PPE: Our Last Line of Defense Against Acute and Chronic Hazards

By David Greene

Modern-day hazardous materials incidents normally have four potential levels of personal protective equipment (PPE) and three zones (hot, warm, and cold). Level A PPE is the maximum level of both skin and respiratory protection and consists of a self-contained breathing apparatus (SCBA) inside a fully encapsulating vapor-proof suit. Level B PPE is a maximum level of respiratory protection with a reduced level of skin protection and consists of a SCBA outside of a non-encapsulating or inside a non-vapor-proof suit. Level C PPE is reduced skin and respiratory protection and usually involves a non-encapsulating suit or coveralls along with an air-purifying respirator. Level D PPE is a normal work uniform with select protective equipment (gloves, booties, hardhat, eye protection, etc.). The hot zone is where the suits are worn to perform the work necessary to save lives, protect property and/or mitigate the incident. The warm zone is where contamination is reduced to allow the workers to exit the suits and enter the cold zone, which is where PPE is not necessary. Since hazardous materials incidents are low-frequency incidents, consideration of PPE that is appropriate for each zone is essential as the risks are often high and can be both acute or chronic.

In the fire service, we have another low-frequency incident that is also high-risk and has both acute and chronic hazards. It is easy to draw a parallel between modern-day hazardous materials incidents and structure fires. We depend on our PPE as a last line of defense against the acute hazards of structure fires. Our structural PPE and SCBA protect us against flashover, other thermal insults, and breathing the extremely toxic byproducts of combustion (smoke) and superheated air. Over the years, research has demonstrated that the chronic hazards associated with structure fires and our PPE is equally as, if not more, hazardous to our health. Cancer rates among firefighters range from 14% to 100% (double) higher than the rates among other occupations. This research, summarized in the International Association of Fire Chiefs and National Volunteer Fire Council’s Lavender Ribbon Report, offers several best practices.  It is essential that we advocate for these recommendations to protect ourselves and our future ranks.

Best Practice #1: Full protective equipment (PPE) must be worn throughout the entire incident, including SCBA, during salvage and overhaul. For those of us that respond with, shall we say, less than an optimal number of firefighters on the first alarm, wearing an SCBA during salvage and overhaul is thought of as impossible. Those tasked with overhaul could be the same firefighters who first hit the fire. If this is the case, think back to what we do on hazardous materials incidents and slow down. Give your crew an adequate break before they begin overhaul efforts but recognize that they are still at risk even after the fire is no longer visible in the structure. At a hazardous materials incident, we would not take our Level A PPE off in the hot zone just because we think we have the leak stopped. At structure fires, the toxic products that we can breathe are still present during overhaul, and we should ensure that we are properly protecting the troops. We would likely rather listen to them complain about the weight of an SCBA during overhaul than listen to them complain about having cancer years later.

Best Practice #2: A second hood should be provided to all entry-certified personnel in the department.  Hoods have been found to hold large amounts of contaminants, and by providing a clean hood to anyone that has participated in activities inside the building, we are reducing the chance of them keeping the contamination in their vulnerable head and neck areas. At a hazmat incident, we wouldn’t take a Level A suit, turn it inside out, and give it to the next entry team to use. The PPE must be decontaminated and, if not single-use, like a flash hood, should be replaced until it can be thoroughly cleaned.

Best Practice #3: Following exit from the IDLH, and while still on air, you should begin immediate gross decon of PPE using soap, water, and a brush, if weather conditions allow.  PPE should then be placed into a sealed plastic bag and placed in an exterior compartment of the rig, or if responding in POVs, placed in a large storage tote, thus keeping the off-gassing PPE away from passengers and self. The first part of this recommendation, the gross wash, should look familiar as it is the first step in the warm zone at a hazmat incident. Keeping the PPE separate from us (in a storage tote or in a plastic bag in an exterior compartment) is very important. Many years ago, a medical professional was not thought to be proficient unless they had a large amount of blood on them. Today, that practice is unacceptable and unsafe (imagine a surgeon meeting with you ahead of your surgery while covered in blood from head to toe).  The same should be applied to our PPE. Dirty gear is no longer the sign of a competent firefighter.  It is only the sign of our crews being exposed to dangerous carcinogens. We must remember that our PPE is our last line of defense. We do not want to get caught in a flashover just to see how many seconds go by before our structural PPE fails, any more than we want to wade into a lake of hydrochloric acid in a Level A suit just to see how long it takes before the suit material fails. When our Level A suit becomes discolored, we discard it. When our structural PPE becomes covered in soot, we should clean it.  In the absence of discarding or decontaminating it, our PPE will likely not provide us a sufficient defense against the acute and chronic hazards of the next hazmat incident or structure fire.  Contaminated PPE, whether from a hazmat incident or a structure fire, represents an exposure hazard that we are placing in the apparatus and taking back to the station.

Best Practice #4: After completion of gross decon procedures, and while still on scene, the exposed areas of the body (neck, face, arms, and hands) should be wiped off immediately using wipes, which must be carried on all apparatus.  Use the wipes to remove as much soot as possible from head, neck, jaw, throat, underarms, and hands immediately. Again, when we pull a civilian out of a fire, and they are covered in soot, our next thought is that they need medical attention. If our firefighters are leaving a fire covered in soot, we are unnecessarily exposing ourselves to contaminants. Although it may not be that day or next week, we may end up being the one that needs medical attention years later due to repeated exposures to chronic hazards. The contaminants from structure fires have been proven to be cancer-causing. We wouldn’t leave a hazmat call and high-five the responders that have hydrofluoric acid on their necks. The head/neck/arm/hand wipe is essential to ensure we leave the contaminants at the scene.

