Hello, good evening. My name is Kara Molinari, and I'm the Director of Medical Education at the American College of Preventive Medicine. Welcome to this evening's webinar on preparedness on exposures, biological, chemical, mechanical, and radiological with Dr. Miriam Alexander, MD and Master of Public Health, who is the Acting Medical Director of Employee Health and Wellness at LifeBridge Health in Baltimore, Maryland. Oh, am I supposed to move? Whoops. Yes, that's okay. Dr. Alexander has nothing to disclose. Nope. Where are the housekeeping slides? Oh, they're... Oh, sorry. Okay, there you go, the housekeeping slides. The way that this webinar will flow is, number one, you come to the webinars and you ask any questions to the faculty. They'll be posted in the chat, at which point Natasha Whitmore-Smith and I will be answering them. And then you'll complete a survey at the end of the webinar. This will assign both CME credit and also get you any other additional information and the recording post-webinar completion. To continue the discussion on this topic, please feel free to do so on ACPM Pulse. And this is a newer platform for discussion and a forum for all of our members. As I had mentioned, this webinar will be recorded and we will send you instructions post-recording on how to access. Next slide, please. There we go. And with that, I would like to introduce Dr. Miriam Alexander, Medical Doctor and Master of Public Health, who is the Acting Director of Employee Health and Wellness at LifeBridge Health, which is her most current position for full dossier. Happy to provide that link in the chat for all, but so as not to impede on the progress of the meat of the webinar, I give you Dr. Alexander. Hi, thanks very much, Cara and Natasha. Thank you very much for working on my slides with me. It always takes a village to accomplish something. So I want to talk about exposures with you tonight, and I want to give you a flavor of where I'm coming from on this. So I'm obviously GPM board certified. I was starting my career actually at Baltimore City Health Department, one of the programs I oversaw. I oversaw all the infants and toddler programs. So I did the lead poisoning prevention program for the city of Baltimore. So I already started looking at sort of public health and exposures, environmental exposures, sort of the public health impact at that point. I then went, I joined the faculty of Hopkins for 20 years, and some of you may know me as I was the residency director in GPMR at Hopkins for about 20 years. But throughout all that time, I was at Bethlehem Steel as the medical director of occupational health, and then went to McCormick, the spice company for 20 years. And have been in, I left Hopkins eight years ago, I guess, and I've been in healthcare since then. And it's been a very unique, interesting environment to practice occupational medicine. But over all these years, I've done expert witness work around public health emergencies and exposures specifically, which is really an area of interest of mine. And what I'm going to try and do this evening, and I hope it doesn't get too didactic, is talk a little bit, so those of you who are in OMR, this may be repeat, and I'd really like your input, but you're going to see a little bit of environmental health, a bit of toxicology, a bit of physiology, and a bit of how it all comes together. And one of the things we've been talking about in this webinar series to date is really public health, what is our role in public health? But now I really want to talk to you as what is your role as the physician in this role? Because remember, and we'll talk about this as we move on a little bit, that there can be some sort of a hazard, but if it's not of harm to the human being, we don't have to consider it in the same way. So that's really where you and all of us play a role in this whole process. So this is how I'd like to use my time tonight, and I hope that I'll stick pretty much to this process. But let's talk a little bit about exposures. And so when you think about an exposure, then we're going to talk specifically around, if you will, public health preparedness, or thinking about what we do in emergencies. But it's no different in occupational medicine at all. It's no different when you're thinking about a population level or a patient level. And that's really what I'd like you to remember the most, so sort of the concepts. So the details of any particular emergency, as Peter Pendergrass told us last week, you've seen one emergency, you've seen one emergency. I'm not quite sure I agree with all of that, but the actual exposure is going to be different, but the way we think about it should be pretty parallel at each time. And that's the mistake I think many people do. They think de novo, that we have to think sort of from scratch. And certainly if the whole process of incident command and the public health preparedness schema teaches us, we really don't want to think as if like, we've never thought about this kind of problem before. So obviously we have to think about the intensity of exposure, the duration of how long that exposure is going to be a problem, both for the human population, the animal population and the environment, if there's any latent period and the induction period, how long it's going to take to have an effect. And as we all know, each effect has a different intensity, duration, latent period and induction. So now let's talk a little bit about definitions, and this is really quite important to be careful about and to think very clearly about. We have a hazard. Now remember, a hazard is a potential to cause harm. We can prevent that hazard by really affecting the human if we can reduce the risk of the likelihood that this harm is going to actually have a health effect. So hazard is different than risk, and make sure we keep that clear as we're thinking about these topics. So this is very familiar to any of you who've thought before about how we do sort of a risk assessment, risk exposure, but one of the things you have to be involved with, each of us is involved with in a public health emergency or any kind of emergency, is all of these points. And what's interesting is I got the material for this slide from a British journal, and they actually add in the review and evaluation, which is something we don't standardly think about, which is really closing the loop and looking at