Synthetic materials found in today’s residential structures present a unique danger to firefighters. Such materials emit toxic hydrogen cyanide and carbon monoxide when they burn. The toxins then can enter firefighters’ lungs during overhaul when air packs often are removed, or seep into the fabric of their bunker gear — resulting in a high risk of long-term cardiac health problems and incidents of cancer in those who go untreated.

Indeed, hydrogen cyanide (HCN) is a systemic chemical asphyxiant that interferes with the normal use of oxygen by nearly every organ of the body. The Centers for Disease Control and Prevention reports that cyanide exposure quickly can result in a fatality because it affects those organ systems most sensitive to low oxygen levels: the central nervous system, the cardiovascular system and the pulmonary system. For those exposed to cyanide, symptoms can include light-headedness, giddiness, rapid breathing, nausea, vomiting, confusion, restlessness and anxiety. Severe cyanide poisonings progress to stupor, coma, muscle spasms, convulsions and death, the CDC reported.

Such occupational hazards were the impetus for developing firesmoke.org, an informational website about the dangers of cyanide as well as carbon monoxide. The website is run by the Fire Smoke Coalition, a nonprofit organization comprised of firefighters and medical personnel. The site dubs CO and cyanide as the “toxic twins” of smoke inhalation because they are released from rubbers, plastics, laminates and other synthetic materials found in modern-day residential structures, and they have deadly synergistic effects, said Shawn Longerich, the executive director.

“It’s all about helping firefighters understand they have entered a new era of fire smoke because of the synthetic materials being used,” Longerich said.

While firefighters wear their SCBA during active firefighting, the devices often are removed during overhaul. Longerich said in the past, many firefighters may have assumed the air was safe to breathe during this phase, but tests have shown high levels of cyanide still are present while materials continue to smolder and release gases. In addition, firefighters are at risk if they do not properly handle their bunker gear after a fire and clean it immediately.

“We’ve had departments that have actually changed their PPE washing policies based on that,” he said. “In one town, every fighter has two sets of gear because the toxins can seep into the fabric and be absorbed through the skin.”

Longerich admitted that there are no specific studies to support her claims about the effect of cyanide exposure on firefighter health. However, CDC documents always have warned hazmat teams about the dangers of long-term exposure to even small amounts of cyanide.

“We think about the chronic exposures endured during overhaul — they get little bits from every single fire and it starts eating away at the heart and the brain,” she said. “What we are starting to realize is that a lot of the cardiac sudden deaths, dying in their sleep, all of a sudden they got too much cyanide and it took them down.”

Longerich recommended that incident commanders change protocols to protect firefighters. To help chiefs, the organization has developed two programs and associated educational videos — paid for through a Fire Prevention and Safety grant — that will be introduced this month at FDIC. The educational campaigns explore the dangers of toxins and treatment options, and promote the use of atmospheric monitoring — something that currently is not being done on the fireground.

The first campaign, dubbed “Out of Air,” specifically focuses on air management during active firefighting. The campaign stresses the importance of following the rules of air management during an incident and explains how to implement NFPA 1404 without budget impacts.

Sidebar: Antidote for Cyanide Poisoning

“It’s about changing the mindset and the culture,” Longerich said.

The second program, dubbed “Aftermath,” focuses on providing treatment after exposure. It is vitally important to promptly recognize exposure and receive appropriate treatment, Longerich said.

“If they can measure HCN exposure through atmospheric monitoring, they can treat firefighters and civilians properly and save lives,” she said. “The toxins are invisible, so the only way to detect it is through atmospheric monitoring. But people haven’t been trained on how to monitor a perimeter and use the equipment.”

As a result, Longerich is lobbing for a standard protocol to be developed for atmospheric monitoring. The standard would include procedures for measuring toxin levels along the footprint of the property, at incident command, downwind of the fire and even in multi-unit apartment buildings that might be affected. She said toxins often are found within other units in a residential structure, even without the presence of smoke or fire.

“In the second and third division of apartments away from where the actual fire occurred, where there was no smoke, we find high cyanide readings in the apartments,” she said. “What you are doing is allowing residents to go back into the apartments with high levels of HCN.”

Measuring HCN has become a priority at the Columbia (S.C.) Fire Department, said Jason Krusen, shift captain, hazmat team member and incoming president of the Fire Smoke Coalition. Krusen said using detection equipment helps scene commanders determine the risks that firefighters face.

“We’ve known for years what is in smoke,” Krusen said. “We need to be educated and use the right equipment to recognize the hazards that we are subjected to.”

In Krusen’s department, incident commanders use recently purchased HCN and CO mobile chemical detectors to help them measure toxins released into the air during a fire. The department measures carbon monoxide and HCN separately. Since not every unit has a detector, the devices are placed strategically throughout the response area. This is because the sensors have found significant readings outside the burning structures, where firefighters assumed they were safe, he said.

“We found the guys fighting the fire wearing the SCBA were more protected then those at the curb or at the truck,” he said. “It is present without visible smoke, so even though you may be standing outside the smoke, the toxin is still present — even out by the road we still get readings from those meters.”

If toxins are present, affected firefighters are treated with antidotal medicine by an on-scene paramedic.

“The drug is intravenous so it would have to be a paramedic that administers it,” Krusen said.

Krusen said that fire chiefs should ensure that firefighters wear their SCBA through overhaul, ensure PPE is cleaned after an incident and invest in atmospheric monitoring devices.

“We have all these health issues, because we are not protecting ourselves,” he said.

