FIRST AID KIT POLICY AND GUIDELINES _________________________Safety Policy OSHA medical service regulations mandate that the "employer shall ensure the ready availability" of medical personnel and first aid supplies for matters of employee health. Medical care at the (Company) is available through the (Company) Health Service, the workers' compensation providers for each respective campus, and local hospitals (see Chemical and Biological Safety in Laboratories, Medical Emergency Procedures). (Company) safety policy, as established by the Chemical and Biological Safety Committee (CBSC), also manages compliance with this law by requiring principal investigators or lab supervisors to provide a first aid kit for each lab group. First aid kits shall be readily accessible to laboratory staff at all times while they are at work. Lab workers shall be trained to know the location of the kit. Hazard-specific first aid supplies shall be made available, as appropriate, when research work involves particular chemicals such as hydrofluoric acid. Exposures to this severely toxic agent warrants immediate application of a special remedy. GUIDELINES FOR PROVIDING ADEQUATE SUPPLIES General Overview of First Aid Kit Contents OSHA demands that a "consulting physician" approve first aid kits. In essence, this means that the contents of basic kits purchased from safety and laboratory supply companies are expected to have been reviewed for appropriateness and completeness by a physician. Any kit ordered through a commercial distributor is likely to meet this stipulation since the manufacturer will develop the standardized product based on medical counsel (for liability reasons). If in doubt at the time of purchase, request that the distributor enclose formal documentation of the consulting physician's endorsement. An alternative option is for lab groups to "design" their own kits. These kits would need to be approved by a physician as well but, in this case, the kit preparers must identify the medical advisor themselves and maintain individual records of official approval. Factors to consider in selecting a kit: 1. the supplies should be consistent with the types of injuries anticipated in this research space (e.g., will there be burns, cuts, fractures, contusions, or allergic reactions?) 2. its size must be appropriate to the number of people who will be using the kit supplies should be provided in single-use or -dose unit-type packs with suitable wrapping to ensure sterility and hygiene the case should be dust and moisture-resistant with no sharp edges consider the most convenient storage method for easy access-wall-mounted or portable? 3. the assortment choice shall have received final clearance from a qualified medical expert. As a practical model, the American National Standards Institute's Minimum Requirements for Workplace First Aid Kits (ANSI Z308.1-1998) recommends that basic units should contain: ■ absorbent compress (32 sq. in. with no side smaller than 4 in.) ■ 16 adhesive bandages (1 x 3 in.) ■ adhesive tape (total of 5 yd.)

First Aid Kit Policy, Rev. 4-2004 • • • • •

10 individual-use antiseptic applications (0.5 g each) 6 individual-use burn treatment applications (0.5 g each) 2 pairs of medical exam gloves 4 sterile pads (3 x 3 in.) 1 triangular bandage (40 x 40 x 56 in.)

Commercially available kits prepared to ANSI standards will be labeled to indicate this status. ANSI, the Red Cross, and/or ORS propose these optional use items: • bandage compresses of various pad sizes ranging from 2 x 2, 3 x 3, or 4 x 4 in. • eye covering(s) with the ability to cover both eyes (an area of at least 2.9 sq. in. per eye) • eyewash (a minimum of 30 ml of sterile, isotonic, buffered solution in individual-use 15-ml applications) NOTE: Not intended to replace a plumbed eyewash fountain for proper flushing. Meant to be used for the purpose of restoring pH balance. • cold pack (4 x 5 in.) • gauze roller bandage (2 in. wide, 6 yd. long) • adhesive bandages of assorted sizes • plastic bags • scissors with rounded tips • tweezers (forceps) • a small flashlight with extra batteries • a blanket • eyewash cups or eye irrigator loops • suction-type contact lens remover. The listing of the materials included in the ORS first aid kits is available to those wishing to compare their prospective kits to an existing example. Contact ORS for further guidance (CH 3-8300, EV 15581). Eye Irrigation When flushing the eye at an eyewash, it is important to hold the eyelids open and to roll the eyeballs so that water will flow over the entire surface of the eye. A major problem in irrigation at a plumbed eyewash is the difficulty in keeping the eye open due to possible pain or eyelid spasm. Most eyewashes irrigate the central portion of the cornea but may miss the superior cul-de-sacs (recesses of the external surface of the eyeball). Materials trapped in this area could cause significant damage and need to be removed quickly. To solve this dilemma, use of a specialized eye irrigation device is recommended to supplement flushing at the eyewash. This type of product provides an irrigation loop that is designed to slide up easily under the upper eyelid without having to pry open or otherwise traumatize the eye. Sterile saline is the irrigate. Consider supplying an Eye Irrigator™ in your first aid kit. They are available from American Health and Safety, Inc., 6250 Nesbit Rd., PO Box 46340, Madison, WI, 53744, phone 800-522-7554, for $19.95 p. 2

(product # W2020). Personal Protective Equipment for the First Aid Provider Personal protective equipment (PPE) shall be available in each lab for persons providing first aid/CPR assistance. The PPE shall be in close proximity to the kit location. PPE supplies may consist of latex or vinyl disposable gloves, safety glasses, CPR protective shields, and a face shield. Selection will depend on the training of the first aid responders. Training Principal investigators and lab supervisors are responsible for training lab workers regarding the location of first aid kits and PPE accessories. The CBSC and ORS both recommend that at least two members of each lab group receive first aid and CPR training. PIs/supervisors must determine whether to arrange for and/or sponsor first aid and CPR training for their staffs.

