Rural/Environmental Health Emergencies

Rural Health

Top 10 Rural Issues for Health Care Reform

(By Jon M. Bailey of Center for Rural Affairs, Lyons, NE, March 2009)

An economy based on self-employment and small businesses
Public health insurance plans: Dependence and need
A stressed health care delivery system
Health care provider and workforce shortage
An aging rural population
A sicker, more at-risk population
Need for preventive care, health and wellness resources
Lack of mental health services
Increasing dependence on technology
Effective emergency medical services

The following information is from the following sources:

a presentation by Susanna Von Essen, MD, MPH, Professor of Pulmonary & Critical Care Medicine, University of Nebraska Medical Center, Omaha, NE: “Top 5 Health Problems in American Agriculture”
Welch, A. (November 2006). Exposing the dangers of anhydrous ammonia. The Nurse Practitioner, 31(11), 40-45.

Rural culture:

Subtle differences from urban culture
Farming is a way of life, not just a job

Who is at Risk?

Farmers and farm workers
Rural children
Rural elderly
Veterinarians
Farm chemical applicators
Meat packing plant employees

Top 5 Health Problems:

Traumatic injury
Tractors: Need roll over protective structure
Machinery trauma
Pinch points, leading to severe entanglements
Rings caught in moving machine part
Power take-off (PTO) trauma
Confined spaces
Animal confinement waste pits
Silos/Grain bins
Immersion in the grain causing suffocation
Falling from the silo or elevator
Entrapment in the auger or PTO systems that are used to transfer the grain
Settings where machinery is in use (combines, PTOs)
Respiratory illness
“Farmer’s lung”
A granulomatous lung disease that is a form of hypersensitivity pneumonitis
Recurrent febrile illness with dry cough, dyspnea
Often hypoxic, interstitial changes on CXR
Treatment is corticosteroids, avoidance of exposures
Asthma
Farm children have less asthma and allergy
Adults on the farm have the same or slightly higher prevalence of asthma
Many farm exposures to dust and gases exacerbate asthma by irritant effect (e.g. anhydrous ammonia)
Asthma-like syndrome
Seen in animal confinement workers
Organic dust toxic syndrome (ODTS)
Febrile, flu-like illness seen after heavy grain dust, hog dust exposure or after uncapping a silo
Chronic bronchitis more common in those who handle grain, raise hogs but not disabling unless the farmer also smokes
Acute inhalation injury
Carbon monoxide poisoning (can occur from pressure washing a hog confinement building)
Hydrogen sulfide poisoning (from animal confinement waste pits)
Nitrogen dioxide poisoning (from entering a recently filled silo)
Farm chemical exposure
Dermal exposure (pesticides and herbicides, anhydrous ammonia)
By drinking well water (nitrate poisoning
From drinking water with nitrate levels > 10 mg/L (EPA standard)
Caused by feedlot runoff, use of manure and nitrates as fertilizers
Drinking water should be routinely tested
Causes “blue baby syndrome” in infants in the first months of life
Can be life threatening
Causes methemoglobinemia secondary to conversion of nitrates to nitrites in the stomach
Treatment is methylene blue
Inhalation (anhydrous ammonia)
Antidote to acute farm chemical effects: atropine, PAM (pralidoxine chloride)
Additional information re: anhydrous ammonia (NH3)
Anhydrous means “without water”; naturally seeks water from the nearest source, including human tissue
When comes in contact with the body, it will consume 6 times its weight in moisture from body tissue
Usually affects the eyes, skin GI system, and respiratory system because of their high moisture content
