b. Medical and Work Histories

have had a depressant effect on his cholinesterase enzyme levels. It would be important to

include a test of this parameter in the pre-placement examination. Even some nonchemical

activities, such as previous work in a heavily dust-laden atmosphere, might have caused a

decrease of pulmonary function to an extent that an individual might find it impossible to wear

a respirator to provide protection against solvent fumes. Previous exposures to some chemicals

or substances may result in effects delayed for many years, such as the latency periods generally

associated with carcinogens. Among other substances for which any history of prior exposures

might be elicited would be asbestos, dusts, welding fumes, heavy metals, pesticides; herbicides;

acids, alkalis, solvents, dyes, inks, paints, paint thinners, paint strippers, gases, radiation, etc.

If there are any specific areas of concern because the work regimen will involve materials known

to have a possible impact on a given physiological function, or organ, then the physician should

supplement the standard questionnaire for both the medical and work histories with questions

designed to elicit as much relevant information as practicable.

There are any number of common diseases which are not necessarily related to an occupational exposure but which could be a risk in the work environment. Diabetes and

hypertension are certainly not necessarily work related, but the individual, unless treated, could

be a hazard to one’s self and potentially to co-workers. Similarly, a disease of the eyes, such as

glaucoma, could interfere with a person's ability to see properly, but many persons could be

unaware of its onset as it is an insidious disease, primarily a problem to persons over 40. A

relatively simple automatic instrument is available to detect pressure increases in the eyes, which

is a sign of the disease, and which would permit the physician to refer persons to an

ophthalmologist. Loss of hearing could be a problem if persons do not hear warnings and, again,

many persons do not realize that this has become a problem or are reluctant to admit it, even to

themselves, as a sign of increasing age. Although these problems should have been brought

to the attention of the individuals by their family physician, a surprising number of persons do

not have a family physician or do not see one frequently. As noted earlier, at the author's

institution, approximately 15- to 20% of the persons participating in the HA program for the first

time had reasonably serious problems of which they were unaware, and which could have placed

them at risk, or at best, reduced their efficiency and productivity. The scope of the examination

should be sufficient to detect these conditions which may not be job related.

c. Pre-Placement Examination

It would be highly desirable if a pre-placement exam could be given prior to any work exposure

to provide a true baseline for the individual. However, unless a medical examination has been

an integral part of an organization's employment procedure since the inception of the company

or institution, then instituting a HA program will always catch a number of current employees

already in the midst of research programs involving exposure to hazardous materials. A medical

examination at this time will still have significance in the sense that future examinations can still

be compared to the earlier one to detect changes during the interval between examinations.

However, the information gained in the exam, including any test results, will not necessarily

reflect the normal conditions for the employee. If, for example, an individual has been working

within the organization using agricultural chemicals and has a very low level of cholinesterase

enzyme at the time of the initial examination, it may be suspected that the employee's work has

caused the depressed level of the enzyme to occur, but it is uncertain. The individual may be one

who has a naturally low level. If a person is tested at the time of initial employment, then the effect

of the working environment on the parameters measured in the examination will be much more

apparent, although the effect of work exposures on an individual may be confused if similar

exposures are likely to occur outside the workplace. In the example just used, if the initial

examination revealed a normal enzyme level and a later one showed a depressed value, perhaps

after a suspected exposure, then the initial conclusion, barring any alternate exposure mechanism,

would be that an exposure had occurred and remedial steps taken to prevent further exposures

and to prevent future incidents of the same kind. Where alternate exposure conditions exist

outside the workplace which could have caused the same conditions, then there could be

problems for the employee receiving financial compensation for the problems, such as workmans

compensation.

