Occupational hospitals: accidents, exposure to and assault · Occupationalhazardsin hospitals: accidents, radiation, exposureto noxiouschemicals, drug addictionandpsychicproblems,

British Journal of Industrial Medicine 1987;44:510-520

Occupational hazards in hospitals: accidents,radiation, exposure to noxious chemicals, drugaddiction and psychic problems, and assaultJ J GESTAL

From the Department of Preventive and Social Medicine, Faculty of Medicine, University ofSantiago, Santiagode Compostela, Spain

ABSTRACT Except for infectious diseases all the main occupational hazards affecting health work-ers are reviewed: accidents (explosions, fires, electrical accidents, and other sources of injury);radiation (stochastic and non-stochastic effects, protective measures, and personnel most at risk);exposure to noxious chemicals, whose effects may be either local (allergic eczema) or generalised(cancer, mutations), particular attention being paid to the hazards presented by formol, ethyleneoxide, cytostatics, and anaesthetic gases; drug addiction (which is more common among healthworkers than the general population) and psychic problems associated with promotion, shift work,and emotional stress; and assault (various types of assault suffered by health workers, its causes,

and the characterisation of the most aggresive patients).

In a previous paper attention was drawn to the cur-rent importance of occupational hazards to hospitalworkers.' These were classified into six categories(infection, accidents, radiation, exposure to noxiouschemicals, drug addiction and psychic problems, andassault), and the risk of infection was discussed. In thepresent paper the remaining categories are consid-ered.

Accidents

Among the possible types of accidents are includedfires, explosions, electrocution, and gas leaks;undesired effects of electromagnetic fields, micro-waves, lasers, and vibration; cuts, bruises, and frac-tures; asphyxia and burns; and the effects of noise.

EXPLOSIONSExplosions usually occur in laboratories, operatingtheatres, and boiler rooms. All products that areinflammable or otherwise likely to explode should belabelled as such and stored accordingly.2

FIREOfficial regulations concerning the risk of fire in hos-pitals are in general adequate. Each centre shoulddraw up fire procedures and all hospital workers

Accepted 5 August 1986

should be instructed as to what to do in case of fire.Of 300 fires in United States hospitals, 74% were dueto the following four causes, human error being ulti-mately responsible in almost all cases: electrical faults(23%), cigarettes and matches (21%), incorrect use ofanaesthetics, oxygen, and inflammable fluids (19%),and non-electrical heating (11%).The most common direct cause of casualties associ-

ated with ihospital fires is asphyxia by smoke andfumes, which accounts for 78% of deaths and 43% ofnon-fatal casualties.3 Fire prevention measuresshould aim to achieve four main objectives in cases offire: immediate detection, rapid extinction or iso-lation, non-propagation of smoke and fumes, andsafe evacuation of staff and inmates. To these ends,attention should be paid to four basic points:

(1) Construction-for example, evacuation routesand fire escapes.

(2) Use of combustible materials such as plastics orinflammable fluids.

(3) Countermeasures, including compulsory instal-lation of fire extinguishers.

(4) Training of personnel.The hospital's fire procedures should be familiar to

all staff so that they all know exactly what to do incase of fire. Fire procedures should furthermore bereviewed at least every six months and corrected asnecessary, and fire drill should be practised in allshifts.4

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Occupational hazards in hospitals

ELECTRICAL ACCIDENTSElectrical accidents may cause injury both directly,due to the passage of electric current through thebody producing electrocution, internal and externalburns, or gaseous embolism; and indirectly, in theform of burns or asphyxia produced by electrical firesor explosions, or injuries suffered in falls after electricshock. The immediate physiological effects of electricshocks depend on the intensity of the current borne,the point of contact, and the path taken through thebody. Currents near the threshold of perception(1-3 mA) are innocuous even when there is prolongedcontact, but as the intensity of the current rises thetingling sensation becomes progressively moreunpleasant. Sudden application of 8mA generallystimulates a reflex response which may itself bringabout injury-due, for example, to a consequent falloff a ladder-but electrification by currents of thismagnitude does not normally have direct phys-iological consequences. Currents greater than about1OmA produce muscular contractions that lock thehands and arms and prevent the release of the objectsheld. Burns may also appear. When the current borneis of more than 25-30 mA, spasm may affect the mus-cles of the thorax and cause "asphyxia" if artificialrespiration is not rapidly applied.