Best Practice #5: Change your clothes and wash them after exposure to products of combustion or other contaminants. Do this as soon as possible and/or isolate in a trash bag until washing is available. I knew a firefighter once whose spouse was often upset whenever he would wash his structural PPE in the washing machine at his house. Not only does the PPE hold contaminants, but so does the uniform or clothing you wear underneath your PPE. Just like a hazmat incident, entry team members should change their clothes and wash them (separately from any other clothing) as soon as possible. Isolating your clothing in a trash bag until washing is available further reduces the risk of spreading the retained contaminants.

Best Practice #6: Shower as soon as possible after being exposed to products of combustion or other contaminants. “Shower within the Hour.” This one has long been a practice in the hazmat world. Structure fire entry personnel, just like those tasked with entry at a hazardous materials incident, should shower as soon as possible to remove any contaminants that are still present after decontamination was conducted.

Best Practice #7: PPE, especially turnout pants, must be prohibited in areas outside the apparatus floor (i.e., kitchen, sleeping areas, etc.) and never in the household. Unfortunately, I shudder to think the number of times I slept in a fire station with my turnout pants at the foot of the bed or worn them in the day room. Doing this brings carcinogens into areas where our co-workers and/or families are exposed to them. Our fire stations (outside of the apparatus floor) and our homes should be cold zones. When we exit a technical decon line after stopping an anhydrous ammonia leak, our suits are normally placed in an overpack drum to be disposed of or to be cleaned if they are multi-use suits. We would not bring that Level A suit into the dayroom back at the station and place it on the kitchen table. 

Best Practice #8: Wipes, or soap and water, should also be used to decontaminate and clean apparatus seats, SCBA, and interior crew area regularly, especially after incidents where personnel were exposed to products of combustion. In hazmat, we receive direct contamination when we touch something dirty.  Cross-contamination occurs when something clean comes into contact with something dirty. If I am in a Level A suit and grab the shipping papers that are in the middle of a chemical leak, I have direct contamination. If I fail to seal or decontaminate those papers and deliver them to the command post and the IC grabs them to read them, the IC is now cross-contaminated. The IC, who was clean, has now contacted something dirty. Think of it this way. We wouldn’t roll up the salvage cover that sat under our technical decon after a hazmat incident and throw it back on the truck. Although it never entered the hot zone, the salvage cover likely has tons of contaminants from the decontamination process on it.  When it is not disposable, regular decontamination, especially after a fire, of regularly used areas of our apparatus seats, SCBA, and interior crew area should further limit our exposures.  

Best Practice #9: Get an annual physical, as early detection is the key to survival. Anyone with an annual fire brigade clearance or using a respirator should be required, by law, to get an annual physical. That physical should include a blood panel that detects the potential presence of cancer (Prostate Specific Antigen [PSA], CA-125 [Ovarian Cancer Protein Test], Leukocytes [White Blood Cells], etc.). Annual physicals can also detect the presence of heart disease, which is the number one killer of firefighters.

Best Practice #10: Tobacco products of any variety, including dip and e-cigarettes, should never be used at any time on or off duty. As a former smoker, I can relate to how hard it is to quit. Not only does tobacco use increase your risk for many cancers, it can increase your chance of heart disease. As I wrote earlier, we already experience a 1.1 to 2.1 times greater chance of developing cancer due to our occupation. We should probably not try to increase it any further through tobacco use.

Best Practice #11: Fully document ALL fire or chemical exposures on incident reports and personal exposure reports. This is a new one for structure fires, but not so much for hazmat. In a hazmat incident report, we fully document pre- and post-entry vital signs of the entry personnel and any signs and symptoms they had related to the material involved. That report clearly lists who made entry and was exposed to the product(s) present, and those records are maintained for 30 years after the firefighter’s retirement. In a structure fire report, there is usually only a list of personnel and the apparatus to which they were assigned. We do not always clearly delineate who was exposed to the toxic products from the fire and who was not. This is something we need to change.  Following the hazmat routine, we should do a better job of documenting who specifically was exposed to the fire as opposed to those that may have been in support roles. 

By now, I hope you have recognized that structure fires are, in fact, hazardous materials incidents. Although we have been aware of the acute hazards structure fires pose to our personnel for some time, we have just begun to appreciate the chronic risks to our personnel.  Decades ago, when legacy fuel packages such as wood, cotton, etc., fueled structure fires, heat release rates were much lower, and the smoke was much less toxic. Today’s structure fires have fuel packages powered by polyethylene, polyurethane, and other synthetic materials with much higher heat release rates, increasing the acute hazards. More importantly, the byproducts of incomplete combustion (smoke) as a result of contemporary fuel packages in today’s structure fires are capable of harming us long after the fire is out.  Applying the hazardous materials incident tactics that we have used for decades to today’s structure fires by utilizing the best practices above can help reduce the chronic risks that we encounter. Many of us know a firefighter that has battled and perhaps lost a fight to cancer. Do not take these best practices lightly. Young firefighters today, who will be exposed to contemporary fuel packages and extremely toxic smoke their entire careers, are more at risk than those of us that dealt with legacy fuel packages and less toxic smoke early in our careers. Get behind these recommendations and use as many as possible in your department so that our young firefighters can have long careers followed by healthy retirements.

Be safe and do good.

David Greene has over 31 years of experience in the fire service and is currently the deputy chief with Colleton County (S.C.) Fire-Rescue. He holds a PhD in Fire and Emergency Management Administration from Oklahoma State University and an MBA degree from the University of South Carolina. He is a certified Executive Fire Officer through the National Fire Academy, holds the Chief Fire Officer Designation from the Center for Public Safety Excellence, holds Member Grade in the Institution of Fire Engineers, is an adjunct instructor for the South Carolina Fire Academy and is a Nationally Registered Paramedic. He can be reached at dagreene@lowcountry.com.

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