Injuries are directly proportional to the concentration of NH3, the amount of area exposed, depth of injury, type of exposure (gaseous, liquid, or aqueous ammonia), and duration of exposure.
Humans can detect the small of NH3 in concentrations as low as 25 ppm (parts per million)
50-100 ppm, humans experience irritation to eyes, nose, and throat
Exposures at 1,000 ppm can be fatal
Eyes
50-100 ppm: eye irritation with tearing, burning sensation, blepharospasm, conjunctivitis, photophobia
> 140 ppm: corneal ulcerations, iritis, anterior and posterior synechia, corneal opacification, cataracts, glaucoma, retinal atrophy
Permanent occurs as a result of tissue destruction and elevations in intraocular pressure
Treatment with eye drops: pain medication, prophylactic antibiotics (ciprofloxacin one drop qid), mydriatic and cycloplegic agents can also be used to relieve pain but may cause narrow-angle glaucoma. Ophthalmology referral
Skin
Because NH3 is alkaline, it reacts with the moisture in skin to produce ammonium hydroxide.
This caustic substance saponifies the skin, causing liquefaction necrosis and converting fatty tissue into a yellow, soapy, soft substance
Can range from superficial and partial-thickness burns to full-thickness burns (may turn black and leathery)
Frostbite injuries may also occur (NH3 is usually transported as a liquid. When released, its temperature can drop to -28oF, causing objects to freeze on contact)
Referral to general or plastic surgeon
GI System
Injuries usually result of accidental ingestion of aqueous ammonia
Can produce dysphagia, nausea, vomiting, esophagitis
May require feral to GI for endoscopic evaluation within 12-24 hours
Respiratory System
Reacts with abundant supply of water within the mucosal lining of the respiratory tract (nose, mouth, pharynx, larynx, and lungs), thus causing tissue destruction both proximally and distally
Causes increased production of secretions sloughed epithelium, cellular debris, edema, destruction of cilia, and smooth muscle contraction
Initial symptoms: rhinorrhea, coughing, sneezing, pharyngitis, laryngitis, and dyspnea
1,700 ppm: laryngospasm
Can progress to edema anywhere in the respiratory tract, sloughing and necrosis of mucosa, chest pain, bronchospasm, hemoptysis and aspiration pneumonia
Treatment: 100% humidified oxygen; aerosolized bronchodilators (albuterol) to prevent bronchospasm [may be repeated every 20 minutes as needed during the first hour), steroids?, second-generation cephalosporin may be needed. Immediate referral to a pulmonologist if airway is compromised or complications such as pulmonary edema, pneumonia, hemoptysis, or respiratory failure arise
Prognosis after exposure to NH3 is dependent on the type of injury sustained.
If show improvements with the first 48-72 hours, will recover, but may take several weeks or months to recover fully.
Long-term effects: chronic cough, hoarseness, obstructive or restrictive airway disease, bronchiectasis, bronchiolitis obliterans, increased IOP, glaucoma, blindness, cataract formation, scarring of the skin, dermatitis, esophageal strictures, ulcers, dyspepsia, reflux disease
Long-term effects of farm chemicals: Cancer
Modest increase in risk:
Non-Hodgkins lymphoma
Acute leukemia
Multiple myeloma
Soft tissue sarcoma
More common
Skin cancers (melanoma, basal cell)
Lip cancer
Brain tumors
Stomach cancer
Testicular cancer
Prostate cancer
Chemicals associated with increased cancer risk
Sufficient risk: Arsenicals
Probably carcinogenic: chlorophenols; DDT, ethylene oxide; phenoxyacids;
Challenges
Cancer latency often at least 20 years, so recall of exposures is a problem
Difficult to measure exposures
Exposures to multiple chemicals

NOTE: See additional resources: “Agricultural Diseases” and “Agricultural Disease Symptoms sorted by Activity” (to be distributed)