lessons learned and taking any data we've accumulated throughout this emergency and figuring out what happened, what could have been better, what could have happened, et cetera. So let's think about, again, conceptually, we're going to think about exposures and how are they going to affect the human. So we have to figure out, first of all, where the exposure is going to affect the human. Is it the skin? If it's the skin, is it going to be an irritant, just an irritant? Is it going to actually corrode and be a burn, or is it going to sensitize and therefore cause an immune response, either in the moment or more of a delayed? Similarly, the eye, we think about something irritating versus something damaging. And the respiratory trait, which we'll spend quite a bit of time thinking about today, would be irritation, hypersensitivity, or actual damage. And finally, and again, we don't think about it so much in an emergency situation, is what are going to be the potential for germ cell mutagenicity, either way down the road or perhaps to a fetus or a future embryo. So as you saw, when I coined, I gave my talk, a title to the talk, I put it into four categories, but I sort of kind of stand corrected by dividing it into three categories, because people seem to, or scientists or scholars, consider radiologic a physical effect. And although I guess it really is a physical effect, I think it's thought of very differently. And certainly if we look at all the regulatory agencies and the way the public think about radiologic exposures or threats, we do think about them differently from physical. So let's talk a second about, all right, let's think about the exposure. Now you hear that something is happening or is going to happen. So you have to, our role is really to think about, well, how is this going to come to us as human beings? Is it going to be something we're going to inhale? Are we going to ingest it? Is it going to contact our skin or is it somehow going to get into our body by breaking one of the barriers, whether it be the skin, the mucosa, et cetera. So that's the first thing we as physicians have to think about, right? Because we have to think about which, what do we have to worry about? Now, we all know that once someone gets to the ED on an individual basis, the receiving provider, the physician in the ED is going to look much more at what's in front of them. And they're not going to think as much about the exposure, at least initially. They're going to be more worried about, is the person having breathing problems, do they have a burn, et cetera. So we talked about a second for how the substance enters the body. Now, again, we need to think about how the substance is going to leave the body, right? So again, technically or hypothetically, if something comes into the body and then leaves the body in an intact state, we possibly are not going to be worried about something as much as if something metabolizes in the body, either to become a more harmful product or get stuck in the body or as it's metabolizing causes health effects. Obviously, we lose things for the urine, the bile, the feces for our breath and saliva. And again, I don't know if we would call this emergency, but certainly as our limits of detection go down and down and down, we're finding many things in human urine that end up in the water supply that we didn't even think of as possible exposures to the next guy, whether it be a chemical, whether it be chemical, whether it be the chemotherapy to the individual, whether it even be medication. And the same is true of bile and feces. And certainly worldwide, we worry a lot about feces, not as much about bile, but urine urine, we'll talk about in a little bit, but in some ways, things that actually enter the body that go in, come into the urine. Sometimes we're lucky enough that we hydroxylated it and were able to pee it out and hopefully it would be adsorbed or absorbed if we have an intact water supply. And certainly, as we've talked about over the last few sessions, one of the first things that always is we worry about in a public health emergency is disruption of both the efferent and the efferent water supply, i.e., the sewage, sanitation, and the water supply, the intake. And for those of you who are thinking about your boards going forward, when I used to be on the ABPM and we used to write questions, we always used to say that when you think natural disaster, the first thing you have to think about is one to two to three weeks later, you will have a gastrointestinal outbreak because there's been a disruption of sanitation. The disruption of sanitation, then you'll end up with a few organisms from a few individuals who have an infection getting into the potable water and then gastroenteritis in the population. So we always talk about that as really an important, a really important concept to think about in any kind of public health emergency. So what I have up here on the slide are the different target organs that are affected by anything that comes into the body. I'm going to spend most of my time talking about sort of respiratory system and the skin, but all the other body parts, target organs, are absolutely affected, can be affected, can be affected and need to be thought of and need to be protected. Unfortunately, as we all know, because the bone marrow has cells, you know, pluripotent cells constantly being generated, the bone marrow is very susceptible to a significant health effect, but it's usually not seen in the short term. And in the very short term, we typically worry about the respiratory system, the CNS specifically, and the skin. So let's look at the next slide. And I can't emphasize enough why it's important to think about the respiratory system in different parts, because the respiratory system to somebody who's not a medical person seems to be one, you know, from the mouth to the air sacs. But, you know, we really do know differently. And it becomes very important for us to think through what is going to come in and which part of the respiratory system is going to be problematic. Where is the problem going to affect it? Because we really need to think about that in terms of the immediate and the short term and even the intermediate things we have to be prepared for. So we'll get back to that in a few minutes. Let's look at the skin. And I know a heck of a lot less about the skin. And the skin turns out to