The other major purpose of a pre-placement examination would be to avoid placing a person



©2000 CRC Press LLC



in a position in which an existing condition would be aggravated or the individual could be

injured by the work environment. A color-blind person, for example, should not be placed in a

position in which the ability to distinguish colors is essential to being able to work safely. An

individual with severely reduced pulmonary function should not be placed in a position requiring

wearing a respirator for protection. These restrictions may make it impossible for an applicant

to be offered a position, and it should be clearly stated in the advertised job qualifications in such

a case that passing a pre-placement examination is required as a condition of employment. A

byproduct of such a restriction is that the organization may be protected against acquiring a

future liability if, for example, a person with depressed pulmonary function is hired without an

examination and placed in a situation in which exposures could cause the same result, it could

be difficult to prove that the problem did not arise from a recent exposure. On the other hand,

detection of the problem in the pre-placement examination might lead to a decision not to hire

the individual because of the problem.

There are some pitfalls in using the pre-placement examination as an exclusionary device. This

was alluded to in Section VIII.C of this chapter, in which a cautionary flag was raised against

using it as a discriminatory device. This can occur with the best intentions in the world. An

organization may decide to exclude women of fertile age from a position in which they may be

exposed to a teratogen. Discrimination may be claimed if installation of engineering controls to

reduce the exposures to well below the permissible limits are feasible, but not done. A woman

may decide on her own not to work in an area where even low levels of an embryo toxin are

present, but the decision should be clearly her own with no taint of coercion. In the recent

revision to workplace rules involving radiation by the NRC, a provision has been added making

it the employer's responsibility to limit the exposure to the unborn fetus, but before the employer

can take the required steps, the woman has to herself declare her condition. If she should choose

not to do so, no matter how obvious it is, the employer may not be permitted to take the

necessary steps.

A fairly common practice in a pre-placement medical examination program, in addition to a

thorough physical and a battery of tests, is to take a serum sample to be stored in an ultra-low

temperature freezer. These samples take up very little space and are valuable should a question

later arise where a comparison between a current serum specimen and a baseline sample would

be useful. It is also possible and feasible to lyophilize the serum for storage. This might be cost

effective and space saving if a large number of specimens are to be kept.

d. Reexamination

Periodic reexaminations should be scheduled for all participants of a HA program, whether

it is a part of a program mandated by a standard, as is becoming more common in newer

regulations, or as a result of an internal decision based upon the level of usage. Note that the

new laboratory safety standard does not call for periodic examinations but only requires access

to a medical surveillance program on an “as needed” basis should an over-exposure occur or

might have occurred. The frequency of the reexamination need not be any fixed interval, but

should be based on the level of exposure. Returning to the use of pesticides, which could cause

a depression in the cholinesterase enzyme level, as an example, it might be desirable to test for

this one component prior to a period of active use, a second time at the height of the spraying

season, and again at the end of the period of activity (assuming the material is significantly

dangerous to humans). For less toxic pesticides, this amount of testing might be excessive, but

for intensive use of an exceptionally dangerous material such as parathion, it might be desirable

to test daily. However, normally there would be no reason to perform a complete examination at

an accelerated schedule such as this.

An annual testing interval between scheduled examinations is probably the one most often

used in HA programs for individuals with typical exposures in a representative laboratory.

However, for persons only marginally meeting requirements for participation, the interval between



©2000 CRC Press LLC



examinations might be extended to 2, 3, or 5 years. Some programs use a 5-year interval for a

complete physical, but recommend special tests more often. The National Institute of Health

(NIH), in their program for their animal handlers, recommends taking a new serum sample every

5 years, but does not require a complete physical each time. The medical advisor or occupational

physician should evaluate the requirements for each participant to establish the optimum period

between examinations.