Mental Health Issues
Farmers with high stress levels have a higher injury rate
Suicide rate higher among male farmers than men in the general population
Finances, weather and markets, poor physical health can increase stress load
Causes more isolation, alcohol abuse
May lack funds to pay for care
Farmers, farm workers are more likely to have no health insurance, be underinsured
Intergenerational conflict is often a problem on the family farm
Spousal, child abuse may be issue
Families with stress due to financial/medical issues may rely heavily on children for labor
Pride may keep them from seeking help
These are independent people accustomed to problem solving on their own
Stigma of being seen as having a mental health problem is great
Concern about losing assets that are to be passed onto the next generation
Few mental health care clinics and providers so services often provided in other ways
Care through the patient’s faith community may be more culturally acceptable
Primary care providers must be familiar with symptoms/treatment of depression, other common problems
Patients often have other chief complaints, like insomnia, fatigue, GI symptoms
Beware of sedating medications and their potential for contributing to injuries (benzodiazepines, trazodone, diphenhydramine)
Noise-Induced Hearing Loss
50% of farmers > 50 years of age have hearing loss
Farm youth are 2.5 times more likely to have hearing loss than urban children
Causes
Types of exposures
Tractors and machinery
Radios used in tractor cabs
Squealing of pigs
Guns
Duration of exposure
The longer the exposure, the most likely that hearing loss will result.
Difficult to treat so must prevent:
Hearing conservation measures needed if workers must shout to be heard
When the time weighted average sound level is 85 decibels or more (loudness of a combine)
Average sound exposure in 8 hours of work
Hearing conservation program
Noise hazard assessment
Baseline, annual audiometry
Nose exposure reduction
Engineering controls
Administrative controls
Personal hearing protection
Worker education, training, motivation

Practitioner’s Role in Safety on the Farm: Counseling to work towards lessening the number of accidents and fatalities on the farm

Elimination: getting rid of dangerous equipment
Substitution: substituting equipment or practices which have caused accidents in the past
Isolation: Wearing appropriate clothing for weather conditions
Ventilation: in silos and pig barns
Personal protective equipment

Environmental Health/Emergencies

Burns

Chemical burns: Acids/alkalies (see Papadakis, pp. 1571-72)

Ingestion: dilute immediately by giving 4-8 oz. of water; do not induce vomiting
Some recommend immediate cautious placement of small flexible gastric tube: removal of stomach contents followed by lavage
Skin contact: flood with water for 15 minutes (see text for additional specifics)
Eye contact: Flood with water for 15-30 minutes, holding eyelids open. Repeat irrigation until pH is near 7.0; check for corneal damage with fluorescein/slit lamp, refer to ophthalmologist
Inhalation: Remove from further exposure to fumes or gas. Check skin and clothing. Assess/treat for pulmonary edema.

Electrical burns (see Papdiakis, pp. 1552-53)

Low voltage AC (alternating current) = typical household current (< 1000 volts)
High voltage AC = usually occupational exposure with higher morbidity and mortality (> 1000 volts)
Direct current (DC) as with lightning, batteries, and automotive electrical systems
Lightning = massive DC current of millions of volts (Following definitions from: Jepsen, D.L. (August 1992). How to manage a patient with lightning injury. AJN, 39-42.)
Direct strike: struck directly by a lightning current; the victim passively completes the electrical-current pathway between the earth and cloud (standing in an open area during a storm or carrying a metal object, such as a golf club or umbrella can invite a direct strike)
Splash-over strike: the current sometimes flows or jumps from one object or person to another, conducted by the air between them (someone standing under a tree that receives a direct strike would be in danger of a splash-over strike)
Ground strike: a lightning bolt directly strikes the ground, and current radiates outward from the point of impact, such as when a large group of people observing an outdoor sports event concurrently suffer lightning injury. Just as dangerous as a direct or splash-over strike, the ground strike current diminishes in strength as the radius lengthens.
Treatment
Victim must be safely separated from the electrical current prior to initiation of CPR or other treatment.
Separate the victim using nonconductive implements
Resuscitation must then be initiated since clinical findings of death are unreliable.
Extent of injury is determined by the type, amount, duration, and pathway of electrical current.
Skin findings may be misleading and are not indicative of the degree of deeper tissue injury.
Complications: dysrhythmias, altered mental status, seizures, paralysis, headache, pneumothorax, vascular injury, tissue edema and necrosis, compartment syndrome, associated traumatic injuries, rhabdomyolysis, acute kidney injury, hypovolemia from third spacing, infections, and acute or delayed cataract formation.

Heatstroke and Heat Exhaustion

Read: Glazer, J.L. (June 1, 2005). Management of heatstroke and heat exhaustion. American Family Physician. 71(11), 2133-2140. (See

Bite Wounds

History

•Type of animal

•Provoked or unprovoked attack

•Known animal?

•Condition of animal (acting strangely?)

•If human bite, check HIV status

•Self-treatment

•Tetanus immunization status, prior rabies immunization?