be an amazingly diverse organ, you know, that some of us hadn't really thought a lot about in the past. But just the epidermis has multiple different layers. And the reason it becomes important from the perspective of a public health emergency, a natural or man-made disaster, is depending on what the chemical is, it's going to affect different layers. And that becomes vitally important in terms of thinking about what you might see in the immediate and the short term. Okay. So if I had to talk about one important slide, I would say this is the most important slide of the lecture. And the reason for this is that you have an exposure. And obviously, what we're trying to prevent is a health effect, right? That's obvious. But it becomes very important for us, especially for future litigation, which most of us end up being involved with, is there some sort of a biomarker or marker of health effect? And I wanted to tell you a couple of stories from my own recent experience. And obviously, these are in occupational medicine, but they're not particularly unique. And the first story I want to tell you about is an individual who said that her health effect was absolutely because they were using a very specific chemical in the hospital where she worked. And it was used as a disinfectant. And it was absolutely because of that exposure. And the problem was that, unthoughtful by her, was that you only use that very specific disinfectant if there are patients who have a very specific infection caused by a very specific organism, right? So she said, well, you know, obviously, the hospital buys this chemical. And obviously, they have it. And obviously, I have this asthma problem. This chemical caused it. The problem was that there were no patients in the hospital during the time that she developed symptoms who had that infection. And because there was no one who had that infection, the hospital couldn't have been using that disinfectant. So again, you have to really think through exposure, marker, and health effect. And that's really something that we all can uniquely think through and then bring to the table that other people can. Another interesting situation was another patient. Again, it's a patient. And this particular hospital has a pool that they use for aqua therapy. And the patient said, well, you know, they use chlorine, they use chlorine in the pool. And I worked around the pool. And this chlorine obviously must have given me my asthma. The problem is that the chlorine that they use comes in a powdered form. And when you put the powder into the pool, first of all, you'd only have any kind of back spray of the powder when you're actually putting it in the water. And the powdered chlorine that they put in doesn't cause respiratory problems. It doesn't. It's the gaseous form. And interestingly enough, she went to a health center and said she had asthma symptoms, but her oxygenation was perfect and her exam was perfect. And for those of you who know what chlorine gas does, its effect are much further into the alveoli and cause actual significant damage to the tissues. And you'd be really worried about pulmonary edema and really poor oxygenation. So yet again, an example of why it's so important for you to know what is the exposure and then what is the possible mechanism by which it could be causing a health effect or could cause a health effect in your population. So again, and this we all know backwards and forwards, but it really bears discussing that everything I have here on the slide are things that we have to consider. And if you think quite a bit about how we as a country think about infectious, let's call them epidemics, whether we want to talk about the flu or whether we want to talk about like COVID and the whole issue of what happens when something affects a population. And we really have to think through whether something is going to affect different ages disproportionately. And those members of the medical community who were very opposed to masking or closing schools argued or wanted to argue that it was really going to be much more affected, it would affect the young and the old or those with comorbidity. And therefore people who were healthy going to school or healthy going to work should have been allowed to continue on their way. And so really thinking through the age of the group you think is gonna be most susceptible, certainly we know that children by body weight, their skin, by surface area, their skin takes up a much larger percentage of their organ weight, if you will, than those of us who are in our middle years. So it's really very important to think about each one of these responses as we think about what population or which subsets of our population are going to be most affected by some sort of an emergency that's gonna have much some sort of a natural or man-made disaster. So let's think a little bit about how can we think about the way this risk, this exposure is going to actually affect the body. So if we can think about, shall we measure a biomarker? So in lead as an example, which is what I just happened to know more about, we can often look at, you can actually measure lead by itself and there are other chemicals you can do exactly the same way. You can actually measure certain chemicals in the body and that's gonna actually tell you that somebody was exposed. But whether somebody actually has, whether the body has recognized it in some ways, you often need some sort of a measure of physiological alteration. So with the organophosphate of the pesticides, we look at RBCU cholinesterase and the list is extremely long of what one can look for. But again, as the physician on the team, these are things we can think through and should think through and bring that to the table as we look at certainly what we recommend to the health systems in terms of how to help triage people both for the immediate effect and then the short-term effect and then obviously much more long-term as well. So I'd like you to take a quick look at this slide and it's got quite a bit on it, but we did talk already about how something actually gets into the body, whether it was inhalation ingested or it came in through the skin. We then have, if you will, sort of the amount that actually got into the body. So just because your skin is exposed, i.e. let's say to alpha particles, as an example, it doesn't necessarily mean you're going to have a health