BY ROB SCHNEPP, KEVIN J. REILLY, AND MIKE GAGLIANO
Americans are, by and large, assaulted with a steady stream of revolutions. There’s been no shortage of fitness and dietary revolutions over the years, each one offering unbelievable results with little effort and a money-back guarantee. The ongoing technology revolution has promised increased productivity and more free time; and the banking industry revolutionized money lending to the point that it failed and is getting back to the basic principles of borrowing and lending. Unfortunately, the pace of life is so fast and there are so many new widgets and ideas out there that “revolution” has become synonymous with less-volatile terms like “development” and “progress.” Unfortunately, such common usage of the term has watered down its meaning.
In reality, true revolutions are anything but benign. Think about this definition of revolution—a drastic and far-reaching change in behaving and thinking. Revolutions are fueled by a genuinely new way of thinking, risk taking, and the courage to do things completely differently—something the American fire service is not entirely comfortable with. This is not to say that we are backward or unable to embrace new ideas. We are, however, accurately characterized as 200 years of tradition unimpeded by progress.
Why all the talk of revolution? Because the fire service is in the middle of a revolution fueled by smoke—a far-reaching revolution that is challenging and changing everything we thought we knew about smoke, the firefighter’s constant companion.
Research proves to us that smoke is bad. We all know that. We know that smoke kills more people than flames and that breathing smoke isn’t good for a whole host of reasons, including acute carbon monoxide, cyanide poisoning, and long-term cardiac and neurological dysfunction. So why do we still go to fires and not wear our self-contained breathing apparatus (SCBA)? And we’re not talking about wearing the tank with the mask dangling around your neck. After the fire is knocked down, why is it that firefighters drop their SCBA and perform overhaul in the smoldering debris, breathing all those products of incomplete combustion? Why do we put so much effort into rapid intervention teams, when the current method of medically treating someone after the rescue is largely ineffective? We’ve figured out a better way to rescue our own but have not completed the loop by using an effective antidote to correct a potential cause of death in smoke inhalation victims—cyanide poisoning.
AWARENESS
Smoke has become such a constant companion to us that it’s possible that we as an industry may have lost respect for it. It’s important to remember that smoke production is dependent on several factors, including the chemical makeup of the burning material, temperature of the combustion process, oxygen content supporting combustion, and the presence or absence of ventilation. Fire is truly a complicated chemical process, and the smoke produced is an intricate collection of particulates, superheated air, and toxic chemical compounds.
The widespread use of synthetic materials (plastics, nylons and polymers such as polystyrene and polyurethane foam) has a significant impact on fire behavior as well as the smoke produced during a structure fire. Synthetic substances ignite and burn fast, causing rapidly developing fires and toxic smoke, making structural firefighting more dangerous than ever before.
A mattress fire serves as a common example of the nasty smoke firefighters routinely encounter. Polyurethane foam is found in most mattresses. When polyurethane foam is exposed to heat, it begins to chemically break down, creating other new compounds. Some of those compounds are irritants, such as hydrogen chloride and ammonia, causing eye irritation or airway problems during smoke exposure. Other compounds like carbon monoxide and cyanide are also generated. Carbon monoxide is created when carbon and hydrogen bond and is partly responsible for incapacitating a smoke inhalation victim. Cyanide, formed by carbon-hydrogen-nitrogen bonding during the combustion process, disrupts the body’s ability to use oxygen and causes asphyxia at the cellular level. Practically speaking, carbon monoxide reduces the amount of oxygen carried to the cells; cyanide renders the cells incapable of using whatever oxygen is present—or, more simply stated, carbon monoxide kills the blood and cyanide kills the organs.
The mattress example illustrates the potential smoke toxicity of a relatively benign mattress fire, but keep in mind it is only one of many culprits. Sofas, stereo cabinets, drapes, blankets, and carpeting all produce cyanide and other common toxins as by-products of combustion. Vehicle fires are also capable of generating cyanide, along with almost everything found in garage or dumpster fires. It would be safe to conclude that firefighters are assaulted with toxic gases, including cyanide, in virtually every fire scenario imaginable.