•Past medical history to assess risk for infection:

•- diabetes mellitus

•- immunodeficiency of any type

Subjective

•Most are minor: scratches, abrasions, lacerations, puncture wounds

•90%: dogs

•Cat bites more likely to become infected (deep puncture wounds)

•Caution especially over joints

Treatment

•Wound care (cleansing)

•Open-wound management vs. suturing

•Don’t suture: hand/foot bites, bites over 12 hrs. (or 24 hours on face), deep or puncture bites, extensive injury, crush injury, wounds in compromised host

•Antibiotic prophylaxis?

•Dog/Cat: amoxicillin/clavulanate (250-500 mg q8h) [If allergic: cephalosporin or Bactrim PLUS clindamycin]

•Rabies precautions

•tetanus prophylaxis

•hepatitis B immune globulin (passive prophylaxis) if indicated

•TEACH: signs of infection, bite prevention

•F/U Inspect wound within 48 hours

Referral

•Bites of ears, face, genitalia, hands and feet

•Large, contaminated wounds

Insect Bites/Brown Recluse Spider

Insect Stings

•If allergic reaction is present or anticipated based on history, treat immediately

•Epinephrine

•Oral antihistamine

•may need inhaled beta2 agonist (albuterol)

•Emergency Room

• Treatment

•Remove stinger if present (forcepts, or scraping…do not squeeze)

•Cleanse, ice packs

•Oral antihistamines

Brown Recluse Spider

•Severity of local reaction depends on site: fatty areas = more severe reactions

•Tissue necrosis may develop as early as 4 hours after bite

•Blue-gray, macular halo around puncture site, pustule at site, widening of macule and sinking of center, sloughing of tissue deep ulcer

•Treatment

•Conservative treatment

•Gentle cleansing, ice, and elevate

•Avoid strenuous exercise, NO HEAT!

•Steroids?

•Antibiotics for secondary infection: erythromycin 250 mg QID X 10 days

•Elevate 8-12 hours

Lyme Disease

Read: Bratton, R.L. & Corey, G.R. (June 15, 2005). Tick-borne disease. American Family Physician, 71(12), 2323-2330.

Read: Wright, W.F., Riedel, D.J., Talwani, R., & Gilliam, B.L. (June 1, 2012). Diagnosis and management of Lyme disease. American Family Physician, 85(11), 1086-1093.

Cause: the bacterium Borrelia burgdorferi and is transmitted primarily by the deer tick

Stages:

•Early localized:

•Erythema migrans

•Virus-like illness (fatigue, malaise, fever, chills, myalgia, headache)

•Early disseminated: Combination of 4 systems

•Skin Manifestations

•Start: typical insect bite

•Over several days: expands outward , clearing in the center with a bright red outer border, 5-70m cm

•Heart Manifestations

•10% will experience cardiac conduction defects (Lyme carditis)

•Atrioventricular block to a varying degree is most common

•Neuro Manifestations

•15% of patients have neuro symptoms

•May be manifested as:

• headache

•irritability

•Bell’s palsy

•stiff neck

•debilitating fatigue

•Musculoskeletal Manifestations

•50% of affected patients manifest MSK sx.

•Early in course of infection:

•transient arthralgia

•aching

•stiffness

•60% of untreated patients develop inflammatory arthritis (Lyme arthritis)

•Usually affects large joints

•Especially: knees

•Late

•Arthritis

•Neurologic symptoms (encephalomyelitis, peripheral neuropathy)

Difficult Diagnosis

•Except for the characteristic rash, symptoms may be broad and vague

FNP must:

•R/O other diagnoses:

•infective endocarditis

•rheumatic fever

•infectious mononucleosis

•collagen vascular disease

•other spirochetal infections

To Test or Not to Test?

•Laboratory testing should be regarded as an ADJUNCT to thorough history taking and clinical examination and not as the primary tool to diagnose Lyme disease.

Testing for Lyme Disease

•Potential for both false-positive and false-negative tests.

•Cross reactivity of Borrelia burgdorferi spirochete with other spirochetes false positive serologic results

•Other false positive with: SLE, RA, infectious mono, syphilis