effect or something that for instance is not at all lipid soluble. It may sit on the skin much more than will be absorbed. So we really have to think about the internal dose, how much is going to get in. And then we have to think about where it's gonna go in the body. And that's, again, something we can think through. So do we know that something goes to bone? Does it go to, does it go just immediately to the detoxification process for the liver? Is it going to end up in the RBCs? Where is it going to, which organ is it going to go to? And in some ways, this is going to affect the biologic effective dose. Now, one of the things I wanted to keep reminding you of is remember in the blood, which is where the typical fluid that we use to measure things in, most things, and I can't put a percentage to it, but most things are carried by proteins, right? And if our, and remember that proteins marginate back and forth, back and forth from sitting against the walls to floating in the blood. And remember that we are only measuring things that are in the blood. And if something is marginated, either because it's marginated or because it is attached to something that's marginated, we may or may not measure it at the time. So again, something you have to think about. And then looking between the internal dose and the biologic effective dose, a very important thing to look about, look at is, is our body able to detoxify it? And basically, and we'll talk about this in a bit, if the particular product has entered the body, but the C, the P450 system can hydroxylate it in some way so that the kidneys can pee it out, where all, or the kidneys, or it goes in the bile or the breath. But again, main way of excreting things is urine. The body is a lot better off than if we don't have a way of detoxifying or hydroxylating it, and the particular product ends up sitting around in the body. And then we talked a little bit about the altered function, which organ is gonna be affected. We talked the slide before about looking at some of the risks. And then that is, how well is the body going to be able to repair from it? And I was doing a little reading yesterday on a different topic, and I was looking at, and I think we'd all agree when you really think about it, in concept, the inflammatory system is the superb way that we heal, right? I mean, it is the way that our body repairs itself, but the inflammatory system is actually one of the ways that we cause much more damage, whether it be tissue damage, whether it be actual physiologic damage, because whether it's a cytokine storm that destroys all the other blood cells, whether it be something that actually ends up causing fibrinogen or the practice, and we're gonna end up with a lot of fibrosis later down the road, or we're going to end up with other things that the immune system would have done in hopes of healing that actually ends up causing more and more damage. So now let's talk a little bit about chemicals, and this is so beyond what we can talk about tonight. So I really don't wanna get into the details, but I'd like you to think through and keep sort of in your back pocket, these categories of chemicals, because it's gonna be very important in your role in advising the team as to how are we going, how much do we have to worry about something, and how much do we have to worry about acute versus immediate versus intermediate health effects? So obviously we have what is the chemical, is the chemical being released as a gas or is it being released as a powder? Organic versus inorganic, and certainly depending on what the disaster is, we can absolutely have inorganic metals, or we can actually have something more like an organic exposure, which is going to have a different kind of a biomarker and potentially a different health effect. Now, you also have to think through the valency state, and chromium is a perfect example, and as you'll remember, chromium comes in 2+, 3+, and 6+, if I remember correctly, and each one of them, although it's sort of the same compound it is, each one of them behaves totally differently in the environment and in human health. And so it really does become important for you to have a sense of the valency, and is a cation a salt? Is it being released into the environment as a salt or is it by itself? Halogenation becomes really very important also because when we think about, especially some of the pesticides or herbicides or natural gases, if you will, how many halogens, how many chlorides or how many bromides the compound have, I mean, for those of you who are not in love with toxicology, I know it probably gives you palpitations and reminds you about organic chemistry, but for those of us who really worry about exposures to humans on a daily basis, how halogenated a chemical is, it becomes really important. And then we obviously have the heavy metals. So gases, vapors, fumes, and then smoke are four different things that come up through the air. And the terms get thrown around indiscriminately, but again, it's very important for you to reach back into your chemistry days and remember that they are four different ways that things come through the air and how they affect it. I mentioned to you that I had been at Bethlehem Steel in Baltimore for four years. And at that time, Bethlehem Steel, which is no longer, had its second largest plant in Southeast Baltimore. And at its heyday, actually they had 30,000 employees. By the time I got there, they had 7,000. And I promise it wasn't because of me, but a couple of years after I left, they went bankrupt. But it was really very interesting. They had coke ovens. And what happens is coal comes in. And one of the reasons some of the more successful steel companies were on the waterway, as Baltimore is, is that the coal either came from our own coal mines or came from overseas. And coal has to be purified. And the way you purify coal before you make steel is you basically burn the living daylights out of it and to get rid of everything other than carbon. Now, as you can imagine, burning the living daylights out of coal is very dangerous. The fire is very dangerous to employees, but the gases and the smoke are also very dangerous. And the other problem was that over the years that the Bethlehem Steel was there, communities developed in the area. More and more people were moving in the area. And I remember people being, communities nearby, especially