After each examination, the physician should compare the results of the current examination

to the findings of previous examinations. Except in isolated instances, such as the depression

of the cholinesterase enzyme which we have been using as an example, or unless there has been

a severe exposure in which acute effects might be anticipated, the primary means of detecting

problems will be the comparison between the results of successive examinations. Changes in

various parameters which have been measured, such as pulmonary function, might vary slightly

between two successive tests, but a persistent trend toward poorer performance would indicate

damage to the respiratory system. Similarly, should a persistent trend develop for the other

parameter measured, the examining physician should discuss the work environment and other

possible contributing factors, such as leisure time activities, with the employee. In at least one

instance, a spraying program to control insects at a cottage where weekends were spent was a

major threat to an individual's health rather than any personal problem or exp osure from any other

source. The patient did not mention this factor to the physician because he did not recognize

it as a potential problem. As a result, the examining physician had major problems identifying

the cause of the individual's illness and was unable to treat it successfully. By the time the

problem was recognized, the patient had been highly sensitized to any similar material and had

some long-term health problems, that affected his capacity to perform many activities.

e. Utilization of Results

The primary purpose of the examination is to protect the employee, with a secondar y p u r p o s e

being to help protect the organization from the liability associated with unwittingly allowing an

individual to become ill due to the work environment. As noted earlier, a substantial number of

persons involved in a HA program may have existing problems which are not job related or, as

a normal course of events, develop health problems which are clearly not job related. These may

be detected during the HA examination, as readily as in any other comparable comprehensive

physical examination. Some organizations will assume direct responsibility for treating these

illnesses, although most do not, leaving the burden of seeking treatment on the patient.

Financially, there is only a moderate difference to the patient in many cases, due to the wide

availability of group health insurance plans, although the increasing costs of health care has

caused many employers to partially shift costs back to the employees. If the patient has the

responsibility of seeking out medical treatment, however, the condition may remain untreated,

although the examining physician should certainly encourage the individual to seek assistance.

In such cases, the employees should have the right to authorize the release of the medical records

to their own physicians and to have this done promptly by the organization for whom they work.

Where the physical examination reveals a medical condition which may be job related or is

aggravated by the duties of the person's job or the environment in which the individual works,

steps should be taken to protect the employee's health. One of the first things to consider is to

confirm that the condition exists or to obtain additional data to better understand the problem

by seeking additional tests, obtaining a second opinion, or referring the patient to a specialist.

These options should be discussed with the patient. In some cases, the situation is sufficiently

straightforward so that these follow-up steps would not be necessary.

Whether one postpones gathering supportive data from additional examinations depends

somewhat upon the seriousness of the problem which has been discovered and the work

situation. The physician, in consultation with the individual, his supervisor, and usually a



©2000 CRC Press LLC



representative of the department with overall responsibility for the organization's health and

safety program should meet to see what temporary steps can be taken to reduce the risk to the

employee. In some cases, the head of the department in which the employee works may have to

become involved if the supervisor does not have the authority or the flexibility to make changes.

Once all the data are obtained, consideration of the options that are available to protect the

employee should be carefully reviewed. A number of these should be routinely considered.

1. If the condition can be treated, a temporary change in duties may be all that is needed.

2. It may be feasible to make engineering changes to modify the work environment.

3. Personal protective equipment or safety devices can be used to reduce an individual's

exposure if engineering changes are not practicable.

4. It may be possible to change the job activity.

5. Job responsibilities may be distributed differently among personnel in the facility if the

person has a unique problem and if the duties causing the difficulties are not a problem

to the others.

6. It may be pos sible to reschedule the activity causing the problem to another time or to

modify the affected individual's schedule.

7. If there are no suitable options available within the individual laboratory, then relocation

within the organization should be considered.

Some of these options are more easily applied in the industrial environment than in the typical

academic laboratory, where each person may be supported on a grant and each laboratory is

nearly autonomous. There may be very little flexibility available to the laboratory supervisor or

laboratory director. This makes the task of treating the employee fairly much more difficult, since

t he work causing the problem usually must be done, and the laboratory supervisor does not have

the funds to hire a new person and provide work to justify keeping the original employee as well.

There may, in fact, be little flexibility of any kind if there are no positions available at the time for

which the individual is qualified or is willing to accept. However, every avenue must be explored,

because it is not permissible to maintain the individual in a situation in which their health may

be endangered, even if the person wishes to do so. A waiver of responsibility for any future

problems by the corporation or institution signed by the employee is not an acceptable

alternative, nor is it likely to be legally defensible.