First Aid Kit Policy, Rev. 4-2004 If there are lab workers who have particular sensitivities or medical problems that could interfere with first aid procedures, consider discussing this issue with the entire staff. Barring any confidentiality concerns, it is wise to prepare colleagues for possible reactions or symptoms should an employee suffer from an illness that demands special care. An employee with a given medical condition (e.g., asthma, heart disease) may require prescription drugs during a respiratory attack or illness episode. Whenever possible, warn staff of the specific procedures needed to help a worker with a preexisting health complication. MAINTENANCE OF FIRST /41D SUPPLIES (Company) safety policy requires monthly inspections of first aid kits. Inspection elements: •

is the kit at its assigned site?

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are the kit contents complete and have used or damaged items been replaced?

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what is the condition of the contents (are they dry, properly packaged, clean, etc.)?

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are there any signs of tampering or vandalism of the kit or its contents?

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are there extraneous, unnecessary items stored in the kit? (these should be removed)

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check expiration dates and replace any out-of-date contents

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is an instruction book or first aid manual available? is there a notice that warns staff that any injury requiring first aid application should be followed by professional medical attention?

FIRST AID PROCEDURE FOR RESPONDING TO HYDROFLUORIC ACID BURNS Introduction Hydrofluoric acid is an extremely hazardous liquid. It can cause severe skin and eye irritation or deep-seated, slow to-heal burns. In certain cases, exposure can prove fatal. For any major exposure to HF, immediate paramedic assistance is necessary. HF's mode of action is to bind calcium whenever contact occurs with skin or other body tissues. Unlike the action of other acids, which are rapidly neutralized, tissue destruction and neutralization of HF may proceed for days. Because calcium is necessary for cell life, its binding can bring about rapid cell death. If the exposure is extensive, excessive amounts of calcium may be inactivated and inadequate supplies of calcium may be available for vital bodily functions. Inform the physician treating the HF injury the nature of the chemical involved in the exposure and deliver a Material Safety Data Sheet (MSDS). Some medical providers may not commonly encounter HF. Offer as much information as possible regarding the chemical and its effects. Encourage the physician to consult an occupational specialist for further information, if needed.

Skin Contact Skin contact with hydrofluoric acid may cause severe burns. At concentrations of less than 50% hydrofluoric acid, the burns may not manifest immediately. Fluoride ions penetrate the skin easily and, thus, the burns may be deep and can cause considerable damage. Use and application of the antidote gel should not be based on the visible observation of burns but on the knowledge of dermal contact. Be cognizant that exposure may occur under fingernails, where antidote application is especially challenging. Therefore, medical care is absolutely essential. 1. Remove the victim to a safe location. Use protective equipment when handling a contaminated victim. 2. Immediately flush the exposed skin with water for a maximum of 5 minutes. Flush well but briefly. It is critical to apply antidote as soon as possible. 3. Remove contaminated clothing during washing. Cut away clothing, if necessary, to avoid injuring affected skin. 4. While someone is assisting the patient with rinsing of the exposed skin, another lab member shall contact the local police at 911 in an emergency. Paramedics will be necessary for hospital transport. (Police can be reached at _______ for non-emergencies, and ORS can be reached for laboratory assistance at ____________________.)