when there was an unusual line of coke, if you call it, you know, coke, if you will, coal burning, people in the neighborhood would get really upset about the smoke. And they got really upset about all of the soot that they saw and they were concerned about its health effect. Interestingly though, because none of them could see the really problematic gases, the sulfuric acid and the nitric acid, which has really got human health effects, that wasn't something that the community worried about. Now, luckily for the community, and it wasn't even so much the community, the companies had such environmental, broke so many environmental rules that it became so prohibitive for them to, to burn coal that they ended up buying coke overseas. So just, that's my own particular experience with smoke bothers people much more than gases or vapors. Fumes often, because they smell, really do bother people more, but they may in fact have, depending on what the fume is, may have much less human health effect. So when you think about that, the particular chemical as it comes to the human being, you have to ask yourself, well, what is it going to do to the person? Is it going to actually be sort of a simple asphyxiant, which basically instead of oxygen being 78% of the air that the person breathes, it's going to be much less as in when methane and carbon dioxide, there are excess explosions, if you will, that's usually short-term and it becomes relatively easy if you can get people to fresh air or you can get them away from the asphyxiant. A little bit different from a chemical asphyxiant, right? Because with a chemical asphyxiant, the actual chemical may bind to, let's say, the heme group with the carbon monoxide or hydrogen cyanide as an example. And then you actually, no matter how much oxygen you give the person, you can't oxygenate them well enough because the heme group can't carry the oxygen. So those are, other than the immediate worry of a simple asphyxiant, the chemical asphyxiant can be much more worrisome from a human health effect. Upper airway irritants, again, are really bothersome and they cause a lot of coughing and they get people very worried and upset. But again, typically, and again, not always because there are things that really are corrosive, but typically these get people very bothered, but they may not have long-term health effects. Whereas some of the lower airway irritants, which on the surface of it, people aren't worried about because in the immediate, they don't have a health effect, but within 24 hours, the person may be in florid pulmonary edema and you may not be able to oxygenate them at all. So really do think through. Again, you're certainly not going to know all the chemicals, but it's very useful to be able to think this through. So again, just thinking about the respiratory tract as I showed you in that prior couple of slides ago, you want to think about the body part that way. All right, so what do you think about? Again, this is something that the industrial hygiene, hopefully hygienists on your team, hopefully you have one, or the environmental scientist can actually help you with what exactly is the particle because what are the chances that the particle is going to be problematic to the human body? And again, the lectures so far, we've been talking about in general a hurricane or in general a tornado or in general a rainstorm, but we really have to think about what could it be carrying, right? So again, in an area where it's very, very gravelly or very, very dusty, water, huge hurricanes or huge flooding is going to be very, very different than in an area where the hurricane or whatever just brings water that the water itself may not be carrying any product, anything, particles that are going to be particularly problematic. And one of the other things to think about literally is how forceful is it going to be? So hurricanes have their, as an example, a hurricane has obviously its immediate initial problematic health effect because there's just so much force, but then there are all of the other issues that we've talked a little bit over the last number of weeks. So let's talk a little bit about the large particles and large particles, if you can believe it, going back to my story of what happened with the Bethlehem Steel and all the burning coal, if you can see a particle from a human health effect, it's pretty good news because chances are very good it's going to get caught in your nose hairs or even up in your sputum. And if any of you have ever been even near a volcano that's minorly erupting, you'll notice sometimes that you blow your nose or you have some phlegm and you'll actually see particles. And although it's really scary to the individual, it's been trapped in the bodily fluid, the mucus that is in those areas. So we then think about particles between two and 10 microns and these are going to be the ones that cause a lot of problems with people who have asthma or anything that is going to cause some sort of reactive airway condition. And typically this is where you'll have hyper responsiveness of the bronchi and this is what you have to worry about from a health effect quite quickly after you've had the exposure. And again, that two to 10 micron is something that you have to really keep in mind. Very small particles, they're not extremely small but very small, the 0.5 to two microns are the ones we really worry about in terms of going all the way down to the alveoli and either getting stuck in the alveoli or actually blocking airway exchange. And these individuals can potentially have very significant health effects though as we talked about earlier, they may not be immediately recognized. And I don't know if any of you have seen situations where people say, oh, they go to the hospital and they get checked out and everything seems to be fine. And so then they leave and within the day they all of a sudden are gasping for breath and there's no oxygen exchange and they're in florid pulmonary edema. And finally, very, very tiny particles going back to Brownian motion, which I hated from physics and I still don't totally understand, but particles that are so, so tiny just like are floating and never even get in. So again, this just goes a little bit more into depth thinking about the lung function but you have to have a sense of where you think the problem is going to be because you want to know where the