The wildland firefighter is also subjected to many toxins, especially when fighting fires in the wildland-urban interface. Barns and outbuildings that burn during large wildland fires could generate the same (or even worse) smoke than an apartment building. Animal feces, old insecticides, farm machinery, and tires are just a few of the items found in a farm shed. Many farms and ranches have dumps somewhere on the property that, when ignited, produce copious amounts of toxic smoke, mixed in with the smoke from the vegetation that is burning.
PREVENTION
Ultimately, the goal is for firefighters to prevent smoke inhalation by wearing SCBA at the appropriate time and using the air wisely. Collectively, this is known as air management. You may have heard about this concept within recent years in past writings in this magazine and through conference presentations and lectures. The principle of air management involves the discipline of knowing how much air a firefighter has in his SCBA, monitoring the air level, and ensuring the air is being used to safely and effectively accomplish the task at hand.
Unfortunately, the fire service developed some bad habits when the SCBA was first introduced. These bad habits have carried over to poor air management practices. The fire service is paying a price for these behaviors, as numerous fireground deaths are attributed to firefighters running out of air and dying of asphyxiation.
Initially, the majority of firefighters did not wear SCBA because they considered the SCBA too bulky and time consuming to don. This was combined with tremendous peer pressure that insinuated you were a “weak” firefighter if you wasted the time it took to put on your breathing apparatus. These attitudes were demonstrated to be incorrect and unsafe, yet it is still common practice in some departments to routinely disregard wearing SCBA.
Many fire departments mandate the use of SCBA, and new technology continues to improve the units by decreasing weight, improving reliability, and enhancing overall effectiveness. With the availability of better protective equipment, tactical training, and improvements in leadership, firefighter death rates on the fireground should be decreasing. Unfortunately, this is not the case. Fireground deaths hover around the same numbers each year despite a decrease in actual fires.
Even today, with all the improvements in personal protective equipment and respiratory protection, firefighters who die in structures are dying in increasingly higher numbers from asphyxiation. Or, to put it in easy-to-understand terms, when you run out of air, you breathe smoke; when you breathe smoke, you get sick and die. It’s really that simple.
The need for a progressive, comprehensive air management program is obvious for one simple reason: Firefighters are still running out of air on the fireground. The consequences of this vary, including increased firefighter line-of-duty deaths, close calls, injuries, and increased cancer/respiratory disease rates with direct correlation to the smoke firefighters breathe when their air is depleted.
According to National Fire Protection Association (NFPA) firefighter fatality reports, between 1996 and 2003, 103 deaths were directly attributed to asphyxiation. These numbers did not take into account the direct contribution “running out of air” played in deaths that were attributed to other facts, such as thermal insult, cardiac arrest, and collapse. The need for air management is etched on fallen firefighter monuments across the country and in the tragic consequences line-of-duty deaths bring to the families and fire departments of these fallen firefighters.
NFPA 1404, Standard for Fire Service Respiratory Protection Training, outlines that fire departments should train their members to operate in accordance with the Rule of Air Management (ROAM), which states: “Know how much air is in your SCBA, and manage that air so that you leave the immediately dangerous to life and health (IDLH) environment BEFORE your low-air warning alarm activates.”
This will be a significant change for many fire departments on how they perform fireground operations. The current practice is for firefighters to operate until their low-air warning alarm activates and then begin to exit the structure. This practice allows a firefighter to use 75 percent of the air in his SCBA for entry and work in the IDLH environment, leaving only 25 percent for exit and no margin for error.
The new language in NFPA 1404 will be the measure the professional and legal community uses to determine if the fire department has taken the minimum required action necessary to protect firefighters from exposure to IDLH environments. To that end, fire departments must train firefighters to manage their air.
