Author: miguel

A component of the Cancer Awareness & Prevention Program (CAPP) involves marketing material, including both posters and stickers. The posters are intended to create an emotional connection with Firefighters, while the stickers will act as prompts to encourage safe workplace behaviors. We request that posters and stickers be installed/mounted in stations and apparatus as noted.

Cancer Prevention Action Plan

Frequently, firefighters, the public and policy makers perceive the most dangerous aspects of firefighting as those functions associated with actions taken on the fireground, such as search and rescue, advancing hoselines, or vertical ventilation. While these functions are admittedly dangerous, a far less glamorous and insidious foe, occupational cancer, is responsible for greater morbidity and mortality in the fire service than adverse fire events, structural collapse, and fireground disorientation combined. This document serves to briefly review the magnitude and implications of occupational cancer in the fire service and provide a plan for the San Diego Fire & Rescue Department to address this pressing issue.

In recent years, a correlation has been established between the staggering numbers of active and retired firefighters diagnosed with various types of cancer and the exposure to the toxic substances contained within smoke and soot. The International Agency for Research on Cancer (IARC) has categorized “soot” as a Group 1 carcinogen, meaning that it is recognized as one of the worst carcinogens. According to the Firefighter Cancer Support Network, “Cancer has become the most dangerous threat to the health and safety of America’s firefighters.”

Absorption of toxins through the skin is a primary concern, as the skin’s ability to act as a barrier is compromised when body temperature increases. Published research reveals that for every 5 degree increase in skin temperature, permeability of skin is compromised and absorption increases 400%. While exposure to toxins is inevitable in firefighting, we should strive to reduce or eliminate exposure when possible.

To that end, effective July 1, 2016, San Diego Fire-Rescue will implement a system of gross field decontamination of PPE and personnel to remove soot and particulates. Best practice will be for firefighters while still on scene, to wash down with a hose line, their turn-out coat, pants and boots, decontaminate areas of exposed skin with the use of skin wipes and replace contaminated hoods.

The Occupational Safety & Health Committee (OSHC) has undertaken a comprehensive test of available wipes on the market and have selected “Action Wipes” for use by our personnel. Action Wipes were selected because they are made from all organic ingredients and their superior performance for durability, moisture content and cleaning potential.

After a fire incident, personnel should decontaminate by briskly scrubbing their skin with Action Wipes in the most vulnerable exposure routes: the face, jawline, throat, underarms, forearms and hands as a temporary measure until they can shower and lather off remaining contaminants.

Personnel will then replace their Nomex hood with a clean hood and soiled hoods will not be worn until properly laundered. To facilitate this, all personnel are directed to carry both their hoods with them as part of their usual PPE complement.

San Diego Fire-Rescue recognizes that firefighters may experience periods of high activity where both hoods may become soiled prior to laundering. To ensure that clean hoods are available, each front line apparatus will be issued a green zippered bag with four additional hoods and 25 individually packaged Action Wipes. The green hood bag is to be kept inside the cab of the apparatus and the hood side will be sealed with a break-away zip-tie. If hoods from the green bag are used, personnel will launder their two personally issued hoods and the hoods from the green bag will be returned to their respective battalion chief, who will deliver to the Logistics Division for professional cleaning and restocking. 

All personally issued hoods will be laundered at fire stations. Each fire station will be issued a laminated sheet with instructions and a green 3-gallon plastic bucket for the sole purpose of laundering hoods. A mix of 3 ounces of CitroSqueez cleaner in 2.5 gallons of cold water will be used to soak soiled hoods for at least one hour. After soaking, the bucket will be emptied into a deep sink and the bucket and hoods will be rinsed with fresh cold water. The hood(s) will then be placed into the station washing machine with an additional 3 ounces of CitroSqueez in normal-cold cycle. Once washed, the hoods will be air-dried and placed back into service.

Action Wipes can be resupplied from Store 42 or any SDFD Battalion Chief apparatus. Questions related to the use of Action Wipes or the Nomex hood replacement can be directed to Battalion Chief Alfredo Duron at aduron@sandiego.gov.

This direction will be incorporated into the Operations Manual with a future update.

