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FDNY
•
•
Dr. David Prezant, FCCPChief Medical Officer, Office of Medical Affairs, FDNY
CoDirector FDNY WTC Medical Programs
• Professor of MedicineAlbert Einstein College of Medicine Pulmonary Division, Montefiore Medical Center
14,000 Fire & EMS Workers Proudly Serving New York and the USA
DISASTERDISASTER
RESPONSERESPONSE RECOVERYRECOVERY
PrePre--PlanPlan
Af ter Ac tion LessonsAf ter Ac tion Lessons Lear ned , Forgotten or Ignored ?Lear ned , Forgotten or Ignored ?
Good PlanGood Plan --> Seaml ess> Seamless
PrePre--PlanPlan
Poor Plan ning &/ or Exec utionPoor Planning &/ or Exec ution
Prolonged Mi seryProlonged Mi sery
HURRICANE
KATRINA
Aug 2005
TOO EARLY
ON TIME OR TOO LATE
TOO LATE & DISORGANIZED
LEFT BEHIND
WRONG OUTCOME
OOnn 99// 1111// 0011::
•• >>2200 ,,000000 CCiivv ii ll ii aannss EEvvaaccuuaatteedd
•• 22774499 DDeeaatthhss
•• TThhee MMoosstt SSuucccceessssffuu ll EEvvaaccuuaatt iioonn iinn HHiissttoorryy
•• FFuu ll ll SSppeecctt rruumm ooff II nnjjuurr iieess:: TTrraauummaa -->> RReessppii rraattoorryy FFaa ii lluurree
FFrroomm aa HHeeaalltthhccaarree PPeerrssppeeccttiivvee,,
WWhhaatt ddoo AALLLL DDiissaasstteerrss HHaavvee iinn CCoommmmoonn??
•• IInniittiiaall AAccuuttee TTrraauummaa
••TTrriiaaggee && TTrreeaattmmeenntt
••PPuubblliicc HHeeaalltthh RReessppoonnssee
••EEnnvviirroonnmmeennttaall EExxppoossuurreess
••DDiissppllaacceedd PPeerrssoonnss::
••SShheelltteerr MMeeddiicciinnee
••CClleeaann WWaatteerr
••SSaanniittaattiioonn
••IInnffeeccttiioonn
AAccuuttee && CChhrroonniicc IIllllnneessss ??
••
••
RReessppiittee ffoorr LLooccaall MMeeddiiccaall SSttaaffff ??
•• IIff NNeeeeddeedd,, OOrrggaanniizzeedd
HHeeaalltthhccaarree DDeeppllooyymmeenntt
FFrroomm OOuuttssiiddee tthhee AArreeaa
••MMeeddiiccaall SSccrreeeenniinngg ??
••MMeeddiiccaall MMoonniittoorriinngg ??
••MMeeddiiccaall TTrreeaattmmeenntt ??
•• MMeennttaall HHeeaalltthh TTrreeaattmmeenntt ??
FFiirrsstt RReessppoonnddeerrss MMeeddiiccaall && MMeennttaall FFiirree // EEMMSS HHeeaalltthh SSeerrvviicceess
HHeeaalltthhccaarree WWoorrkkeerrss
NNHHPP
IInncciiddeenntt PPuubblliicc CCoommmmaanndd
HHeeaalltthh SSyysstteemm
••DDOOHH LLaaww ••CCDDCC EEnnffoorrcceemmeenntt ••EEPPAA
EEmmeerrggeennccyy
MMaannaaggeemmeenntt
TThhee PPhhyyssiicciiaann RRoollee iinn DDiissaasstteerr MMeeddiicciinnee
CCOOMMMMUUNNIICCAATTIIOONN UUnnddeerrssttaanndd YYoouurr CChhaannggiinngg RRoolleess::
•• IICCSS CCoooorrddiinnaatteess IInniittiiaall PPuubblliicc MMeessssaaggee •• LLiiaaiissoonn •• AAddvviissee •• AAddddiittiioonnaall PPuubblliicc && PPrriivvaattee MMeessssaaggeess •• PPaattiieenntt // PPuubblliicc HHeeaalltthh AAddvvooccaattee •• EEvvaalluuaattee && TTrreeaatt •• TTrraannssiittiioonn ttoo RReeccoovveerryy •• SSttrreessss tthhee PPoossiittiivvee,, tthhee NNeeggaattiivvee oorr BBootthh??