AIR MANAGEMENT PHILOSOPHY
In addition to the changes in regulatory mandates, departments across the country are making dramatic changes in their overall approach to breathing smoke and air management. Rather than sending firefighters out into the toxic, carcinogenic, and asphyxiating mess of the modern smoke environment and simply hoping things work out, progressive departments are altering the way they approach smoke at a core level.
Three primary changes must occur in the way departments think about smoke and how they train to allow for the deadly nature of its consequences. This new approach includes the following three elements:
1 Don’t breathe smoke. The routine breathing of smoke by firefighters should be a thing of the past. In our actual emergencies and in every training scenario we conduct, it is a guiding principle that we will not breathe smoke unless it is absolutely unavoidable. This is a no-brainer. Since we know without a shadow of a doubt that the modern smoke environment will asphyxiate us, will cause us to get lost/disoriented, will poison us, will give us cancer, and will kill us, what other conclusion can we reach?
2 Your air is your responsibility. Instill in firefighters the belief and the reality that the air they bring on their backs is their lifeblood inside the hazardous area. They should treat that air with the respect and importance it deserves and never put it in the hands of someone else. Having someone else monitor it outside is fine. Having a new piece of equipment tracking it is great as well. But the primary responsibility should always rest with the individual who will be sucking in superheated, toxic smoke if something goes wrong.
3 Keep the fireground alarm-free. It is now being recognized across the country that the “false-alarm mentality” created by having multiple low-air alarms going off at fires is harmful and counterproductive to effective fire attack. Any honest evaluation of the chorus of bells ringing inside most fires will result in the reality that they are ignored and treated simply as more noise. By taking the routine allowance of these alarms out of the equation, the sudden introduction of it into the fireground now becomes anything but routine. The alarm becomes an actual alarm and indicates there is a problem. It is now something that will be checked out instead of ignored.
With these three elements, the majority of the problems that arise from air management issues are solved—without expensive training programs, extra personnel to the fireground, or expensive new equipment. Departments are finding that they can transform their air management program without breaking the bank. By changing the philosophy of how they approach air management, fire departments everywhere are making their firefighters safer, more situationally aware, and more effective as they tackle their work.
TREATMENT
Despite understanding the toxic dangers of smoke and prevention techniques, firefighters could still be exposed to high levels of smoke, which may ultimately require treatment or antidotal therapy. Understanding smoke inhalation is one of the most complex and challenging patient presentations all levels of medical care providers face, and understanding the illness is key to successful treatment. Patient outcomes vary greatly, influenced by such factors as the extent and duration of the smoke exposure, the amount and nature of toxicants in the smoke, the degree of thermal burns to the skin and lungs, the quantity/size of inhaled particulates (soot), and the patient’s age and underlying medical condition. Nationwide there are few established protocols for treating smoke inhalation, leaving paramedics and other prehospital care providers with limited tools or training to properly care for smoke inhalation victims.
In most cases, treating smoke inhalation outside the hospital boils down to supportive care—monitoring and appropriately responding to vital signs, providing high-flow oxygen, establishing intravenous lines, performing advanced airway management techniques, monitoring cardiac rhythms, and ensuring rapid transport. However, if hydrogen cyanide (HCN) is present, and it likely will be in victims of smoke inhalation, supportive care alone will not correct the adverse effects of the synergistic relationship between HCN and carbon monoxide. Without reversing the underlying cause of asphyxia at the cellular level, normal oxygenation is not possible. This requires a chemical intervention—an antidote—to restore the body’s ability to use oxygen.
In the United States, there are two approved cyanide antidotes: the Cyanide Antidote Kit (CAK, sometimes referred to as the Lilly Kit, Taylor Kit, or Pasadena Kit) and the Cyanokit™. Each has a distinctly different mechanism of action.