Discussion:
In 2000, the Phoenix Fire Department (PFD) studied airborne toxic/carcinogenic chemicals during the overhaul phase at 25 structure fires (Bolstad-Johnson, et. al., 2000). Chemicals measured included: aldehydes, benzene, toluene, xylene, hydrochloric acid, poly-nuclear nuclear hydrocarbons, respirable dust and hydrogen cyanide (Bolstad-Johnson, et. al., 2000). The results showed that there is no correlation between CO levels and other toxic/carcinogenic airborne chemicals (Bolstad-Johnson, et. al., 2000). Based on this finding, it was recommended that Firefighters wear SCBA’s throughout overhaul (Bolstad-Jonson, et. al., 2000). PFD Standard Operating Procedure (SOP) for SCBA use states, SCBA’s shall be worn “…where invisible contaminants are suspected to be present” (Phoenix Fire Department [PFD], 1997). According to PFD Deputy Fire Chief Brian Tobin, PFD Firefighters wear SCBA’s “on-air” throughout overhaul, no exceptions. PFD does not routinely monitor air quality at structure fires because the environment is assumed to be contaminated.

Chief Tobin also addressed the issue of decreased work capacity and increased fatigue as a result of 100% SCBA use. This concern is remedied by frequently rotating crews throughout various functions to distribute the workload and by providing frequent breaks for hydration and “cooling off”. During the hottest part of the year, PFD assigns an additional company to each alarm. 

In 2011, the Tualatin Valley Fire & Rescue Department, a 22 station department located south of Portland conducted a similar study. Dual function Firefighter/Hazmat Technicians responded to 38 structure fires over the course of 8 months (Tualatin Valley Fire & Rescue Department [TVFRD], 2011). Results were similar to that of the PFD research, no correlation between CO and other toxic/carcinogenic airborne chemicals existed (TVFRD, 2011).

Additionally, neither cartridge respirators (APR) nor N-95 masks provide meaningful respiratory protection during overhaul. In 2000, 26 Phoenix Firefighters wearing APR’s during overhaul were compared to 25 Tucson Firefighters not wearing respiratory protection during overhaul (Burgess, et. al., 2001). The results showed decreased pulmonary function and increased lung permeability in both groups, meaning APR’s did not provide adequate protection (Burgess, et. al., 2001). A primary limiting factor of APR’s is the fact that the contaminants must be known in order to ensure the right filter is used, a near impossibility at structure fires.

N-95’s provides almost no protection during overhaul. N-95 masks are designed to filter 95% of particles 0.3 microns and larger (US Food & Drug Administration [FDA], 2015). The dilemma is that many of the toxins encountered during overhaul are far smaller, ex: tobacco smoke which contains numerous known carcinogens can be as small as .01 microns and gas molecules can be as small as .0001 microns (National Institute of Environmental Health Sciences [NIEHS], 2006).

Lastly, when considering 100% SCBA use during overhaul the Assigned Protection Factor (APF) should be considered. APF is a term used to rate the degree of respiratory protection provided by a particular device (Occupational Safety and Health Administration [OSHA], 2009). Essentially, the APF reflects how much safer the air you are breathing inside your respiratory protection is compared to the air outside, a safety factor of sorts.

Discussion:
In 2013, researchers utilizing functional brain imaging (fMRI) confirmed what we have intuitively known for years, emotions drive our decision making to a far greater degree than do rational facts and figures (Murray, 2013). Therefore, to effectively market the CAPP brand and sell the benefits of behavioral change, we need to emotionally connect with Firefighters.

Crafting a program targeting emotional connection with Firefighters represents a significant departure from historical cultural norms. Traditional Fire Department training speaks to the rational mind, ex: tie this knot, soften the structure like this, etc. However, when it comes to long-term sustained behavioral change, the notion that people will choose the right brand/product based simply on an abundance of facts and figures is flawed. This “fallacy of rationality” (McKee, 2007) is evident in the 30-year smoker that knows smoking is killing them, yet cannot quit, despite repeated attempts. However, when their coworker suffers and dies of lung cancer an emotional connection is forged, resulting in newfound willpower that drives the smoker to quit overnight, cold turkey. Creating a powerful emotional connection with Firefighters will ideally provide them with the willpower required to quit unsafe workplace behaviors (cold turkey), even when surrounded by “salty” smoke-eater peers.

The value of creating an emotional connection powerful enough to drive behavioral change can be explained by the Health Belief Model (HBM), the most widely used theory in health education and promotion (Hayden, 2014). The underlying concept of the HBM is that health behavior is determined by personal beliefs or perceptions, or more succinctly, cost vs. benefit as it relates to engaging in safer workplace and/or health behaviors. The chief constructs of the HBM include: perceived susceptibility, perceived benefits, perceived barriers, perceived seriousness, cues to action, and self-efficacy (Hayden, 2014).

