of depot operations

(Exhibit 18-1).

According to DA PAM 50-6, 2 medical officers

supporting chemical surety operations are required

to complete the Toxic Chemical Training Course

for Medical Support Personnel (given by the US

Army Chemical Materials Agency) and the Medical

Management of Chemical and Biological Casualties

Course (given by the US Army Medical Research

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Occupational Health and the Chemical Surety Mission

Institute of Chemical Defense [USAMRICD]). Both

courses are offered at Aberdeen Proving Ground,

Maryland, and provide the basic concepts needed to

recognize the clinical signs and symptoms of chemi-

cal agent exposure and the appropriate therapeutic

interventions for treating and managing chemical

agent casualties. The Toxic Chemical Training Course

also presents material on the medical challenges of

supporting demilitarization operations.

Understanding patients’ occupational healthcare

needs is an integral part of a physician’s practice.

This responsibility includes identifying occupational

and environmental health risks, treating disease and

injury, and counseling patients on preventive behav-

ior. Occupational health alone is time consuming; the

occupational health nurse, the industrial hygienist,

and other clinic staff members can help perform

required tasks. Although industrial hygienists are

not often assigned to health clinics, they are an es-

sential part of the healthcare team. The industrial

hygienist maintains a hazard inventory that contains

conventional hazards as well as a list of chemical

agents located at the installation. They routinely

design primary prevention strategies and frequently

oversee hearing conservation, respiratory protection,

and occupational vision programs. The information

provided by the hygienist is necessary to evaluate a

work environment and to determine the appropriate

frequency of periodic medical examinations. Close

and frequent coordination with this individual is

imperative for developing knowledge of the work-

site and the subsequent development of a medical

surveillance program.

In addition to the industrial hygiene and safety

personnel, medical personnel must work in accord

with the command, supervisors, personnel officers,

and employees who handle chemical agents. Maintain-

ing these relationships is frequently difficult, but by

identifying and addressing concerns of both manage-

ment and individual workers, medical personnel can

establish a basis for formulating appropriate preven-

tive medical measures.

ExHIBIT 18-1

ADVISING AGENCIES FOR THE TREATMENT OF CHEMICAL AGENT INJURY

Agency

Contact Information

The preventive or occupational medicine department of

Specific to location

the supporting medical department activity or

medical center

US Army Center for Health Promotion and Preventive

Director, Occupational and Environmental Medicine/

Medicine

MCHB-TS-M

5158 Blackhawk Road

Aberdeen Proving Ground, Maryland 21010-5403

US Army Chemical Materials Agency

Command Surgeon/AMSCM-RD

5183 Blackhawk Road, Bldg E-4585

Aberdeen Proving Ground, Maryland 21010-5424

Proponency Office for Preventive Medicine

Surety Medicine Consultant/DASG-PPM-NC

5111 Leesburg Pike, Suite 538

Falls Church, Virginia 22041-3258

US Army Medical Research Institute of Chemical Defense MCMR-CDM

3100 Ricketts Point Road

Aberdeen Proving Ground, Maryland 21010-5400

US Army Reserve Unit for Chemical/Biological

Detachment Surgeon

Consequence Management

1309 Continental Avenue, Suite K

Abingdon, Maryland 21009-2336

US Army Materiel Command

AMCSG/Deputy Command Surgeon

9301 Chapek Road

Fort Belvoir, Virginia 22060

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Medical Aspects of Chemical Warfare

THE CHEMICAL AGENT WORKPLACE

Chemical agent operations are conducted in a

variety of job settings, including storage depots,

demilitarization facilities, research laboratories, and

transportation units. Before a chemical agent employee

can be placed in a job, a physician must consider the

occupational and environmental health risks associ-

ated with the position. The physician must understand

the various workplaces in which chemical agent

operations are performed to effectively identify the

corresponding risks.

The chemical agent worker uses different kinds of

personal protective equipment (PPE) and engineering

controls based on the work environment. The use of

protective clothing itself can create significant haz-

ards, such as heat stress, physical and psychological

stress, and impaired vision, mobility, and communi-

cation. The physician must understand these PPEs

and engineering controls in order to select the most

appropriate preplacement examination and medical

surveillance for the initial and continued safety of the

worker. DA PAM 385-61 6 defines the protection levels

(A through D) for chemical agent workers and lists the

personal protective clothing and equipment required

for each level. The following text and accompanying

figures describe the various types of chemical agent

workplaces.

The purpose of the US Army Chemical Materials

Agency is to protect and safely store the nation’s aging

chemical weapons. The agency works toward the ef-

fective recovery, treatment, and ultimate elimination of

the nation’s chemical warfare materials, and it manages

a national inventory control point and national mainte-

nance point to ensure that the stockpile is maintained

safely during its remaining storage life. Chemical depot

workers routinely check storage containers for poten-

tial degradation and leaks. During these inspections,

the workers operate in Level A protective clothing, the

demilitarization protective ensemble, which consists

of a totally encapsulated, positive-pressurized suit

(Figure 18-1). A mask (manufactured by Mine Safety

Appliances Company, Pittsburgh, Pa) and backpack,

both certified by the National Institute of Occupational

Safety and Health and the Occupational Safety and

Health Administration, are contained within the suit

to provide a continual air supply via an umbilical cord.