The CAK contains amyl nitrite, sodium nitrite, and sodium thiosulfate (amyl nitrite is administered as an inhalant; sodium nitrite and sodium thiosulfate are given intravenously). The nitrites are administered to convert hemoglobin in the red blood cells to methemoglobin. Methemoglobin pulls cyanide away from the cytochrom oxidase, restoring the cell’s ability to take in oxygen and continue the process of aerobic metabolism. Thiosulfate is then administered to chemically bond with cyanide, rendering it less harmful to the body. When thiosulfate binds with cyanide, it becomes thiocyanate, which is then excreted by the kidneys. The downside of this treatment method is that methemoglobin does not transport oxygen. Since smoke inhalation patients are commonly exposed to carbon monoxide, which also prohibits oxygen from binding to the red blood cells, the oxygen-carrying capacity of the red blood cells is severely compromised, possibly to fatal levels. And while methemoglobin does draw cyanide away from the cytochrome oxidase, it also eliminates the oxygen-carrying capacity of the red blood cells—a bad trade-off in smoke inhalation patients. Additionally, nitrites may cause a drop in blood pressure, exacerbating the hypotension commonly found in smoke inhalation exposures. Because of these adverse impacts, most experts agree that administering the current Cyanide Antidote Kit is a risky proposition for smoke inhalation patients.
The Cyanokit antidote may be more appropriate for smoke inhalation patients. Approved by the U.S. Food and Drug Administration for use in the United States, Cyanokit has proven to be an effective and safe antidote for acute cyanide poisoning. Hydroxocobalamin (a precursor to vitamin B12) is the chemical compound in the Cyanokit. It is a relatively benign substance with minimal side effects, making it well suited for use in the prehospital setting. The Cyanokit, also approved in France and other parts of the world, is used as a prehospital antidote for smoke inhalation patients and other types of cyanide exposures, including those associated with potential acts of terrorism.
Hydroxocobalamin has no adverse effect on the oxygen-carrying capacity of the red blood cells and no negative impact on the patient’s blood pressure—significant benefits when treating victims of smoke inhalation. The mechanism of action is surprisingly simple: Hydroxocobalamin binds to cyanide, forming vitamin B12 (cyanocobalamin), a nontoxic compound ultimately excreted in the urine. You can administer the Cyanokit to a smoke inhalation patient without first verifying the presence of cyanide in the body with little fear of making the patient’s condition worse.
Patients tolerate the drug at high doses. Some quickly passing side effects such as a reddish color to the skin, urine, and mucous membranes may interfere with some colorimetric laboratory values (blood glucose, iron levels, creatinine, etc.). To date, however, no allergic reactions have been documented.
When rescuers and victims breathe toxic smoke at a fire, they require some level of medical attention. With this in mind, firefighters and emergency medical personnel must dedicate themselves to understanding the injuries caused by structure fires and smoke inhalation.
Prevention is simple: Wear your air! Unfortunately, there will always be situations when everything was done right and something goes wrong. In those instances, understanding how to treat smoke inhalation, with the new consideration that HCN will most likely be the culprit that leads to debilitation, is critical to lifesaving treatment.
Safety Tips
SCBA bottle pressure. This starts in the firehouse at the beginning of your shift. SCBA air pressure is the key to airtime longevity. When conducting your SCBA check, what does the bottle pressure read? Is the bottle full? Are you aware that the low-air alarm allows as much as a 250-psi discrepancy from one SCBA to another? Look at it this way: If you were going on a long trip with your vehicle, would you start with three-quarters of a tank of gas? Use common sense, and make sure your air bottle is full. If it isn’t, take the two minutes to replace it with a full one. Realize that every 100 psi in a 4,500-psi half-hour bottle is the equivalent of approximately eight to 12 breaths of air. Being familiar with discrepancies in your bottle pressure gauge and the variances between different SCBA bottles can save your life or the life of your fellow firefighter. Using a digital gauge to accurately assess precise SCBA bottle pressures during SCBA training is the best practice to meet this preventive objective.