A Mistaken Assumption

The International Association of Fire Chiefs, patient-monitoring solutions vendor Masimo and the International Association of Fire Fighters all are concerned about the toxic chemicals released into the air by fires. They together recently launched “Silent Killer,” an educational campaign aimed at raising awareness about the duty-related dangers of carbon-monoxide poisoning. The campaign includes a 6-minute video that highlights health risks associated with CO exposure and a new website to educate fire leadership about how best to protect personnel, especially during the overhaul phase when SCBA often are removed.

“Chiefs need to recognize during overhaul that there’s still a significant risk of the firefighters taking in CO and that CO poisoning is very dangerous to the health and well-being of our personnel,” IAFC President Jack Parow said.

The campaign also discusses mitigation strategies and tactics for monitoring personnel on scene, including using approved, noninvasive portable chemical detectors to measure the CO levels of those working the fire scene. Parow said that such devices can provide near-real-time readings and can signal when a firefighter needs to be removed from the scene.

To prevent exposure, the campaign encourages firefighters to wear protective masks during active fire and overhaul operations because CO still is present in the air, Parow said. For example, at his fire department in Chelmsford, Mass., fire investigators who sift through smoldering debris during overhaul are required to wear pressurized filter masks. The department also places mobile chemical monitors in the area to measure oxygen and CO levels.

“The Silent Killer program makes people aware that you have to be really careful after the initial stage of the fire to keep your SCBA on, and even monitor the area for CO and oxygen levels to make sure firefighters are safe,” Parow said.

Other silent dangers include ultrafine particles released in the air during a fire, according to the findings of a study that involved the University of Cincinnati, Underwriters Laboratories and the Chicago Fire Department. Researchers found exposure to harmful ultrafine air particulates could predispose firefighters to heart disease — particularly those in less-than-optimal personal health, said C. Stuart Baxter, associate professor in the university’s department of environmental health.

The study was the first to characterize the size and distribution of particulates, including those in the ultrafine range, during domestic fires, Baxter said. Researchers conducted a series of simulated house and automobile fires to measure breathable particulates released during combustion and fire suppression, including the knockdown phase where firefighters are required to wear protective breathing equipment, and the overhaul phase when they are not. He said that researchers found that levels of ultrafine particulates invisible to the naked eye were highest during overhaul.

“This is the stage when a firefighter may remove their equipment,” Baxter said. “A firefighter would normally assume he can breathe the air, but that may be a mistaken assumption.”
Baxter said that more than 70% of the particles in the air during overhaul were invisible, and that ultrafine particles have been found to cause heart disease.

“We think firefighters should be aware that they should be wearing some breathing protection right through overhaul,” he said. “Air during overhaul is still hazardous to breathe.”

Sidebar: Treatment for Inhalation of Cyanide

While it’s probably too much to ask a firefighter to wear heavy gear all the way through overhaul, which may last an hour or more, Baxter said that firefighters should have breathing protection throughout the firefighting process. At the least, firefighters should be encouraged to wear well-fitting filter masks. He also recommended that chiefs swap out personnel during overhaul.

“Have firefighters with fresh air rotate in and bring the other ones out who have been working for awhile,” he said. “Of course, that will be difficult in these times, where unfortunately the fire service [personnel numbers] have been reduced.”

There’s More to Worry About

Toxic exposure isn’t found in smoke alone. In fact, Deepwater Horizon oil-spill responders already are reporting chronic health problems that may be associated with toxicant-induced loss of tolerance (TILT) disease, said Claudia Miller, a professor at the University of Texas’s Health Science Center in San Antonio. The multisystem-symptomatic disease causes fatigue, sleep problems, headaches, digestive difficulties, and problems with memory and concentration.

TILT results when first responders are exposed to toxins and then later develop new intolerances to everyday exposures, such as feeling dizzy or nauseated around engine exhaust, cleaning chemicals and fragrances, or ill after eating certain foods or drinking just one can of beer, Miller said.

“The hallmark for the TILT phenomena is that [first responders] are showing new intolerances toward food, medications, caffeine and, most commonly, everyday chemical exposures that weren’t a problem for them before,” she said.

TILT is a new theory of disease, and scientists now are able to link multisystem symptoms after chemical exposure to the post-World War II chemical age that introduced into the environment synthetic organic chemicals derived from oil, plastic, coal and gas, among others, Miller said. As a result, TILT almost always is caused by exposure to petrochemicals, so all Gulf Coast clean-up crews were at risk, she said.

Flu-like symptoms after an exposure are common. But Miller said that new symptoms arise in as little as two weeks after exposure.

“Stage 1 of TILT is having flu-like symptoms,” she said. “Stage 2 is when lots of different exposures trigger symptoms and perpetuate illness.”

Miller said that oil-spill responders reported difficulty breathing, headaches, fatigue, sleep difficulties, confusion, memory and concentration problems, irritability and mood changes. Also reported were new intolerances, including feeling ill after exposure to diesel- or gas- engine exhaust, fragrances or cleaning products. “We think these new intolerances people develop … are the hallmark symptoms of TILT,” she said.

Miller suggested that incident commanders running hazmat and fire scenes should monitor those exposed to chemicals. Those exposed tend to become symptomatic on scene and immediately should be relieved. If they are not getting better overnight or over a few days, a chronic problem may be setting in.

Miller offers the QEESI test to help first responders determine whether they are susceptible to TILT. She also recommends that chiefs download the “Chemical Exposures: Low Levels and High Stakes” report to learn more. Both are available free of charge at http://drclaudiamiller.com/publications-presentations/.