In extreme cases in which every option has been examined and none are feasible, individuals

may have to cease to work in the organization either by resigning or being terminated for their

own protection. An employee relations specialist in matching persons to jobs as well as an

individual charged with seeing that employees are not discriminated against should be brought

into the situation well before this drastic step is considered. In such a case a financial severance

settlement, insurance such as workers compensation, or disability retirement options may be

available to the employee.

f.



Physician Training

Any physician involved in a health assurance program will have had the usual training and

exposure to a variety of medical experiences. It also is highly desirable for the individual to have

specific training in industrial medicine. Since the actual conditions of employee exposure to

hazardous materials will differ with each organization, the physician should be sufficiently familiar

with the types of exposures represented by the job descriptions of the employees to be able to

apply his own expertise and experience to the potential exposures. The more complex and

diversified the research programs in an organization, the more difficult this task will be, and

unfortunately, there are relatively few physicians trained as occupational physicians. It probably

would be desirable for the physician to set aside some time to visit the various research areas,

and visit with both the supervisors and individual employees.

Since OSHA requires that a medical surveillance program be made available to employees



©2000 CRC Press LLC



working with regulated carcinogens and a number of other materials, the physician should be

provided with all current information related to these standards as well as appropriate technical

information relating to these materials and other hazardous materials used by the employees. The

physician, should, for example, have access to a set of all current MSDSs for the chemicals used

by the employees. Subscriptions should be provided to some of the excellent services available

to keep track of the rapidly changing regulatory and technical information, as well as the usual

medical journals. The physician should have an opportunity to attend relevant workshops,

seminars, and professional meetings to ensure that his background is maintained at a high

standard.

Finally, the way in which the employees perceive the physician is an extremely important

component of an organization's health and safety program. He should be perceived as

professionally capable. It also is important that the employees do not perceive him as a

“company” man. They must feel that their health is important to the physician and that if they

are having a problem on the job, the physician is concerned about it for their sake, not because

it will cause a problem for the organization. Certainly the physician should be concerned about

the welfare of the organization, but this can be done by working to make sure that the health and

safety of the organization's employees is protected. This is one reason, as noted earlier, why the

name “health assurance program” is recommended over “medical surveillance program.” The

former has a much more positive sound than does the latter. Since a pre-placement medical

examination is recommended for individuals exposed to hazardous materials, the physician has

a superb opportunity to establish from the beginning that the company or institution is concerned

about the employee's well-being.

g. Records

Because many materials are now known to have long term effects and extended latency

periods are known to exist for many carcinogens, it would be desirable to maintain all records

pertaining to the medical examinations as well as those relating to exposures and monitoring for

an extended period, even after the employee had left the organization. Many of the specific OSHA

standards describe the records which must be maintained and the period for which the records

must be kept. However, 29 CFR 1910.20 covers the topic of health and safety records in general.

Some of the more, critical portions of this section are given below. Note that some of the language

is omitted (indicated by ...) where it was felt to be non-essential. Some of the requirements are

very detailed and demanding. The reader is referred to the OSHA Standards for General Industry

for the complete version of the requirements for record maintenance in the event that changes

were to be made.

Access to employee exposure and medical records

(a) Purpose: The purpose of this section is to provide employees and their designated

representatives a right of access to relevant exposure and medical records, and to provide

representatives of the Assistant Secretary a right of access to these records in order to fulfil

responsibilities under the Occupational Safety and Health Act....

(2) This section applies to all employee exposure and medical records, and analyses thereof,

of employees exposed to toxic substances or harmful physical agents, whether or not the records

are related to specific occupational safety and health standards.

(4) “Employee” means a current employee, a former employee, or an employee being assigned

or transferred to work where there will be exposure to toxic substances or harmful physical agents.

In the case of a deceased or legally incapacitated employee, the employee's legal representative

may directly exercise all the employee's rights under this section.



