Download 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)
1. An economy based on self-employment and small businesses
2. Public health insurance plans: Dependence and need
3. A stressed health care delivery system
4. Health care provider and workforce shortage
5. An aging rural population
6. A sicker, more at-risk population
7. Need for preventive care, health and wellness resources
8. Lack of mental health services
9. Increasing dependence on technology
10. 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:
1. Traumatic injury
a. Tractors: Need roll over protective structure
b. Machinery trauma
i. Pinch points, leading to severe entanglements
ii. Rings caught in moving machine part
iii. Power take-off (PTO) trauma
c. Confined spaces
i. Animal confinement waste pits
ii. Silos/Grain bins
1. Immersion in the grain causing suffocation
2. Falling from the silo or elevator
3. Entrapment in the auger or PTO systems that are used to
transfer the grain
d. Settings where machinery is in use (combines, PTOs)
2. Respiratory illness
a. “Farmer’s lung”
i. A granulomatous lung disease that is a form of hypersensitivity
pneumonitis
ii. Recurrent febrile illness with dry cough, dyspnea
1. Often hypoxic, interstitial changes on CXR
2. Treatment is corticosteroids, avoidance of exposures
b. Asthma
i. Farm children have less asthma and allergy
ii. Adults on the farm have the same or slightly higher prevalence of
asthma
iii. Many farm exposures to dust and gases exacerbate asthma by
irritant effect (e.g. anhydrous ammonia)
c. Asthma-like syndrome
i. Seen in animal confinement workers
d. Organic dust toxic syndrome (ODTS)
i. Febrile, flu-like illness seen after heavy grain dust, hog dust
exposure or after uncapping a silo
e. Chronic bronchitis more common in those who handle grain, raise hogs
but not disabling unless the farmer also smokes
f. Acute inhalation injury
i. Carbon monoxide poisoning (can occur from pressure washing a
hog confinement building)
ii. Hydrogen sulfide poisoning (from animal confinement waste pits)
iii. Nitrogen dioxide poisoning (from entering a recently filled silo)
3. Farm chemical exposure
a. Dermal exposure (pesticides and herbicides, anhydrous ammonia)
b. By drinking well water (nitrate poisoning
i. From drinking water with nitrate levels > 10 mg/L (EPA standard)
ii. Caused by feedlot runoff, use of manure and nitrates as fertilizers
iii. Drinking water should be routinely tested
iv. Causes “blue baby syndrome” in infants in the first months of life
1. Can be life threatening
2. Causes methemoglobinemia secondary to conversion of
nitrates to nitrites in the stomach
3. Treatment is methylene blue
c. Inhalation (anhydrous ammonia)
d. Antidote to acute farm chemical effects: atropine, PAM (pralidoxine
chloride)
e. Additional information re: anhydrous ammonia (NH3)
i. Anhydrous means “without water”; naturally seeks water from the
nearest source, including human tissue
1. When comes in contact with the body, it will consume 6
times its weight in moisture from body tissue
2. Usually affects the eyes, skin GI system, and respiratory
system because of their high moisture content
3. 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.
a. Humans can detect the small of NH3 in
concentrations as low as 25 ppm (parts per million)
b. 50-100 ppm, humans experience irritation to eyes,
nose, and throat
c. Exposures at 1,000 ppm can be fatal
4. Eyes
a. 50-100 ppm: eye irritation with tearing, burning
sensation, blepharospasm, conjunctivitis,
photophobia
b. > 140 ppm: corneal ulcerations, iritis, anterior and
posterior synechia, corneal opacification, cataracts,
glaucoma, retinal atrophy
c. Permanent occurs as a result of tissue destruction
and elevations in intraocular pressure
d. 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
5. Skin
a. Because NH3 is alkaline, it reacts with the moisture
in skin to produce ammonium hydroxide.
