From the Massachusetts Nurse Newsletter
January/February 2004 Edition
By Evelyn Bain, M Ed, RN, COHN-S
Associate Director/Coordinator, Health & Safety
This article is part of a continuing series about chemical exposures. In this edition, an MNA member who chose not to be identified shared her experience about exposure to formalin in the operating room at the hospital where she works.
The nurse brought the specimen to the specimen refrigerator. At that time, nurses were required to bring specimens to this specific refrigerator and pour the formalin from a spigot on a large container into the jar containing the specimen. As the nurse opened the refrigerator door, she noticed a strong odor of formalin and quickly closed the door.
She immediately notified the charge nurse, who implemented the spill containment procedure. This required that the spill be corralled off so it would not spread and so that the clean up (by specially trained employees) could proceed.
Immediately on inhaling the formalin vapors, the nurse noted burning in her eyes and chest (immediate reaction). She mentioned this to her co-workers who urged that she report it and request medical attention. But, in her own words, she "chose to ignore the symptoms."
Within a few hours, (delayed reaction) the nurse began to feel a fluttering sensation in her chest and she became dizzy. Her co-workers quickly convinced her to get medical attention and she was taken to the ER by stretcher. The physician in the ER evaluated her for cardiac symptoms and drew labs in order to evaluate her need for an MI. She was immediately placed on a monitor and it was noted that she had ST changes on her EKG.
Because of the cardiac changes, she was kept overnight for evaluation and discharged the following day—returning to work the day after that. Her diagnosis by the occupational health physician and the ER physician was a "cardiac episode related to chemical exposure." Since this incident, it is has been determined that she has developed asthma—most likely reactive airway dysfunction syndrome—related to a specific incident of inhalation of a toxic substance. She has been relieved of any duties that require exposure to formalin. She notes that her co-workers are very cooperative in relieving her of these tasks.
The MNA has encouraged her to report her asthmatic condition to the Massachusetts Department of Public Health, Occupational Health and Safety Program. Massachusetts state law requires reporting of all cases of suspected or actually diagnosed occupational asthma. The associated reporting forms are available from the Health and Safety Program at the MNA.
The affected nurse also completed a detailed NIOSH (National Institute of Occupational Safety and Health) history and report of occupational exposure that was provided by the occupational health department at her hospital.
OSHA requires annual training for workers with exposure to formaldehyde or formaldehyde containing products. The hospital where this particular incident occurred has held annual trainings on formaldehyde. The nurse who became ill immediately recognized that situation required specific actions and she was aware of the adverse health effects of exposure to formaldehyde. Her co-workers also knew what measures should be taken.
According to OSHA, formaldehyde is a sensitizing agent that can cause an immune system response upon initial exposure. It is also a suspected human carcinogen that is linked to nasal cancer and lung cancer. Acute exposure is highly irritating to the eyes, nose and throat and can make you cough and wheeze. Subsequent exposure may cause severe allergic reactions of the skin, eyes and respiratory tract. Ingestion of formaldehyde can be fatal and long-term exposure to low levels can cause asthma-like respiratory problems and skin irritations such as dermatitis and itching. Concentrations of 100 ppm are immediately dangerous to health or life.
Reporting to occupational health
Hospitals should communicate to employees that exposures like the one outlined above, (exposure to a chemical spill, inhalation of a toxic substance) should immediately be reported to occupational health. If symptoms occur immediately, the exposed employee should be evaluated in the emergency department or by occupational health. Some chemicals may have a delayed reaction, so a report to occupational health should always be completed immediately so there is a paper trail that validates the employee’s symptoms should a delayed reaction occur.
An incident like this is usually reported to the hospital’s insurance company and may become a "medical only" case—meaning medical bills are paid, but no lost time (or not the required five days before a report to the state is generated) occurs that would be paid by the insurance company.
Affected employees should request copies of all medical and insurance reports that pertain to any event of occupational injury or exposure.
Procedures to eliminate exposure
Formaldehyde is a very toxic substance, yet it is still used in the majority of ORs in Massachusetts. Alternative substances for tissue preservation exist, but are not widely used in this country. The nurses at the hospital where this exposure occurred are working with management to develop a plan where all specimens would be "fixed" in the lab. Customarily, lab technicians perform much of their work under an exhaust hood that eliminates the potential for exposure to formaldehyde. Keep in mind that exposure to low concentrations occur continuously whenever one is working with formaldehyde without the engineering controls of an exhaust hood.
According to OSHA, formaldehyde is a sensitizing agent that can cause an immune system response upon initial exposure. It is also a suspected human carcinogen that is linked to nasal cancer and lung cancer.