Electric shock may be fatal if the current passesthrough the brain or the thorax, especially if the heartis affected. Since electric current takes the path ofleast resistance, particular danger thus attends doublecontacts in which the body forms a bridge between alive wire and a conductor (right hand and left foot orvice versa, right and left hands, or hand and head).Double contacts affecting a single limb are less seri-ous.

There are two contributions to the electricalresistance of the human body: the external resistanceof the surface at which contact is made and theresistance of internal tissues. The external resistancevaries from one individual to another and from onepart of the body to another (a calloused palm is muchmore resistive than the back of the same hand), andalso depends greatly on the humidity of the surface(due, for example, to sweating: more than 60% ofelectrical accidents suffered by hospital personneloccur during the hottest five months). A skin with aresistance of several hundred thousand ohms whendry may offer just 1000 ohms resistance or less whenwet. The resistance of the area of contact alsodecreases as the contact pressure increases. Theresistance of internal tissues varies less and is esti-mated at between 100 and 5000 ohms.The chief electrical hazard in hospitals is the large

static charge that may accumulate in electrical appa-ratus. Arcing may occur between charged materialand neighbouring conductors, and the human body

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may receive electric discharges if insulated from earthby rubber soled footwear. In fact, if the atmosphere isdry just walking about on asphalt flooring, or even ona woollen carpet, can charge the body sufficiently asto produce small sparks that, though not normallyharmful in themselves, may ignite inflammablevapours and gases, cause dust explosions, or (morecommonly) startle the person in question so thatother types of accidents occur. An idea of the risk ofsparking may be given by the fact that an insulatedhuman body dressed in nylon overalls can easilyacquire up to 5 or 10 mJ of electrostatic energy just bysitting down on a chair covered in polyvinyl chlorideand getting up again.The control of electrostatic charge is difficult and

generally entails facilitating its loss. In the case of thehuman body both footwear and flooring should besufficiently conductive as to prevent the accumulationof charge. Flooring should be of wood, footwear ofantistatic rubber, and polyester or polyamide clothingshould be worn. The risk of sparking may also bereduced by increasing the humidity of the air and bywearing clothing with antistatic coatings (althoughmost of the latter are lost in the wash, some haveappeared in recent years which are relatively per-manent). As regards other types of electrical accident,apart from the instruction of personnel in the properuse of electricity and the frequent periodic mainte-nance of apparatus and mains wiring, the measures tobe taken to minimise risk include the earthing of allapparatus, the installation of circuit breakers, the useof low mains voltages, and the separation of mainscircuits.5

CUTS, BRUISES, AND FRACTURESCuts, bruises, and fractures may occur in hospitalwork just as in any other human activity. Dominguez-Carmona, for example, mentions the case of a nursingnun who was killed in 1976 in the Hospital Clinico,Madrid, when a lift she was entering started up onbeing called from a higher floor, the second fatal acci-dent of this type in the centre in question.6 The risk ofaccident is greatly increased by physical fatigue,which is common towards the end of the day's workbut varies in intensity from one department toanother and also depends on the building in which thedepartment is housed and the type of personnel con-cerned. In old fashioned buildings it may be necessaryto do a lot of walking from place to place, and even inwell designed hospitals nurses spend most of the dayon their feet, with the consequent prevalence of vari-cose veins and foot complaints. Long working hours,changes of shift, and the arrangements before suchchanges, eating hours, and coffee or tea breaks, andfree time and holidays all greatly affect the fatigue andgeneral health of nursing staff. Training and



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512qualifications nevertheless reduce the risk of acci-dents: a survey carried out in the United Statesshowed that nurses who had received a diplomasuffered fewer injuries than less qualified nursing staff.Among nurses with a diploma about 30% of all acci-dents were due to overeffort and 20% to falls.7 Acci-dents due to overeffort when lifting heavy weights,however, are far from being restricted to hospitalnurses; domestic nurses being quite as much at risk, ifnot more. The risk of accidents from falling objects,burns, machines, beds, operating tables, glassware,needles, or scalpels is similar to that encountered inother occupations in which comparable equipment isused.The nature of dental work exposes dentists to a

special set of hazards. The use of pointed metalinstruments carries a risk of pricks and cuts (whichmay also be caused by the edges of gold or steelcrowns) and of face and eye wounds caused by frag-ments of tooth or metal when drilling. In the past,painful and deforming cervical, dorsal, and lumbarcomplaints were also frequent as the result of the den-tist spending all day on foot leaning over the chair.Modern workposts have largely solved this problemby allowing the patient to be positioned so that thedentist may work comfortably while seated orstanding.

