Tuesday, October 20, 2020

EFFECTS OF TOXIC EXPOSURES ARE CUMULATIVE - ESPECIALLY WITH FIREFIGHTERS

From an interview with (RET) FDNY Chief Anthony Bruno

Chief Anthony Bruno, decorated career firefighter with the FDNY (1962-1989) achieved top ranks of leadership as Captain of ladder 12 on 17th Street in Manhattan in the late 70's then Chief in Bushwick, several years later.  Celebrating his official retirement from the department in 1989, Chief Bruno found himself suiting up again, this time as a volunteer in the 9/11 WTC disaster of 2001.  He and the thousands of first responders raced to southern Manhattan to help all survivors, only to be exposed to some of the most lethal neurotoxins and carcinogenic compounds expelled by the incinerated building materials where The World Trade Center towers once stood.

Throughout his career, Chief Bruno took the initiative to research and investigate the health effects of carbon monoxide exposures to first responders. Standardized blood samples showed reports of lethal levels of carbon monoxide in the system three or four hours after the event. Because of this, he implemented the use of advanced testing devices (c/o the NY EPA) to check for CO levels in the exhaled breath- with 97% accuracy. Chief Bruno saw the value in this testing protocol as he proposed a department-wide screening program to identify those suffering from too much exposure.

"Doctors (at the time) posed the misconception that carbon monoxide did not have a cumulative effect. The average resident in a house fire may not usually get affected this way, but firefighters on regular duty can often be exposed frequently throughout a single night. This frequency in exposure holds somewhat of a half-life theory, similar to radiation as far as toxins staying in the bloodstream. The build-up from elevated levels continue to rise after further exposures. 

SURVIVING THE FIRE SERVICE & THE "NEW KILLER SMOKE"

During active duty, Chief Bruno claimed to directly know (and work with) firefighters who died from frequent exposures -- having gone to three or four fires each shift while never getting tested for carbon monoxide. "From what we now know, early detection and regular exposure testing could have prevented a lot of occupational injuries. Learning from history is also why the firefighter is much more protected these days. Today's use of masks is much more universal and mandatory, unlike the old days where firefighters hardly used them. Technology evolved and eventually so did we... but sometimes a little bit too late."

Referencing historical fires in NYC with recorded health effects to the responders, Chief Bruno noted landmark disasters including the 1975 NY Tel Fire and the 699 firefighters who were all exposed to the most lethal black smoke from burning PVC's and hazardous plastics. He also shared his own experience as the covering captain in 1979 at the fire in St. Batholomeow's Church (several blocks from St. Patrick's Cathedral) where he recognized great similarities to both incidents - including the deadly effects of burning pool & gardening chemicals and PVC's from the church.  Responders of both fires (within the same era) identified "a new type of fire"- incinerating high levels of carcinogens resulting in latent mortality cases.



The Diagnosis and Treatment of Carbon Monoxide Poisoning:
Excerpt from source: NCBI/NIH


The symptoms of carbon monoxide poisoning are usually non-specific. In patients with unclear neurological symptoms and possible exposure, carbon monoxide should be urgently considered as a differential diagnosis.

The treatment aims in particular to prevent long-term harms, such as cortical dysfunction, Parkinson‘s syndrome, Parkinson‘s disease, dementia, cardiac complications, as well as reduce mortality in the long term. All patients with symptomatic carbon monoxide poisoning should be treated with 100% oxygen as soon as possible. In severe cases of fire fume intoxication, combined poisoning with CO and cyanides should be considered. The evidence for the benefit advantage of hyperbaric oxygen is weak in view of the heterogeneity of the available studies. The decision in favor of HBOT seems sensible in severe CO intoxication or in pregnant women.

Assessment of hyperbaric oxygen therapy versus normobaric oxygen therapy
According to a report from the NIH, the intracellular and extracellular effects of carbon monoxide poisoning affect in particular the organs without oxygen reserves (heart, brain). Toxicologically, the quickest possible elimination of the poison is the most sensible way to prevent further injury. The higher the partial pressure of oxygen provided, the shorter the elimination period—which would in theory support hyperbaric oxygen therapy (HBOT). In practice, however, HBOT is the subject of controversial discussion (20, 21). Critics point out the great logistical challenges and lacking evidence. In actual fact, the heterogeneity of the studies to date (in terms of study design, kind of exposure, severity of intoxication, delay in treatment, treatment pressures applied, and follow-up period) barely allows for any evidence-based recommendation regarding the type and extent of HBOT (25). What adds to the dilemma is the fact that the HBOT therapy schemes applied vary widely across Europe (e57), which imposes limitations on future meta-analyses and their validity too. (See complete report on NIH)