©2000 CRC Press LLC



(5) “Employee exposure record” means a record containing any of the following kinds of

information concerning employee exposure to toxic substances or harmful physical agents:

(i) environmental (workplace) monitoring or measuring, including personal, area, grab, wipe,

or other form of sampling, as well as related collection and analytical methodologies, calculations,

and other background data relevant to interpretation of the results obtained;

(ii) biological monitoring results which directly assess the absorption of a substance or

agent by body systems (e.g., the level of a chemical in the blood, urine, breath, hair, fingernails,

etc.) but not including tests which assess the biological effect of a substance or agent;

(iii) material safety data sheets; or

(iv) in the absence of the above, any other record which reveals the identity (e.g., chemical,

common, or trade name) of a toxic substance or harmful physical agent.

(6)(i) “Employee medical record” means a record concerning the health status of an employee

which is made or maintained by a physician, nurse, or other health care personnel, or technician,

including:

(A) medical and employment questionnaires or histories (including job description and

occupational exposures),

(B) the results of medical examinations (pre-employment, pre-assignment, periodic or

episodic) and laboratory tests (including X-ray and all biological monitoring),

(C) medical opinions, diagnoses, progress notes, and recommendations.

(D) descriptions of treatments and prescriptions, and

(E) employee medical complaints.

(ii)“Employee medical records” does not include the following:

(A) physical specimens (e.g., blood or urine samples) which are routinely discarded as

a part of normal medical practice, and are not required to be maintained by other legal

requirements,

(B) records containing health insurance claims if maintained separately from the

employer's medical program and its records, and not accessible to the employer by employee

name or other direct personal identifier (e.g., social security number, payroll number, etc.), or

(C) records concerning voluntary employee assistance programs (alcohol, drug abuse,

or personal counseling programs) if maintained separately from the employer's medical program

and its records.

(7) “Employer” means a current employer, a former employer, or a successor employer.

(8) “Exposure” or “exposed” means that an employee is subjected to a toxic substance or

harmful physical agent in the course of employment through any route of entry (inhalation,

ingestion, skin contact or absorption, etc.) and includes past exposure and potential (e.g.,

accidental or possible) exposure, but does not include situations where the employer can

demonstrate that the toxic substance or harmful agent is not used, handled, stored, generated,

or present in the workplace in any manner different from typical non-occupational situations.

(9) “Record” means any item, collection, or grouping of information regardless of the form

or process by which it is maintained (e.g., paper document, microfiche, microfilm, X-ray film, or

automated data processing).

(d) Preservation of records. (1) Unless a specific occupational safety and health standard

provides a different period of time, each employer shall assure the preservation and retention of

records as follows:

(i) Employee medical records. Each employee medical record shall be preserved and

maintained for at least the duration of employment plus thirty (30) years, except that healt h

insurance claims records maintained separately from the employer's medical program and its

records need not be retained for any specified period;

(ii) Employee exposure records. Each employee exposure record shall be preserved and

maintained for at least thirty (30) years, except that:



©2000 CRC Press LLC©



(A) Background data to environmental (workplace) monitoring or measuring, such as

laboratory reports and worksheets, need only be retained for one (1) year so long as the sampling

results, the collection methodology (sampling plan), a description of the analytical and

mathematical methods used, and a summary of other background data relevant to interpretation

of the results obtained, are retained for at least thirty (30) years; and

(B) Material safety data sheets and paragraph (c)(5)(iv) records concerning the identity

of the substance or agent need not be retained for any specified period as long as some record

of the identity (chemical name if known) of the substance or agent, where it was used, and when

it was used is retained for at least (30) years; and

(iii) Analyses using exposure or medical records. Each analysis using exposure or medical

records shall be preserved and maintained for at least thirty (30) years.

(e) Access to records. (1) General. (i) Whenever an employee or designated representative

requests access to a record, the employer shall assure that access is provided in a reasonable

time, place, and manner, but in no event later than fifteen (15) days after the request for access

is made.