NOISENoise constitutes an increasing problem in hospitalsand clinics as elsewhere. No cases have been reportedin dentists in which actual loss of hearing may beattributed to the use of low, medium, or high speeddrills, though the latter are extremely noisy7; but it isless clear whether the noise made by drills may notgive rise to psychological problems such as loss ofconcentration, character changes, or irritability.7Other health workers likely to be exposed to highnoise levels produced by certain of the machines theywork with include traumatologists, orthopaedicsurgeons, and ear, nose, and throat specialists.8 Theharmfulness of noise depends not only on the charac-teristics of the noise itself (its intensity and cadence)9and those of the place in which the noise is experi-enced but also on the susceptibility of the exposedsubject,' -15 many cases of acoustic trauma havingbeen reported in which the noise level was not partic-ularly high.'6 17 It should also be remembered thatquite soft noises of certain types may be extremelyunpleasant and their continual repetition may consti-tute a long term psychic health hazard. In the UnitedStates the recommended maximum noise levels forhospital wards are 45 dB (A) during the day and 35 dB(A) at night.'8 Hospital rooms should be suitablysound proofed, noisy faults in taps, cisterns, trolleys,and so on should be repaired as quickly as possible,

Gestalsoft soled footwear should be worn, and medical sys-tem alarms and telephones should be muffled. Othersuggested measures for limiting noise levels in hospi-tals include restrictions on conversations betweenstaff and patients with hearing difficulties and theisolation of noisy patients.'9

There have been several studies of the economiceffects of accidents in various Spanish hospitals.2023R Fernandez-Crehuet estimated that in the five years1978-82 the working days lost through accident in theHospital "Reina Sofia" in Cordoba cost 16117629pesetas (about £80,600).

Radiation

Serious hazards are presented to health workers bythe medical use of ionising radiation. The radiation towhich hospital staff may be exposed includes bothphotonic radiation (x rays and y rays) and chargedparticle radiation (a and ,B rays).x Rays are generated by conventional radio-

diagnostic and x ray therapy equipment and by highenergy x ray tubes. Gamma rays are produced bycobalt and caesium bombs and by radioelementsencapsulated in needles, tubes, or pearls, which mayalso emit ,B rays. Finally, unencapsulated radio-elements are used in solutions or colloidal sus-pensions administered to patients and laboratory ani-mals or applied in radionuclear laboratories tobiological material obtained from patients or ani-mals. The use of these unencapsulated sources entailsthe risk of laboratory equipment, workspaces, andpersonnel becoming contaminated.2425

IONISING RADIATIONThe effects of exposure to ionising radiation appearsooner or later after a latency period and may beeither stochastic or non-stochastic. Most of the casesmentioned in textbooks of radiobiology involve eithermassive exposure to radiation used for military pur-poses or doses of the same order of magnitude asthose administered to patients subjected to radio-therapy. Personnel working in properly constructedcentres should never be exposed to such large doses solong as they observe the necessary precautions,25 butmany health workers are none the less the object ofchronic low intensity radiation and as a consequencea small percentage may suffer somatic and genetic sto-chastic effects and possibly certain non-stochasticeffects also. In 1959 it was reported that there hadbeen 359 deaths from radiological causes throughoutthe world.

Non-stochastic somatic effectsNon-stochastic somatic effects may arise in the hae-matopoietic system, with occasional hypoplasia or



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Occupational hazards in hospitalseven aplasia, and yearly or half yearly analyses ofperipheral blood should be carried out to check forthis condition. Dermatological effects may includebrittle, cracked, or grooved nails, the disappearanceof body hair and fingerprints, and chronic radio-dermitis. Cataracts may develop. Irradiation ofembryos or intrauterine fetuses by doses ofmore thanI rem may cause abortion, fetal death, or the seriousmalformation of those fetuses that complete theirgestation. Alterations may also be produced byunencapsulated radioisotopes able to cross the pla-cental barrier.

Stochastic effectsStochastic effects include the shortening of life, theinduction of cancer and leukaemia, and genetic effects(an increase in the frequency of mutations).26 27Nowadays, the main radiation hazard occurs not in

hospital radiological departments28 -30 but in theconsulting surgeries of general practitioners and smallprivate clinics where adequate safety measures havenot been put into effect, and in hospital departmentsother than the radiological department that may alsohave occasion to use radiation (operating theatresand casualty and paediatric departments, for exam-ple). Professional radiological staff are also less likelyto expose themselves to radiation than other person-nel such as casualty staff or paediatricians, amongwhom cases of radiodermitis and skin cancer stillsometimes occur. The most dangerous operations forthese workers include radioscopy and the use of x raysurveillance of the setting of fractures, searches forforeign bodies, and the introduction of catheters.