SCBA training. Training with SCBA typically includes everything except how to breathe efficiently. It’s common to think breathing properly with SCBA comes naturally, but that’s not usually the case. It’s important to be familiar with individual limitations. All firefighters need to be properly evaluated on their level of breathing efficiency. There are various breathing methods; research and compare to see what works best for you. One breathing method is the Reilly-Emergency Breathing Technique, also known as the “Humming” method. By humming during exhalations, the average firefighter can extend airtime by more than 36 percent. Practice different breathing methods during mask confidence training. Perform breathing method evaluations. Properly and accurately calibrating SCBA bottle pressures during SCBA training and breathing evaluations to know the precise amount of air in an SCBA tank is also imperative. This can only be achieved with a digital gauge. It’s critical to know your breathing limitations so you know when to exit before your low-air alarm activates. Knowing how much breathing time you have during training will prove vital when it’s for real.
Donning SCBA at structure fires. Thinking that you will conserve air by donning your SCBA close to the door is a misconception. Doing so can be very taxing to your cardiovascular system. Levels of carbon monoxide ALONE can be in excess of 1,300 parts per million, and that’s not in direct smoke. Taking the precaution of donning SCBA LOW and just a few more feet AWAY from the door can help you reduce exposure to toxic gases.
Metering. We need to better understand what meters are telling us when it comes to an immediately dangerous to life and health (IDLH) situation. Each IDLH applies to a specific toxin by itself. Combining any number of toxic gases such as carbon monoxide and hydrogen cyanide, which are present at all structure fires, is an IDLH no matter what the reading. Know that when carbon monoxide is detected during overhaul, it’s not alone. There are many other toxins present.
Another consideration is for meters to have a hydrogen cyanide sensor. You can’t practically meter for all kinds of toxins. However, now that we know the synergistic effects of carbon monoxide and cyanide when combined, consider a meter that can detect both toxins. Remember, conduct thorough metering continuously during overhaul operations. It is important that firefighters and investigators continue metering any time personnel are in the structure.
To learn more about HCN and the health effects of smoke exposure, attend the Smoke Symposium workshop at FDIC on Monday, April 19, 2010, 1:00 p.m.-5:00 p.m., hosted by the Cyanide Poisoning Treatment Coalition. Instructors include Rob Schnepp, Bruce Evans, Kevin Reilly, Mike Gagliano, and Frank Ricci.
Rob Schnepp will teach “Fire Smoke and Cyanide: Truth and Treatment” as a classroom session on Wednesday, April 21, 10:30 a.m.-12:15 p.m., at FDIC 2010.
ROB SCHNEPP, a 20-plus-year veteran of the fire service, is assistant chief of special operations for the Alameda County (CA) Fire Department. He is a member of the task group charged with revising NFPA 473, Standard for Competencies for EMS Personnel Responding to Hazardous Materials. He is a member of the Fire Engineering editorial advisory board and the Fire Department Instructors Conference executive board. He is a former hazardous materials team manager for California Task Force 4, FEMA Urban Search and Rescue program, and an instructor for the U.S. Defense Threat Reduction Agency.
KEVIN J. REILLY is president of the Cyanide Poisoning Treatment Coalition. He is a member of the Ridgewood (NJ) Fire Department; an FDIC H.O.T. instructor; a member of the Board of Directors of the Fire Safety Directors Association of New York City; a subject matter expert for To Hell and Back IV—Cyanide Poisoning; an EAP writer and high-rise/life safety consultant in New York; and co-founder of www.FirefighterSafety.net.
MIKE GAGLIANO has 24 years of fire/crash/rescue experience with the Seattle (WA) Fire Department and the United States Air Force and is a captain of Ladder 5 and a member of the department’s Critical Decision/Tactical Training Group. He is co-author of Air Management for the Fire Service (Fire Engineering, 2008) and the SCBA chapter of Fire Engineering’s Handbook for Firefighter I and II (Fire Engineering, 2009). He is a member of the FDIC Associate Advisory Board and a director for the Cyanide Poisoning Treatment Coalition.