health effects are going to be. And I have to talk to you a little bit about asbestos way in the bottom left corner because it's an area that sort of I learned about as I started my career at Bethlehem Steel because Bethlehem Steel also had a shipyard and the shipyard, as you may know, sort of takes apart boats or refurbishes them or whatever. And asbestos has always been used as a wonderful insulator. And so it was used quite a lot in covering pipes and whatnot and so the ship builders used it very extensively. Well, what ended up happening in Baltimore was that at Bethlehem Steel, there were two huge steel unions and we always talked about the cold side and the hot side and the hot side also covered the ship builders and there was a huge union hall and on the top floor of the union hall, there was a, let's call them a two-bit workers comp attorney's office and the union, whenever somebody had a workplace health exposure would just send people upstairs to the lawyers to look into whether they had a compensable claim. So they were getting all these people who seemed to be getting these asthma, but that was nothing sort of new for them because when you work in that environment before the environmental controls, people were always having hyperreactive airway disease because they did such a poor job at really protecting the workers' health. But they started seeing mesothelioma and they started seeing, when I back for those of us who are a little bit more aged, you know, mesothelioma was something that we kind of heard about, but it wasn't a huge, a huge, huge, recognized, if you will, as such a huge, huge health effect, environmental health effect. And so what ended up happening was the workers' comp attorney, someone named Peter Angelos, started saying, well, you know, let me see if I can take these and make them workers' comp cases. And as you know, for those of you who do occupational health, workers' comp in the United States has some huge benefits to the employee, huge benefits, and it really prevents them from suing their employer. But it makes it much easier for them to go through the legal process. The downside for employees is under workers' compensation, you can never get huge settlements against your employer, you just can't. And that's the downside. But Peter Angelos kind of said, you know, I'm just not making, you know, and I'm obviously making up, or I'm, what's the word, I'm embellishing the story, so please take it with a grain of salt. Peter Angelos said, oh, you know, I'm not making enough money off these cases. But hey, you know, the asbestos might be affecting these people from use at the employer, but, you know, there's a third party who is, there's a third party who is providing this asbestos to the employer, let's do a third party suit against the manufacturers of asbestos. And that really was the beginning of him becoming a billionaire, when he was able to assemble enough employees across multiple states, to be able to sue multiple companies for the asbestos that they put into their product. So that was the beginning of him becoming a billionaire, him recognizing that this environmental effect that was playing out for the occupational effect, really had some significant health effects. So let's go away from chemical for a second, and let's talk about physical hazards. So for those of us who practice occupational medicine in America, a lot of what we see is mechanical. In my world now, in healthcare, that's really what I see the most of. I used to in when I was doing manufacturing would see quite a bit of noise and vibration, I personally have never really had problems with light exposures. And for anybody who has any exposure with significant pressure changes, deep sea diving, or massive, massive atmospheric pressure changes, there are health effects, we'll spend a second. But the what we see the most really in public health emergencies are the first three, mechanical and heat. And fortunately, much less radiation and natural, but we'll talk a little bit about it a second. Now, I want to talk to you about mechanical in a second. It's not enough to know that someone is had physical force applied to them becomes really very important that you have an idea of what is that that force or what is the force. So again, in a tornado, you might have the tornado may throw somebody. But similarly, a tornado very likely could pick up buildings and throw that building against someone. So those are sort of direct blows. But not not always, but often a direct blow you see when they get medical care. And so you can often anticipate what you're going to the health effect is going to be. But twisting is something that I worry a lot about, again, on a individual basis in terms of joints that are twisted, or, or, you know, the body that has a real torque to it in the mechanical mechanical harm, because the damage in a twist, whether it be to a joint or to say the abdomen, or the brain, if you think about as the brain, you know, if you think about the brain moving in the in the skull becomes really very important. And that leads us to the the actual damage to to to the organ that might be affected. So hit this slide. And you can look at these later, if you look at them, you'll get a chance to look at them. But I wanted to show you let's switch a second to electromagnetic radiation. And again, not that I want to bring you back to physics, but you got to think about this, when you're thinking about the health effect of the particular of what is possibly going to be affecting the population you are concerned with, you know, gamma rays, x rays are very, have very, very different health effects than microwaves and infrared heat, which is in the middle is really what we worry about very often with whether there's a fire, whether there's a flash fire, or whether people are going to get burned. So we when we think about heat, again, you know, you really have to think about heat from a fire, the real fire, where there may be combustion, where there's heat and flames, and then smoke. And as we all know, more and more fires are not just the carbonaceous material burning, but they're very often the chemicals that might be used, whether it's on furniture, on upholstery, on pipes, and then any vapors, fumes that might be released there. Heat is becoming more and more of a public health emergency. And we don't really have time to talk a lot about heat, but