Discussion:
NFPA 1851 covers the Standard Care and Maintenance of Protective Ensembles for Structural Firefighting and Proximity Firefighting. There are three types of turnout cleaning as defined by NFPA 1851, basic, advanced, and specialized (National Fire Protection Association [NFPA], 2014). Basic cleaning is employed for simple spot cleaning and is done in a utility sink with a soft brush and soap (NFPA, 2014). For PPE contaminated beyond a simple spot, the process of advanced cleaning is required (NFPA, 2014). Advanced cleaning is done in a washing machine, with liners and shells separated and washed separately (NFPA, 2014). Specialized cleaning is done by a professional contractor when PPE is exposed to unusual contaminants and is beyond the scope of this discussion.

In regards to cleaning PPE, NFPA 1851 directs organizations to “…examine the manufacturer’s label and user information for instructions on cleaning and drying that the manufacturer provided with the element. In the absence of manufacturer’s instructions or manufacturer’s approval of alternative procedures for the ensemble or ensemble element, the advanced cleaning and drying procedures provided in [NFPA 1851] shall be used” (NFPA, 2014). Lion Manufacturing provides extensive care and maintenance instructions with their PPE. When washing PPE, Lion recommends using a “…front-loading extractor or front-loading washing machine with a tumbling action for washing” (LM, 2011).

Historically, many Firefighters, thought (incorrectly) that extractors provided the best cleaning, because they “extracted” contaminants. However, the term extractor is misleading. Therefore, a brief overview of washing machine history and technology is warranted.

Spinning wet laundry to remove water using centrifugal force became possible with the advent of high speed electric motors (Ndola, n.d.). This process was originally done in a machine called an extractor, as the water was “extracted” while spinning (Ndola, n.d.). As technology evolved, the processes were combined and the modern washing machine as we know it today came to be (Ndola, n.d.). Because modern washing machines accomplish both washing and extraction (spinning) they were once referred to as washer/extractors (Ndola, n.d.). However, over time the term extractor was dropped and now washer/extractors are simply referred to as “washers” (Ndola, n.d.).

In the lodging, prison and hospital industries the term washer/extractor has remained, largely for marketing purposes. By extracting water at very high speeds nearly all the moisture is removed, greatly reducing drying times resulting in lower utility costs and faster turnaround times (Wash, 2011). The irony is that high-speed extraction (spinning) of PPE is prohibited by both NFPA 1851 and Lion Manufacturing (NFPA, 2014) (LM,2011). NFPA 1851 and Lion Manufacturing explicitly state that PPE should not be subjected to high extraction (spin) speeds due to the potential for damage to garments (max. allowable is 100G’s) (NFPA, 2014) (LM, 2011). It is the washing and rinsing with an appropriate cleaning solution that cleans PPE, not “extraction”.

In addition to extract/spin speed guidelines, Lion Manufacturing and NFPA 1851 recommend that washer water temperatures not exceed 105 degrees (NFPA, 2014)(LM, 2011) and Lion Manufacturing and Citrosqueeze PPE cleaning solution recommend that PPE be run through multiple rinse cycles during the washing process. Therefore, what is required is a front-loading washing machine that can be programmed for multiple rinse cycles, a spin speed of less than 100G’s, and a water temp less than 105 degrees in order to adequately clean turnout gear in accordance with Lion Manufacturing, NFPA 1851 and Citrosqueeze PPE cleaning solution.

It is important to note that currently there is no published literature that quantifies the degree to which front-load washers vs front-load washer/extractors vs top-loaders clean PPE. However, front-load washers and/or front-load washer/extractors are considered by industry to be the standard in PPE care, as evidenced by manufacturer recommendations.

Lastly, many Firefighters have expressed concern over the potential for cross contamination as a result of washing Class B uniforms, linens etc. in the same machine that PPE is washed in. There is currently no evidence to support this concern and NFPA 1851 allows for this practice, so long as an empty load with detergent is run after cleaning PPE (NFPA, 2014). However, industry and others including the Interagency Board, a voluntary working group of more than 150 emergency preparedness and response professionals recommend that “Protective clothing should be washed in machines specifically designated for this type of use in accordance with procedures meeting the manufacturer’s specifications” (Interagency Board [IAB], 2016).