(ii) Whenever an employee or designated representative requests a copy of a record, the

employer shall, within the period of time previously specified, assure that either:

(A) a copy of the record is provided without cost to the employee or representative,

(B) the necessary mechanical copying facilities (e.g., photocopying) are made available

without cost to the employee or representative for copying the record, or

(C) the record is loaned to the employee or representative for a reasonable time to enable

a copy to be made.

Employers can charge reasonable direct expenses for additional copies of records, except that

a certified collective bargaining agent for the employee can receive a copy without cost, and if

new information is added to the record, this information is available to the employee without cost

under the same conditions as the original record.

For certain medical records, there is protection for the privacy of the individual in making

records available:

Section (e)(2)(ii)(E) Nothing in this section precludes a physician, nurse, or other responsible

health care personnel maintaining employee medical records from deleting from the requested

medical records the identity of a family member, personal friend, or fellow employee who has

provided confidential information concerning an employee's health status.

and, under “Analyses using exposure or medical records:”

Section (e)(2)(iii)(B) Whenever access is requested to an analysis which reports the contents

of employee medical records by either direct identifier (name, address, social security number,

payroll number, etc.) or by information which could reasonably be used under the circumstances

indirectly to identify specific employees (exact age, height, weight, race, sex, dates of initial

employment, job title etc.), the employer shall assure that personal identifiers are removed before

access is provided. If the employer can demonstrate that removal of personal identifiers is not

feasible, access to the personally identifiable portions of the analysis need not be provided.

New employees have certain rights concerning records from the beginning of their employment.

(g) Employee information. (1) Upon an employee's first entering into employment, and at least

annually thereafter, each employer shall inform employees exposed to toxic substances or harmful

physical agents of the following:

(i) The existence, location, and availability of any records covered by this section;



©2000 CRC Press LLC©



(ii) the person responsible for maintaining and providing access to records; and

(iii) each employee's rights of access to these records.

Corporations are often bought out, merge with other firms, or cease to operate, and provision

is made in the standard for the retention of records for the required periods by transfer of the

records to the successor firm, or under requirements of specific standards to NIOSH. This is rarely

a problem for academic research institutions which seldom cease to operate, although

semiautonomous components which retain their own records may cease to exist. In such a case,

their records should be subsumed into those of the parent institution.

h. CPR and First Aid Training

Subpart K - Medical and First Aid, 29 CHR 1910.151 of the OSHA Standards for General

Industry describes the minimal medical care which must be available to employees, although there

are references to first aid in several other sections of the standards. This short section is given

below in its entirety:

Sec. 1910.151 Medical services and first aid.

(a) The employer shall ensure the ready availability of medical personnel for advice and

consultation on matters of plant health.

(b) In the absence of an infirmary, clinic, or hospital in near proximity to the workplace which

is used for the treatment of all injured employees, a person or persons shall be adequately trained

to render first aid. Adequate first aid supplies shall be readily available.

(c) Where the eyes or body of any person may be exposed to injurious corrosive materials,

suitable facilities for quick drenching or flushing of the eyes and body shall be provided within

the work area for immediate emergency use.

Appendix A to Sec. 1910.151--First aid kits (Non-Mandatory)

First aid supplies are required to be readily available under paragraph Sec. 1910.151(b). An

example of the minimal contents of a generic first aid kit is described in American National

Standard (ANSI) Z308.1-1978 “‘Minimum Requirements for Industrial Unit-Type First-aid Kits.”

The contents of the kit listed in the ANSI standard should be adequate for small worksites. When

larger operations or multiple operations are being conducted at the same location, employers

should determine the need for additional first aid kits at the worksite, additional types of first aid

equipment and supplies and additional quantities and types of supplies and equipment in the

first aid kits.

In a similar fashion, employers who have unique or changing first-aid needs in their workplace

may need to enhance their first-aid kits. The employer can use the OSHA 200 log, OSHA 1OP1s

or other reports to identify these unique problems. Consultation from the local fire/rescue

department, appropriate medical professional, or local emergency room may be helpful to

employers in these circumstances. By assessing the specific needs of their workplace, employers

can ensure that reasonably anticipated supplies are available. Employers should assess the

specific needs of their worksite periodically and augment the first aid kit appropriately.