it's something and certainly in the occupational arena, employers are supposed to be and are much more comfortable worrying about heat, but it's not, it's something we don't think enough about in public health emergencies. And so you have to think about heat very much in a public health emergency, and how you're going to prevent significant heat effects to your population and what you really can do. And then finally, there's the electromagnetic radiation. So I want to just take you really quickly to remembering the different wavelengths. And again, you know, this probably put shutters for you, but it's, it's really very important in a public health emergency, because your role really is knowing, based on the wavelength of what the exposures are going to be, what the possible health effects are going to be. So heat exhaustion, you know, going back to heat, you know, we have, we have heat exhaustion, when people are just beginning to affect to, to have health effects. And then when people really start having very significant health effects, and certainly this past summer throughout the United States and throughout the world, there was much more heat exhaustion, heat stroke, that I don't know if it wasn't planned for, or if it wasn't thought through, but it should have been anticipated given what the public health emergency was, what the actual problem was. And so you could not turn on the news without real health effects of heat. And it's something that we should really be, be, be ready to deal with. And we have to make sure that whether the emergency workers are protected, or all the people in the area. So let's just talk a little bit about UV. And depending on where in the country you are, or where in the world you are, the amount of UV radiation that just comes from the sun becomes really very important. And the time of day that people are working to take care of the emergency. And, again, you know, daylight, the middle of the day, or sometimes the very worst time for people to be outside, when they're either when there is an emergency, or when they're cleaning up an emergency. And one of the things that we can keep reminding everybody is depending on the time of day, and how close you are to the equator, or the season, the absolute importance about thinking through how you're going to prevent people from having a health effect in the aftermath of the emergency. So, um, when we think about radiation, again, we typically always think about ionizing, which we'll talk about in a second. But non ionizing is becoming more and more of a problem, especially with lasers. And the things that are interesting about lasers is, if we all remember back to our physics, again, typically, we think about one over r squared, remember the radius squared. So typically, there's a cone of light that gets wider and wider, the further away you are from the source, not true with lasers. And so laser beams are unique in how, how much they can really target the organ that they're going after, and the burn that they can cause. And initially, we were using lasers in healthcare a lot. And in healthcare, supposedly, when people turn the laser on, they're really protected. But lasers are used an awful lot now in manufacturing, and, and have to really be thought about in times of emergencies when they have lost all of their, all of the, all of the controls in place. So I'm sorry, I have this slide out of, out of, out of order. But again, when we think about health effects of UV, and again, we're not really thinking more about skin, we worry about the skin burn in the short term. And that's really what ends up bringing people to medical attention. But I don't want you to forget the the other effects, the more intermediate long term effect of skin cancer and cataract. So this is just a picture looking at where the UV ray hits the health of the skin. And again, something for you to be able to, to advise around. So let's talk a few seconds about ionizing radiation. I'm going to finish up in a second and talk about the non-stochastic and the stochastic effects. And again, the non-stochastic is what we worry about, again, in the immediate effects. And I don't know if any of you hopefully have not been involved in any nuclear disasters or, or radiation, excess exposures, but the acute radiation syndrome that gets seen with the, the total decimation of blood count, the CNS destruction, and, and the GI leakiness are really something to behold. So I want, I'd like you, for those of you who want to look at this slide later, I think this is an excellent summary slide, if you will. And it really looks quite a bit, it's a, it's a CDC slide, and it really looks at different exposures, what our background exposures are and the symptoms of radiation exposure. So let's finally quickly talk about human health effect, biologic. And we're going to talk quite a bit about this when we talk about infections, but infections come from multiple places and we have to think about them. Remember that when animals die, their carcasses and their bedding really can cause health effects, can cause exposures. And we have to also think about human bodily fluids and, and it's either from living people or from carcasses. And so really do think about the, the different places that in your emergency, people are being exposed to, and then be prepared for those would be the hazards and be prepared for how you are going to protect your workers. And one of the things that drives me nuts, and I don't know if you, any of you had these experiences, but a lot of the EMS get to this or come to the scene without gloves on and wearing short sleeves, and that's their uniform and they are not prepared for the worst. And it drives me absolutely nuts. And I have more than once or twice have to tell an EMT to step away, gown up before they step back in. And often, you know, they're so engaged in the emergency that they do not protect themselves. And certainly those of us who are healthcare workers are much better at preparing ourselves for the emergency, but not so in the field. So again, when we talk about biologic hazards, we're going to talk about these, these different hazards, but do remember that plants and animals bring biologic hazards as well. And we now have genetically modified agents, which may affect the humans in ways that we are not necessarily used to. And if we all think about the avian flu virus right now, you