SOUTH TOWER & NORTH TOWER SOUTH TOWER & NORTH TOWER COLLA PSE DURING RESCUE EFFORTS COLLA PSE DURING RESCUE EFFORTS
x x
FFii rrsstt RReessppoonnddeerrss �������� RReessppoonndd OOnn--dduuttyy oorr OOffff--dduuttyy CCaarreeeerr oorr VVoolluunntteeeerr WWii tthh oorr WWii tthhoouutt RReesspp ii rraattoorrss oorr ootthheerr PPPPEE
PPeeooppllee nnoott BBuu ii lldd iinnggss aarree tthhee VViicctt iimmss
This isThis is NOTNOT thtorosts
ehe type of respi rat ytype of respi rat ry prot ect ion that firpr ot ect ion that fir t respon der s shouldrespon der s should wear at a FI RE orwear at a FI RE or HAZMA T even tHAZMA T even t
Expos ures wereExpos ures were INEVI TABLEINEVI TABLE
MMMMWWRR 22000022;;5511::6688..
Percent
On day 1 when working, mask type worn & frequency
56 70
149 718
26
SCBA
Half
Face
Resp
Dust
Mask
N95
M
e dica l
M o
stly
W
orn
R a re ly
W orn
Non
e W
orn
Percent
70
0
38 323022
8
SCBA
Half Face
Resp
Dust
Mask
N95
Medical
M ostly
W
orn
R arely
W orn
N one
W orn
On wk 2 when working, mask type worn & frequencyMMWR Sept 2002
TTHHII SS II SS WWHHAATT WWEE IINNHHAALLEEDD OONN TTHHEE FFIIRRSSTT DDAAYYSS AANNDD OOVVEERR TTHHEE NNEEXXTT WWEEEEKKSS
•• AANNDD PPEERRSSII SSTTEENNTT FFIIRREE CCLLOOUUDDSS AADDDDEEDD TTOO TTHHEE IINNHHAALLAATTIIOONN EEXXPPOOSSUURREE
WWTTCC DDUUSSTT == PPaarr tt ii ccuu llaattee MMaatt tteerr TThhee MMaajjoorr TTooxx iinn ii ss DDuusstt ::
•• PPUULLVVEERRII ZZEEDD CCOONNCCRREETTEE
•• FFII BBRROOUUSS GGLLAASSSS && SSII LLIICCAATTEESS
•• CCAARRBBOONN PPAARRTTIICCUULLAATTEESS
•• AASSBBEESSTTOOSS
•• AALLKKAALLIINNEE ppHH
2
1
0
1
2
3
0 20 40 60 80 100
Neutrophils (percent)
Lan(MMP9)
FDNY Firefighter Dust-Induced Inflammation
Induced Sputum – 10 months later Fig 1a
Fireman, Prezant, etal. Environmental Health Perspectives: In Revisions
Rom, Weiden, Prezant, etal. Am J Resp Crit Care Med 2002, 166; 797
FDNY Firefighter with Pneumon itis BAL Lavage Dust Particles
A B C
Fly ash particleUncoated asbestos fiber Degraded fibrous glass
Event:•Fire
•Hazmat
•Rescue
•Recovery
•Medical
•Criminal
•Terrorist
•Secondary EventsFirst Responder
Environment •Thermal, N,B,C •Interior or Exterior •Day or Night •Summer or Winter •Land, Below grade •Sea or Air
Environment•Thermal, N,B,C•Interior or Exterior•Day or Night•Summer or Winter•Land, Below grade•Sea or Air
P
MicroEnvironmen
PPE Use
Chief Medical Officers
Drs. Kelly & Prezant
•Protocol Development
•SubSpecialty Evals.