If it is reasonably anticipated that employees will be exposed to blood or other potentially

infectious materials while using first aid supplies, employers are required to provide appropriate

personal protective equipment (PPE) in compliance with the provisions of the Occupational

Exposure to Bloodborne Pathogens standard, Sec. 1910.1030(d) (3) (56 FR 64175). This standard

lists appropriate PPE for this type of exposure, such as gloves, gowns, face shields, masks, and

eye protection.

[39 FR 23502, June 27, 1974, as amended at 63 FR 33466, June 18, 1998]



©2000 CRC Press LLC



Effective Date Note: At 63 FR 33466, June 18, 1998, Sec. 1910.151 was amended by revising

the last sentence of paragraph (b) and by adding appendix A to the section, effective Aug. 17,

1998.

The need for access to medical services in emergencies was discussed at some length in

Chapter 1. Prompt action can frequently save an individual's life or can significantly reduce the

seriousness of injuries. Although not intended as an instruction manual, Chapter 1 presented

some first aid procedures for accidents involving chemicals and CPR techniques. It would be

highly desirable for individuals working in facilities where hazards are present to be trained in

both of these subjects. By working carefully so as not to tempt fate too much, and with a great

deal of luck, an individual may go through an entire working career without personally

experiencing an accident or being present when someone else does, but this cannot be counted

upon. Although you cannot perform CPR on yourself, and you may be incapacitated so that even

simple first aid is beyond you, if enough personnel in a laboratory do make the effort to become

trained, it is likely that someone will be available to start emergency aid while waiting for more

skilled personnel to arrive. The institution at which the author worked had an in-house volunteer

rescue squad and the members of this squad as well as the town squad were scattered throughout

the university. Although the rescue squad was normally present within 3 to 4 minutes, on several

occasions these on-scene personnel were instrumental in ameliorating severe accidents prior to

the squad’s arrival. The training for basic first aid and single-person CPR is not difficult, and

everyone should annually devote the few hours necessary to receive and maintain these skills.

Many rescue squads, fire departments, hospitals, and other public service agencies offer the

training at a minimal fee covering only the cost of the manuals and supplies.

i. Vaccinations

All of us as children probably received some vaccinations against a number of diseases. A

number of common diseases afflicting children who were born in the first third of this century

are now decreasing in frequency as a result of widespread vaccination programs. A recent

controversy centered around whether the last smallpox virus in the world, being maintained in

a laboratory, should be destroyed. Yet this used to be one of the world's great killers. Relatively

recently vaccinations for other diseases have been developed, and diseases such as polio and

measles are relatively rare now in the United States, although, unfortunately, there has been a

modest resurgence of these two illnesses. Tuberculosis is also on the rise as a consequence of

the spread of AIDS. It would appear that with the obvious benefit, vaccination against a disease

would be a matter of course, providing that a vaccine exists. This is not necessarily the case.

Several factors need to be considered in determining whether vaccination is desirable or not.

The first clearly is: Does a safe, reliable vaccine exist? At one time, rabies vaccine using duck

embryos was the best available. However, it did not always provide a reliable immunization, and

a significant fraction of the persons on which it was used had reactions, some of which were

neurologically very severe. Now, a much more reliable human diploid rabies vaccine is available

which provides protection for a very high percentage of persons, and the incidence of untoward

reactions is very low. It is probably desirable to mandate vaccination for all personnel who face

a high risk of exposure to rabies, i.e., persons who work directly with animals that might be rabid,

individuals who do necropsies on such animals, and technicians who work with untreated tissue

from potentially rabid animals. The second question is: What is the risk-benefit to the individual

if the disease is contracted? The disease may not be sufficiently serious as to warrant the risk

of a possible reaction to a vaccination. On the other hand, if the disease is sufficiently life

threatening, then the use of a vaccine would be indicated. Third: Is there a satisfactory post-



©2000 CRC Press LLC