20. Wolf SJ, Maloney GE, Shih RD, Shy BD, Brown MD. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute carbon monoxide poisoning. Ann Emerg Med. 2017;69:98–107. [PubMed] [Google Scholar]
21. Buckley NA, Juurlink DN, Isbister G, Bennett MH, Lavonas EJ. Hyperbaric oxygen for carbon monoxide poisoning. Cochrane Database Syst Rev. 2011;4 CD002041. [PMC free article] [PubMed] [Google Scholar]
22. Mintegi S, Clerigue N, Tipo V, et al. Pediatric cyanide poisoning by fire smoke inhalation: a European expert consensus. Pediatr Emerg Care. 2013;29:1234–1240. [PubMed] [Google Scholar]
25. Hampson NB, Piantadosi CA, Thom SR, Weaver LK. Practice recommendations in the diagnosis, management, and prevention of carbon monoxide poisoning. Am J Respir Crit Care Med. 2012;186:1095–1101. [PubMed] [Google Scholar]




TOXICOLOGY 101: A THREAT TO FIREFIGHTERS HEALTH
As part of our evaluation of all occupational illnesses contracted by first responders, we enter the world of TOXICOLOGY- the branch of science focused on the effects and detection of poisons.  It is also the discipline overlapping chemistry, biology and pharmacology- studying the adverse effects of chemical substances on living organisms.  In pursuit of first responders’ safety as far as chemical effects on the body, we connected with Professor David Purser of the Hartford Environmental Research (UK), a renowned toxicology expert who conducted major reviews on fire-exposed carcinogens published worldwide. “9/11 was unusual in that a major environmental hazard resulted from the dust cloud released as and after the Towers collapsed,” says Prof. Purser.  “The dust inhaled by responders at the time, and afterwards working at the site, has resulted in serious ongoing and developing health conditions and to this day.  For fires in general, there is also increasing evidence and concern regarding FF exposure to carcinogens, especially from soot contamination to skin and clothing following attendance at incidents and during training.” An abstract from Prof. Purser’s latest presentation – “ Toxins Including Effects of Fire Retardants, During Fires and Post-Fire Investigation Activities” indicates a remarkable breakdown of some of the major toxins and carcinogenic compounds that the average firefighter would be exposed to. (See complete article)

"THE TELLTALE COUGH"- EXPLAINED
According to Dr. Paul Schulster, (pulmonologist from Oceanside, NY) the COUGH can say a lot, but often misleads the patient as a "nothing" or a "simple little cough".  For firefighters, it is usually a telltale sign of various possible issues. The first syndrome often comes from a post-nasal drip. The second most common cause is from irritation, inflammation and bronchiospasm. Third is Gastroesophageal Reflux Disease. My 9/11-related patients that have GERD starts with that warning cough while others' coughs can trigger the asthma.  Finally, Irritative Cough Syndrome can also happen where one cough leads to another cough, irritating the airway, exacerbating another cough - and then another.

Having a cough here or a wheeze there is not enough for most first responders to raise the flag of alarm. Seasoned specialists like Dr. Schulster recognizes that unique and unusual symptoms or maladies do not reach the patient's consciousness for quite some time.  Ignoring or not paying more attention to these "little" anomalies tend to often be the norm.  These coughs may progressively grow worse over the years and then one day they begin to wheeze a little more than usual and wind up with advancing shortness of breath.  Once this becomes significant and finally enters their consciousness, only then will the thought of seeking medical help actually come to mind.


DIAGNOSTIC OPTIONS
Oftentimes, an exam from the pulmonologist starts with the CAT scans of the chest. The firefighters are being tracked for pulmonary nodules. They're referred to as sub-centimeter nodules, which are so small that you can't read it. "You don't really see them on a plain X-ray, chest X-rays, PA and lateral. A lot of these first responders already come to me with CAT scans from the past and have been followed by World Trade Center program and the FDNY doctors that are also pulmonary doctors"- states Dr. Schulster.

In a pulmonologist's tool kit exists certain standard pulmonary function examss- including the SPIROMETRY [2].  This test estimates the narrowing of your bronchial tubes by checking how much air you can exhale after a deep breath and how fast you can breathe out [5].   This allows us to  see the best way of determining the lung function in numbers, more or less, is a complete pulmonary function test.  Next is the METHACHOLINE CHALLENGE [3] - also known as an asthma trigger that, when inhaled, will cause mild constriction of your airways.  If you react to the methacholine, you likely have asthma. This test may be used even if your initial lung function test is normal. [5]   Another test used is THE COLD AIR CHALLENGE [4]. The  patients generally come with having had those in the past and most are positive for asthma. In the asthmatics. 

See original article published 7/2019 @ The Journal of Modern Healing



 

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