Introduction Workers handling hazardous wastes can experience high levels of stress. Their daily tasks may expose them to toxic chemicals, safety hazards, biologic hazards, and radiation. They may develop heat stress while wearing protective equipment or working under temperature extremes, or face life-threatening emergencies such as explosions and fires. Therefore, a medical program is essential to assess and monitor workers' health and fitness both prior to employment and during the course of work; to provide emergency and other treatment as needed; and to keep accurate records for future reference. In addition, OSHA recommends a medical evaluation for employees required to wear a respirator (29 CFR Part 1910.134[b]), and certain OSHA standards include specific medical requirements (e.g., 29 CFR Part 1910.95 and 29 CFR Parts 1910.1001 through 1910.1045). Information from a site medical program may also be used to conduct future epidemiological studies; to adjudicate claims; to provide evidence in litigation; and to report workers' medical conditions to federal, state, and local agencies, as required by law.
This chapter presents general guidelines for designing a medical program for personnel at hazardous waste sites. It includes information and sample protocols for pre-employment screening and periodic medical examinations, guidelines for emergency and non-emergency treatment, and recommendations for program record-keeping and review. In addition, it supplies a table of some common chemical toxicants found at hazardous waste sites with recommended medical monitoring procedures.
The recommendations in this chapter assume that workers will have adequate protection from exposures through administrative and engineering controls, and appropriate personal protective equipment and decontamination procedures, as described elsewhere in this manual. Medical surveillance should be used to complement other controls.
5-2 Developing a Program A medical program should be developed for each site based on the specific needs, location, and potential exposures of employees at the site. The program should be designed by an experienced occupational health physician or other qualified occupational health consultant in conjunction with the Site Safety Officer. The director of a site medical program should be a physician who is board-certified in occupational medicine or a medical doctor who has had extensive experience managing occupational health services. A director and/or examining physician with such qualifications may be difficult to find, due to the shortage of doctors trained in occupational medicine in remote geographic areas where many hazardous waste sites are located. If an occupational health physician is not available, the site medical program may be managed, and relevant examinations performed, by a local physician with assistance from an occupational medicine consultant. These functions may also be performed by a qualified Registered Nurse, preferably an Occupational Health Nurse, under the direction of a suitably qualified physician who has responsibility for the program.1 All medical test analyses should be performed by a laboratory that has demonstrated satisfactory performance in an established inter-laboratory testing program . The clinical or diagnostic laboratory to which samples are sent should meet either (1) minimum requirements under the Clinical Laboratories Improvement Act of 1967 (42 CFR Part 74 Subpart M Section 263[a]), or (2) the conditions for coverage under Medicare. These programs are administered by the Health Care Financing Administration (HCFA), U.S. Department of Health and Human Services (DHHS).
A site medical program should provide the following components:
- Pre-employment screening
- Periodic medical examinations
(and follow-up examinations when appropriate)
- Termination examination
- Non-emergency(on a case-by-case basis)
- Program review
Table 5-1 outlines a recommended medical program; screening and examination protocols are described in the following sections. These recommendations are based on known health risks for hazardous waste workers, a review of available data on their exposures, and an assessment of several established medical programs. Because conditions and hazards vary considerably at each site, only general guidelines are given.
The effectiveness of a medical program depends on active worker involvement. In addition, management should have a firm commitment to worker health and safety, and is encouraged to express this commitment not only by medical surveillance and treatment, but also through management directives and informal encouragement of employees to maintain good health through exercise, proper diet, and avoidance of tobacco, alcohol abuse and drug abuse.
In particular, management should: Urge prospective employees to provide a complete and detailed occupational and medical Certified, state-licensed (where required) Physician's Assistants may also perform these examinations if a physician is available on the premises. 5-3
- Assure employees of confidentiality
- Require workers to report any suspected exposures, regardless of degree
- Require workers to bring any unusual physical or psychological conditions to the physician's attention
- Employee training should emphasize that vague disturbances or apparently minor complaints (such as skin irritation or headaches)may be important