•Research
•Respond to Major
Injuries
•Liaison, Counsel,
Treatment
Host DataDisaster
Age TrainingI nj ury Gender Experience I l l n ess M o del
Health Fatigue Fitness Uni t Issues
Goal is to ImproveOutcomes:
• Wellness
• Injury • Burn • Trauma
• Illness • CardioPulm
• Stress
• Infectious
• Reduce Deaths
PostEvent •Rehab •Rescue •Medical
PostEvent•Rehab
•Rescue
•Medical
FDNY WTC Medical Monito ring Program
9/11 WTC Exposures9/11 WTC Exposures
Spectrum of symptoms,coping, wellness & illness
Spectrum of symptoms,copin, wellness &illness
Health AssessmentsHealth
AssessmentsSocial Support AssessmentsSocial Support Assessments
LONG-TERM MEDICAL MONITORING TREATMEN T & PREVENTION PROGRAMLONG-TERM MEDICAL MONITORING TREATMENT & PREVENION PROGRAM
•• BBAASSEELLIINNEE AANNDD FFOOLLLLOOWW--UUPP WWTTCC MMEEDDIICCAALL MMOONNIITTOORRIINNGG && TTRREEAATTMMEENNTT II SS OONN--GGOOIINNGG
•• WWHHAATT HHAAVVEE WWEE LLEEAARRNNEEDD FFRROOMM TTHHEE FFDDNNYY WWTTCC MMEEDDIICCAALL MMOONNIITTOORRIINNGG && TTRREEAATTMMEENNTT PPRROOGGRRAAMMSS
••
CANNOT DO TIMELYPOST- DISASTER MEDICAL MONITORING WITHOUTPRE-EXISITNG INFRASTRUCTURE
FDNY WTC MEDICALS
FDNY WTC MEDICALS
••
••
IN 1996, FDNY, IAFF & 9 OTHER CITIES COLLABORATED IN A JOINT LABOR-MANAGEMENT INITIATIVE FOR MEDICAL MONITORING WELLNESS-FITNESS PROGRAMS
FDNY USED THIS INFRASTRUCTURE FOR POST-WTC & POST-KATRINA MEDICAL EVALUATIONS
• Questionnaires
–– Exposure, Medical & Stress
• Physician Eval uation
• PFT – Spirometry for everyone
–– Met hacholine Challenge for selected groups
• Chest Radiographs for everyone
–– Chest CT for selected groups
• Bloods/Urine Bio-Monitoring
• ECG & Audiometry
COMPONENTS OF FDNY WTC MEDICAL:
FDNY WTC MEDICALS
•• October 2001 to Marc 02:
11,000 medicals done
FDNY: Firefighters Officers EMS
By 1/2006 = 13,700
Coupled with Aggressive Medical & Mental Health Treatment Programs
334433 FFDDNNYY FFAATTAALLIITTII EESS 1144 ,,000000 FFDDNNYY SSUURRVVIIVVOORRSS11663366++,, AArrrr ii vv iinngg AAtt WWTTCC DDuurr iinngg TThhee AAMM OOff TThhee CCooll llaappssee
66995588++,, AArrrr ii vv iinngg AAtt WWTTCC OOvveerr TThhee NNeexx tt 4488 HHoouurrss
11332200++,, AArrrr ii vv iinngg AAtt WWTTCC TThhee NNeexx tt WWeeeekk
AA FFeeww HHuunnddrreedd AArrrr ii vv iinngg TThheerreeaafftteerr
In Partnership with CDC & NIOSH (n=400; October):
•• Hydrocarbons
•• Antimony
•• Dioxin & PCB Congeners
•• Slight Elevations iin Above–– None Clinically Elevated
–– Most Normal compared to•• FDNY FIREFIGHTER CONTROLS
FDNY WTC MEDICALS
FDNY WTC MEDICALS
• Total Serum PCBs
– Electrical Eqpt. & Food
– USA: 0 to 6 PPB = normal
– WTC• Avg < 6 PPB• 480 / 10,000 (5%) > 6 PPB• 36 > 12 PPB
FDNY WTC MEDICALS
• Heavy Metals