The suit is also equipped with a self-contained emer-

gency breathing system in case the hose air supply is

compromised. The workers wear butyl rubber boots

and gloves over the ensemble as an additional layer

of protection and can communicate with each other

and the control station by way of a radio internal to

the demilitarization protective ensemble.

Another mission of the Chemical Materials Agency

is to manage the safe treatment and disposal of chemi-

cal agents and weapons. To accomplish this mission,

the agency uses various technological tools, many of

Fig. 18-1. A team of chemical workers wears Level A pro-

tective clothing, the demilitarization protective ensemble,

which provides the greatest level of protection against agent

exposure.

Photograph: Courtesy of US Army Chemical Materials Agen-

cy, Aberdeen Proving Ground, Md. Available at http://www.

cma.army.mil/multimediagallery. Accessed December 2005.

Fig. 18-2. Two chemical agent operators wear Level C pro-

tective clothing and use a glovebox as they drain mustard

agent from ton containers in the neutralization process at the

Aberdeen Chemical and Biological Agent Disposal Facility.

Photograph: Courtesy of US Army Chemical Materials

Agency, Aberdeen Proving Ground, Md. Available at http://

www.cma.army.mil/multimediagallery. Accessed December

2005.

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Occupational Health and the Chemical Surety Mission

Fig. 18-3. Chemical agent operators wear Level C protec-

tive clothing in a professional laboratory research setting to

discover and develop medical countermeasures and thera-

peutics to chemical warfare agents.

Photograph: Courtesy of US Army Medical Research Insti-

tute of Chemical Defense, Aberdeen Proving Ground, Md.

Fig. 18-4. Soldiers from the 22nd Chemical Battalion (Techni-

cal Escort) work in Level C protective clothing to conduct a

sampling mission.

Photograph: Courtesy of Major Chadwick T Bauld, 22nd

Chemical Battalion, Technical Escort, US Army 20th Support

Command, CBRNE.

which are at least partially automated. However, the

worker must handle chemical agents during other

phases of the treatment and disposal process. For

example, operators at the Aberdeen Biological Chemi-

cal Agent Disposal Facility drain mustard agent from

ton containers using a glovebox in the neutralization

process (Figure 18-2). During this procedure, workers

don Level C protective clothing consisting of work

coveralls, safety glasses with side shields, and M40A1

protective masks worn in the slung position.

In a research laboratory setting such as USAM-

RICD, chemical agent operators conduct experiments

to discover and develop medical countermeasures

to and therapeutics for chemical warfare agents. The

experimental parameters, and therefore the working

conditions, are tightly regulated to maintain a climate-

controlled environment. Agent operators conduct

studies in a certified chemical fume hood, and prelimi-

nary airflow measurements are taken using a worker’s

velometer. Operators wear several layers of PPE, as

shown in Figure 18-3, and work in Level C protective

clothing. The first layer of PPE is a laboratory coat and

nitrile gloves. The second, outer layer of PPE consists

of a 7-mm–thick butyl rubber apron and butyl rubber

gloves. Many operators wear a second pair of nitrile

gloves over the butyl rubber gloves to improve dex-

terity. Laboratory safety glasses with side shields are

worn at all times and protective masks are kept readily

available or are worn in a slung position.

The mission of the 22nd Chemical Battalion is to

deploy task-organized teams throughout the world

to conduct technical escort and chemical, biological,

radiological, and nuclear hazard characterization,

monitoring, disablement, and elimination support

operations. The 22nd Chemical Battalion provides

emergency response to incidents involving weapons of

mass destruction and chemical, biological, radiological,

and nuclear hazards, homeland defense, contingency

support operations to combatant commanders and

lead federal agencies, and site remediation and restora-

tion support operations for the Department of Defense.

The battalion works at a high operational tempo in a

wide variety of settings, including hostile and austere

environments. In addition to the PPE and engineer-

ing controls described above, battalion members use

specialized protective measures unique to each mis-

sion (Figure 18-4). If the members are faced with an

unknown agent or unsafe oxygen level, they require

a higher respiratory protection level (Level B or Level

A, with self-contained breathing apparatus).

MEDICAL SURVEILLANCE FOR CHEMICAL AGENT WORKERS

Medical surveillance is the systematic collection,

analysis, and dissemination of disease data on groups

of workers. It is designed to detect early signs of work-

related illness. 7 A chemical worksite medical program

should provide the following surveillance: preplace-

ment screening, periodic medical examinations (with

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