b. This caustic substance saponifies the skin, causing
liquefaction necrosis and converting fatty tissue into
a yellow, soapy, soft substance
c. Can range from superficial and partial-thickness
burns to full-thickness burns (may turn black and
leathery)
d. 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)
e. Referral to general or plastic surgeon
6. GI System
a. Injuries usually result of accidental ingestion of
aqueous ammonia
b. Can produce dysphagia, nausea, vomiting,
esophagitis
c. May require feral to GI for endoscopic evaluation
within 12-24 hours
7. Respiratory System
a. 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
b. Causes increased production of secretions sloughed
epithelium, cellular debris, edema, destruction of
cilia, and smooth muscle contraction
c. Initial symptoms: rhinorrhea, coughing, sneezing,
pharyngitis, laryngitis, and dyspnea
d. 1,700 ppm: laryngospasm
e. Can progress to edema anywhere in the respiratory
tract, sloughing and necrosis of mucosa, chest pain,
bronchospasm, hemoptysis and aspiration
pneumonia
f. Treatment: 100% humidified oxygen; aerosolized
bronchodilators (albuterol) to prevent
bronchospasm [may be repeated every 20 minutes
as needed during the first hour), steroids?, secondgeneration 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
8. Prognosis after exposure to NH3 is dependent on the type of
injury sustained.
a. If show improvements with the first 48-72 hours,
will recover, but may take several weeks or months
to recover fully.
b. 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
f. Long-term effects of farm chemicals: Cancer
i. Modest increase in risk:
1. Non-Hodgkins lymphoma
2. Acute leukemia
3. Multiple myeloma
4. Soft tissue sarcoma
ii. More common
1. Skin cancers (melanoma, basal cell)
2. Lip cancer
3. Brain tumors
4. Stomach cancer
5. Testicular cancer
6. Prostate cancer
iii. Chemicals associated with increased cancer risk
1. Sufficient risk: Arsenicals
2. Probably carcinogenic: chlorophenols; DDT, ethylene
oxide; phenoxyacids;
iv. Challenges
1. Cancer latency often at least 20 years, so recall of
exposures is a problem
2. Difficult to measure exposures
3. Exposures to multiple chemicals
NOTE: See additional resources: “Agricultural Diseases” and “Agricultural Disease
Symptoms sorted by Activity” (to be distributed)
4. Mental Health Issues
a. Farmers with high stress levels have a higher injury rate
b. Suicide rate higher among male farmers than men in the general
population
c. Finances, weather and markets, poor physical health can increase stress
load
i. Causes more isolation, alcohol abuse
ii. May lack funds to pay for care
iii. Farmers, farm workers are more likely to have no health insurance,
be underinsured
d. Intergenerational conflict is often a problem on the family farm
e. Spousal, child abuse may be issue
i. Families with stress due to financial/medical issues may rely
heavily on children for labor
f. Pride may keep them from seeking help
i. These are independent people accustomed to problem solving on
their own
ii. Stigma of being seen as having a mental health problem is great
iii. Concern about losing assets that are to be passed onto the next
generation
g. Few mental health care clinics and providers so services often provided in
other ways
i. Care through the patient’s faith community may be more culturally
acceptable
ii. Primary care providers must be familiar with symptoms/treatment
of depression, other common problems
1. Patients often have other chief complaints, like insomnia,
fatigue, GI symptoms
2. Beware of sedating medications and their potential for
contributing to injuries (benzodiazepines, trazodone,
diphenhydramine)
5. Noise-Induced Hearing Loss
a. 50% of farmers > 50 years of age have hearing loss
b. Farm youth are 2.5 times more likely to have hearing loss than urban
children
c. Causes
i. Types of exposures
1. Tractors and machinery
2. Radios used in tractor cabs
3. Squealing of pigs
4. Guns
ii. Duration of exposure
1. The longer the exposure, the most likely that hearing loss
will result.
d. Difficult to treat so must prevent:
i. Hearing conservation measures needed if workers must shout to be
heard
ii. When the time weighted average sound level is 85 decibels or
more (loudness of a combine)
1. Average sound exposure in 8 hours of work
iii. Hearing conservation program
1. Noise hazard assessment
2. Baseline, annual audiometry
3. Nose exposure reduction
a. Engineering controls
b. Administrative controls
c. Personal hearing protection
4. 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
1. Elimination: getting rid of dangerous equipment
2. Substitution: substituting equipment or practices which have caused
accidents in the past
3. Isolation: Wearing appropriate clothing for weather conditions
4. Ventilation: in silos and pig barns
5. 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
o 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
o 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
o Victim must be safely separated from the electrical current prior to
initiation of CPR or other treatment.