– Serum Lead• 25 mc g/dl• 7 / 10,000 above limit
– Urine Mercury• 35 mccg/g creat inine• 1 / 10,000 above limit
– Urine Beryllium• 1 or 2 mcg /liter• 1 / 10,000 above limit
FDNY WTC MEDICALS
•
ACCURATE ANALYSIS REQUIRES PRE EXPOSURE COMPARISONS
- -
WTC SYMPTOMS
0
20
40
60
80
100
120
Cou
gh
DOE
Whe
eze
Che
stPain
Nos
e/Th
roat
percent
PreWTC
WTC9/11
PostWTC 1moPostWTC 6mo
This was a carefully selected healthy workforce pre WTC with new, persistent symptoms post WTC
Chest X-ray: PA view–
Compared to pre-WTC Chest Films•
Comparison to Baselines Reduce Unneeded Workups
–
Less than 30 of 9,000were abnormal and these were in the symptomatic group
FDNY WTC MEDICALS
FVC FEV1 FEV1/FVC
FDNY PFT from MEDICALS Pre-WTC vs. 1- year Post-WTC
FDNY Cohort (n=1 1,766 exp osed w ith acceptable quality pre- & post-PF T),w ith or w ithout symptoms, adjusted fo r exp osure
Po st-WTC PFT wers at the lower l imits of normal
Wo uld not have appreciated the problemw ithout having Pr e-WTC PFTs fo r comparison
% Predicted 120 Post-WTC95 102 *100 Pre-WTC85*80
60 40
20 0
83 9489
FDNY PFT from MEDICALS Pre-WTC vs. 1- year Post-WTC
Entire FDNY Cohort, Wi th or Wi thout Symptoms, Adjusted fo r Exp osure •Arrival Time:
•Early (High Exp .)•AM of Collapse
•Intermediate•Ne xt 44 hrs
•Late (Low Exp )•Aft er First 48 hrs
Adjusted FEV1 Loss During The First Year After 09/11/2001 By Arrival Time Exposure Category
500
475
450
425
400
375
350
Arrival Time Exposure Category
A d ju
s te
d F
E V
1 L
o s s
(m
l) LateEarly Intermediate
*
*
*
FDNY PFT from MEDICALS Pre-WTC vs. 1- year Post-WTC
Percent Predicted FEV1 Values Before and After 09/11/2001 Full FDNY Cohort
0
5
10
15
20
25
30
35
<60 6070 7080 8090 90100 100110 110120 120130 130140 >140
Percent Predicted FEV1
P ercent o
f C ohort
Before 09/11/2001After 09/11/2001
20% FALL IN AIRFLOW AFTER IRRITANT VAPOR20% FALL IN AIRFLOW AFTER IRRITANT VAPOR
120
BRONCHIAL HYPERREACTIVITY Methacholine Challenge Testing
Abnormal Result is a 20% or Greater Fall in AirflowIndicating Reactivity or Potential for an Asthma Attack
% Baseline 100 BD respo nse
80
4060
PC20 < 8
200
0 0.025 0.25 2.5 10 25BD
MC Dose
1
1 Month 3 Month 6 Month Control
Hyperreactive Subjects PC20 < 8
Percent Hyperreactive
30
25
20
15
10
5
0
Highly Exposed
Moderately Exposed
Control
n=19/77
n=21/76
n=19/80
n=2/25n=3/44
n=3/36
n=1/28
* **
1 month 3 month 6 month Control Time-point When Measured Aft er 9/ 11/ 01
Banauch, Kelly, Weiden, Prezant et al. ARRCCM Sept. 2003
•
FDNY WTC MEDICALS
IMPROVED OUTCOMES WILL OCCUR IF COUPLE MONI TORING WITH TREATMENT
“WTC COUGH”• The Most Sym ptomati c Required:• Medical Leave >4 wk• Ove r 2,000 needed majo r Rx• Ove r 600 fi led disabi lity reti rement