know, again, it's not genetically modified, but we all know that based on what we know about the virus, it mutates a lot. And my understanding is it needs one more genetic modification to be able to be a human health hazard. And so again, for us to have a little understanding of the, either a genetically modified agent or the potential for it. And finally, we're going to cover this again, but I don't want to finish talking without us thinking through bacteria and viruses, which we think a lot about in the United States, much less around parasites, though there's certain areas we do think about. And in much of the world around the topic, parasites become hugely problematic. And again, you know, we don't think enough about the toxins produced by certain microorganisms. And for those of us who have worked with certain bacteria, it's their toxin that causes so much health effect. And then that toxin really is essentially a chemical, a chemical hazard. So I'd like to leave our last few minutes for questions and I'll take whatever comes my way if there is anything. Thank you so much, Dr. Alexander. It was a wonderful presentation. We did have a question come in while you were speaking. One, it's two parts. The first part is, can you share one successful strategy to convince mom and pop firms to protect their workers from chemical exposure? So how does this strategy differ from those used at larger firms such as Bethlehem Steel? So I will be the first public health, can you hear me? I will be the first public health social liberal to say that policy and regulation is what protects health. And so, you know, the advantage of a larger company that has over 50 employees is that OSHA can, there are OSHA standards and employers are hypothetically more worried about meeting regulatory standards. And certainly if you are a smelly company or well-known or well reviled in the community, your state OSHA or your state EPA is much more likely to be on their case and to be much, much more careful. And certainly I know at McCormick, McCormick often had smells in the air when they were making cinnamon, etc. And they also actually had times when there were microbiological wastes that ended up in the water supply. And you can bet your bottom dollar that the county EPA was in very quickly. The mom and pop is really very difficult, very difficult. And there are two things that can be a saving grace. One is knowledge and education. Another is about the exposure. Another is explaining or showing or providing the correct protective, you know, the PPE, the personal protective equipment, because often mom and pops don't even know what they can do, or they don't know simple things such as ventilation system or how often to change their filters, etc. And they worry that it's going to be expensive. So sometimes knowledge and even things like the fire department providing education or providing smoke detectors to small mom and pop sometimes helps because actually protecting their employees can be much less daunting when you really break it down into what the problem is to worry about. So certainly if you're a mom and pop deli, it's going to be very different than if you're a mom and pop hardware store, for instance. The other thing that sometimes helps is if they are, if you will, a law-abiding mom and pop shop, they have workers' compensation insurance and liability insurance, and often they actually have risk managers who for no fee will come in and help the mom and pop. So those are all things to really break it down and not just talk about exposure is big, but really break it to in this particular environment, what should we most worry about? Wonderful. Thank you, Dr. Alexander. And that was the only question I had in the Q&A. I wanted to direct the 24 remaining participants to the chat area if you'd like to pose any more questions. We also have provided the link that you are to complete post webinar, if you would, please. If anybody has any problems accessing, please feel free to reach out to myself or Natasha. And please, I'd be glad to take any questions or comments from anybody offline. And I know it was a little dry, but I think in some ways the concepts will hold everyone in good stead for their careers. We have another person who said, thank you. You're welcome. You're welcome. And actually, you know what I want to do, especially for those of you in PrevMed and public health, I urge you to do a rotation in either environmental health or occupational health. And during that rotation, for those of you who are in PrevMed, who aren't doing a lot, I would really recommend you read the Lange book on occupational and environmental medicine and actually have it in your library, either your electronic library or whatever, because first of all, I think it's a beautiful review of the subject. I think it's a great prep for the boards. And I think that it should stay on your shelf again, metaphorically or physically for your entire career, because I think as a public health physician or most other jobs in preventive medicine, you're going to need it. And someone else had complimented you, Dr. Alexander on the callbacks to chemistry and physics were actually very lovely. Oh my God. And another thank you. It's pretty upsetting to think that we still go back. Well, it's and the Lange book, we can also provide that link post webinar for everyone. It is sometimes it is nice to know that even when you've been practicing for the number of years I have, having taken those subjects way back when actually are useful. But I do want to say to all of you as physicians, this is something we are indispensable at marrying the population approach, and the clinical piece of it, and the real knowledge of human health, which no one else, nobody else can can do. That's amazing. You also had another compliment of great talk. Oh, thank you. Well, there you go. And I learned a lot and I'm not even medical. So thank you. You're a citizen of this world. That's exactly right. Thank you so much. Okay, wonderful. Thank you all. Anything else? I don't see any other questions. Okey doke. All right. Thank you so much, Dr. Alexander. All right. Good night, everybody. Thanks for listening.

public health emergencies

exposure preparedness

biological hazards

chemical hazards

radiological hazards

personal protective equipment

environmental pollutants

occupational health

risk management

preventive medicine