 Separate the victim using nonconductive implements
o Resuscitation must then be initiated since clinical findings of death are
unreliable.
o 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.
o 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
http://my.ilstu.edu/~ddwilso2/nur475/assignments.htm)
Bite Wounds
History
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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:
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- diabetes mellitus
- immunodeficiency of any type
Subjective
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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
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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?
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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
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Bites of ears, face, genitalia, hands and feet
Large, contaminated wounds
Insect Bites/Brown Recluse Spider
Insect Stings
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If allergic reaction is present or anticipated based on history, treat immediately
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Epinephrine
Oral antihistamine
may need inhaled beta2 agonist (albuterol)
Emergency Room
Treatment
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Remove stinger if present (forcepts, or scraping…do not squeeze)
Cleanse, ice packs
Oral antihistamines
Brown Recluse Spider
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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
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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:
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Early localized:
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Erythema migrans
Virus-like illness (fatigue, malaise, fever, chills, myalgia, headache)
Early disseminated: Combination of 4 systems
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Skin Manifestations
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10% will experience cardiac conduction defects (Lyme carditis)
Atrioventricular block to a varying degree is most common
Neuro Manifestations
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Over several days: expands outward , clearing in the center with a
bright red outer border, 5-70m cm
Heart Manifestations
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Start: typical insect bite
15% of patients have neuro symptoms
May be manifested as:
headache
irritability
Bell’s palsy
stiff neck
debilitating fatigue
Musculoskeletal Manifestations
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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)
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Usually affects large joints
Especially: knees
Late
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Arthritis
Neurologic symptoms (encephalomyelitis, peripheral neuropathy)
Difficult Diagnosis
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Except for the characteristic rash, symptoms may be broad and vague
FNP must:
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R/O other diagnoses:
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infective endocarditis
rheumatic fever
infectious mononucleosis
collagen vascular disease
other spirochetal infections
To Test or Not to Test?
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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
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Potential for both false-positive and false-negative tests.
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Other false positive with: SLE, RA, infectious mono, syphilis
Cross reactivity of Borrelia burgdorferi spirochete with other spirochetes  false
positive serologic results
Other Testing Problems
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False (-) may be due to an idle immune response occurring early in the illness
May take 4-6 weeks before the Lyme antibody test is positive
If erythema migrans present and pt. Is treated, there will most likely be a clinical cure
before the test turns (+)
Follow-up Serologic Testing?
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Not recommend during and after antibiotic testing
If (-) or borderline test results in presence of history of exposure but non-specific
clinical findings, it is reasonable to repeat test In 6 weeks
Treatment for Lyme Disease
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doxycycline 100 mg bid X 14-21 days (some treat as long as 30 days)
amoxicillin 250-500 mg tid X 14-21 days (some treat as long as 30 days)
Advantages of doxy:
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twice a day dosage
low cost
lack of SE other than photosensitive rash
Doxy should not be used in young children or pregnant women
No Objective Clinical Signs?
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For patients without objective clinical signs: antimicrobial prophylaxis after a tick bite
is not recommended because of low rate of transmission (transmission requires 24-48
hours of tick attachment)
Patient Education: Prevention
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Clear brush/tall grass
Avoid tick-infected areas in late spring/summer
Check body, pets
Wear light colors: easier to see ticks
Tuck pant legs into socks; long sleeves
Use permethrin (Elimite, Nix) on clothing
Prognosis
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Most patients respond to appropriate therapy with prompt resolution of symptoms