First Aid Kit Policy, Rev. 4-2004 5. After adequate 5-minute rinsing, apply calcium gluconate gel to the skin gently and freely. Aggressively massage the gel into the affected part (wearing gloves) and continue to reapply and massage until pain is entirely relieved. If medical assistance is delayed, apply gel every 15 minutes until pain and/or redness disappear or until the emergency rescue team arrives. If the exposure is to a hand, the gel may be placed in a latex glove and the glove placed over the hand to maintain beneficial contact with the affected area. • Use as many tubes of calcium gluconate gel as required by the directions but throw away all tubes that have been opened during first aid treatment of the injury. Opened tubes should not be saved for later reuse. Fresh tubes are sealed for sterility protection. • Following an incident involving use of the gel, ensure that the supply of gel remains adequate. Replace the gel when the expiration date is exceeded. 6. All hydrofluoric acid burns are to be evaluated by a physician, usually in the emergency room setting. This includes burns to a very small area of the skin and those treated with gel. Further reapplication of antidote gel or other medical procedures may be necessary at the emergency room in order to prevent reversion of the acid burn. Eye contact Hydrofluoric acid can cause severe eye burns, with destruction or opacifıcation of the cornea. Blindness may result from severe or untreated exposures. Immediate first aid is necessary. 1. Immediately flush eye(s) for at least 5 minutes. 2. Irrigate the eye repeatedly with 500-1000 ml of a 1% calcium gluconate solution applied through a syringe. 3. Call for prompt emergency room transport. Apply ice-water compresses during transport. 4. Send the patient to an eye specialist as soon as possible. Inhalation Concentrated solutions and anhydrous hydrofluoric acid produce pungent fumes on contact with air. These fumes can cause nasal congestion and bronchitis, even in low concentrations. Burns that occur when the vapors or liquid contact the oral mucosa or upper airway may cause severe swelling, to the point of airway obstruction. 1. Immediately move the victim to fresh air and seek medical attention. Trained medical responders will be necessary to administer oxygen and nebulized calcium gluconate. 2. Keep the victim warm, quiet, and relatively comfortable. 3. If breathing has stopped, start artificial respiration at once. CALCIUM GLUCONATE GEL AS ANTIDOTE TO HYDROFLUORIC ACID BURNS ON SKIN 1. •

Calcium Gluconate 2.5% Topical Gel can be purchased from Pharmascience Inc., 175 Rano St., Buffalo, NY, phone 1-800-207-4477. The cost per 25-gram tube is $27.55 but a minimum order of 6 tubes is required. A reduced price of $22.05 per tube is attached to purchases of 12 or more tubes. Pharmascience will add a 5% shipping and handling fee.

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Cameron Medical, 9430 Burtis Street, South Oak, CA, 90280, phone 1-800-777-3723, Item #751500. The price is currently $33.11 per 25-gram tube. This does not include the cost for delivery.

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Attard's Minerals, 5081 Field Street, San Diego, CA, 92110. Order by phone 1-619-275-2016. A 30-gram tube is $28 and a 60-gram tube is $46. There is no minimum to buy. Orders of 6 or more get a 10% discount. Orders have a$5 flat rate S&H charge.

This gel is available without a prescription (although please be aware that it is not approved by the FDA). Prices are current for Apri11999. FYI, ORS stocks two tubes on each campus: one in the first aid pack and one in the waste room. The philosophy behind the stock distribution is to have the gel immediately available in any location where HF may be handled. Some lab workers keep gel supplies ready-to-grab on the air foils (sills) of the fume hoods where they will be working with this highly corrosive agent.

First Aid Kit Policy, Rev. 4-2004 2. If the commercial gel product is not available, an emergency in-house version can be prepared for treatment of hydrofluoric acid burns on skin. This homemade gel is composed of 3.5 grams of calcium gluconate powder mixed into 5 ounces of water-soluble lubricant such as K-Y Jelly or Surgilube. Pre-made stock should be kept on-hand whenever HF is to be used. There is little time for deliberation and searching for the tubes. HF users may want to run practice drills for possible HF incidents to guarantee that they can follow appropriate procedures quickly and automatically. 3. A local pharmacy may also be available to prepare antidote gel. The pharmacist may choose to substitute magnesium for calcium. NOTE: The major action of either of these two gels, commercial or homemade, is to provide excess (or substitute) calcium stores so that bone tissue does not act as the calcium supply. The calcium from the gel will function as a fluoride scavenger to generate calcium fluoride, a product that may be excreted from the body. Removal of calcium from blood and tissue by fluoride ion attack results in a serious, frequently life-threatening condition known as hypocalcaemia. All HF burns require a medical evaluation, whether treated with gel or not.

REFERENCES Segal, Eileen B, "First Aid for a Unique Acid: HF," Chemical Health and Safety, September/October 1998, Vol. 5, No. 5, p.25. Bronstein, A. C. and Currance, P. L. "Emergency Care for Hazardous Materials Exposures." Mosby Company, 1988.

FIRST AID KIT MONTHLY INSPECTION RECORD Procedure 1. Perform the inspection by visually evaluating each item in the first aid kit. Confirm that the contents are m agreement with the list of contents approved by the consulting physician. Ensure that the items are present in sufficient quantity and, if appropriate, in good working order. 2. Enter the date, your initials or name, and the outcome of the inspection. Record a "YES" if the condition is acceptable. 3. Note any observations and the date and nature of any remedial action. Note if any expiration dates have been exceeded and arrange to replace these items immediately. 4. Maintain this record in the laboratory-specific Safety Desk Book or with the kit.

Date

Inspection performed by:

Condition Yes O No O Yes O No O Yes O No O Yes O No O Yes O No O Yes O No O Yes O No O Yes O No O Yes O No O Yes O No O Yes O No O Yes O No O Yes O No O Yes O No O Yes O No O Yes O No O

Notes