• To da te , ove r 420 pe rmanent disability
Chart Title
Pos t-WTC
23
16
63
25
54
0
10
20
30
40
50
60
70
>500
ml d
eclin
e FEV1/FVC<0.75
Bronch
odila
torRes
ponse
RV/TLC>0.40
Bronch
ial H
yperreac
tivity
percent
Prezant et al. NEJM 2002
WTC COUGH PATIENTS - PFTS
CHEST IMAGING IN “WTC COUGH PATIENTS”
1. CHEST FILMS
• NORMAL IN NEARLY ALL CASES
• CHEST CT SCANS (n=500)
– Confirmed above chest film results
– Normal Inspiratory Views
• Expiratory Views Showed Airway Inflammation
– Bronchial Wall Thickening, Air Trapping
Figure Expirat
Fory
DHRC
NT, h
Yo
we
Fve
Ir, re
Rvea
Els
Fnu
Imer
Gous
Hfoci
T of
EAT
R, i
denti
Wfie
Id a
Ts lo
Hw
de
“nsity regions which maintain their volume
t expirF
a atioDn. NNotYe loFbulIar RAT iEn tFheI rigGht lHoweTr loEbe R( b lack WarIroTws), Hs e g“mental AT in the right upper lobe (white arrow), and near complete lobar AT in the left lower lobe (curved arrow) (see SecWWtioTTn DCC. 2 .c.CCii.).OOUUGGHH”” 3. AT in a Symptomatic FF. (A) Inspiratory HRCT demonstrates homogeneous lung attenuation. (B)
A
EXPIRATORY IMAGI NG:AIR TRAPPING
INSPIRATORY IMAGI NG
McGinness, Prezant et al
Rare Findings in this 14,000 FDNY Cohort
•
2 with new onset Eosinophilic Pneumonitis completely reversed with treatment
• 3 with new onset Progressive Pulmonary Fibrosis• 1 Fatality
• 1 with Mesothelioma - Fatal
• 20 with new onset Sarcoidosis
• A 3 to 5 fold increased incidence rate for FDNY• All stable, some resolved
FDNY FIREFIGHTERS WITH PNEUMONITIS
• COUGH, SINU S CONGESTION , ACID REFLUX• EXERTIONAL SHORTNESS OF BREATH
WTC DUST CAUSED• REDUCTIONS IN PULMONARY FUNCTION• AI RWAY S INFLAMMAT ION• Many Cases of ASTHMA or RADS• Rare Cases of Pneumon itis• Major Health Con cerns
FDNY HEALTH CONCERNS
Persons Who Worried About Their Health By Exposure Group (01 yr exam)
81
9594
56
85
0
20
40
60
80
100
All High
Exposure
Moderate
Exposure
Low
Exposure
Control
Group
P e r
c e n
t a g e ( %
)
Persons Who Feel Their Future May Be Cut Short By Exposure Groups (12 yr exam)
9.51017
29
18
0
20
40
60
80
100
All High
Exposure
Moderate
Exposure
Low
Exposure
Control
Group
P e r
c e n t a
g e ( %
)
48
36
34
33
32
0
20
40
60
80
100
Difficulty
GettingGood
Night'sSleep
Unusual
Irritability
Difficulty
Concentrating
Anxiousor
unusually
restless
Difficulty
FallingAsleep
5Most Com
mon
MentalHealthSym
ptomsReported
5 Most Com
mon
Mental Health
Sym
ptoms Reported
%
FDNY WTC Priorities :
9/11 WTC Exposures9/11 WTC Exposures
RespiratorRespiratoryyMental HeathMental Heath Late Emerging Diseases
(ex. Cancer)
Late Emerging Diseases
(ex. Cancer)
LONG-TERM MEDICAL MONITORING
& TREATMEN T PROGRAM
LONG-TRM MEDICAL MONITORING
& TREATMENT PROGRAM
THANK YOU