NON-IONISING RADIATIONTheoretically, non-ionising radiation used in hospi-tals may also constitute a health hazard. Such radi-ation includes ultraviolet light, laser beams, magneticfields, and radiofrequencies. Ophthalmologists whowork many hours a week with lasers have beenreported to suffer from reduced central visual acuity,abnormal colour perception, and other defects indica-tive of possible macular damage,31 and althoughthese claims have not been confirmed, various bodieshave established norms for the use of laser equip-ment.32-34 Monitor screens have been blamed foreye strain, postural complaints, and psychologicalalterations leading to "technostress."35 42 In gen-eral, however, the risk of health problems derivedfrom non-ionising radiations is negligible. Perhapsthe only individuals clearly put at risk by a subclass ofradiations of this type are those who have had pace-makers implanted, since exposure to strong magneticfields such as those used in nuclear magnetic reso-nance equipment will probably disrupt the timing ofthe pulses generated by the pacemaker.

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Exposure to noxious chemicals

Many of the hazards faced by hospital staff consist inthe wide variety of chemical substances used. Apartfrom cutaneous infections, dermatological effects ofother infectious diseases, and infestation by parasites,and leaving aside the now quite rare occurrence ofradiodermitis discussed above, the cutaneousoccupational diseases suffered by hospital workersmay be classified as either irritations (caused bychemical disinfectants and detergents) or allergies(caused, for example, by antibiotics, rubber, nickel,disinfectants, aldehydes, or phenothiazines). Theoccupational origin of dermatosis may be ascertainedon the basis of the shape of the area affected, its distri-bution and location, the recurrent coincidence in timewith particular occupations, the patch test, and theresponse to treatment. Skin complaints make up halfthe total number of occupational illnesses bothamong hospital workers and among the working pop-ulation in general, 90% of them being cases ofcontactdermatitis. Some 60-80% of these cases are caused bychemical irritants (eczema due to primary irritants)and the remainder are of an allergic nature (allergiceczema).

Occupational allergic eczema is more commonamong nurses, surgical assistants, and other auxilia-ries than among doctors because of their continualcontacts with drugs, anaesthetics, and antiseptics.Resistance is reduced by repeated washing with soapand, especially, by scrubbing the hands and forearms,which destroys the skin's protective layer of fattyacids. Surgical and casualty personnel may sufferfrom "dry hand syndrome" due to handling plaster ofParis. Dentists and dental technicians are oftenaffected by contact eczema caused by handling acrylicmonomers, local anaesthetics, essential oils, dentalmould paste, epoxy resins, and amalgams. Labora-tory personnel are likewise put at risk by many of thechemicals they handle.43 -47

Mutagenic or carcinogenic effects result from manysubstances used or found in hospitals. Thus beta-propiolactone is known to be carcinogenic481 50;hexachlorophene is neurotoxic when applied to theskin, as was illustrated by the neural degenerationsuffered some years ago by French infants to whomit was applied in talc, and its teratogenic effects inpeople are also currently being investigated5 -53;sodium orthophenylphenate and glycols have beenresponsible for cancer of the bladder; and benzol(and xylol, toluene, and xylene contaminated withbenzol54 55) produces leukaemia and chromosomicaberrations. Busch and Nelson have reported cases ofacute respiratory distress in histological laboratorystaff exposed to xylene,"6 which may also give rise toheadaches, nausea, loss of appetite, lassitude, and



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impaired coordination.57

FORMOLSince 1894 formol has been used for terminal disin-fection of hospital rooms, beds, and apparatus. It isalso used as a preserving agent in pathological anat-omy and in the preparation of Salk and hepatitis Bvaccines. Apart from these medical uses of formol inhospitals,58 -62 there are also non-medical sources,including chipboard and plywood, carpet glues, par-quet varnishes, and urea-formol foam plastics used asthermal insulators.63-'70 The emanation of for-maldehyde from these materials depends on the tem-perature, the humidity, the age of the materials, andthe technical quality of the products.68 - 71 A volumeconcentration of 40 ppm of formaldehyde is also con-tained in tobacco smoke,7274 and an individualsmoking 20 cigarettes a day may retain some 0 38 mg.Uptake of formaldehyde occurs chiefly through the

digestive and respiratory systems, absorption throughthe skin being negligible.75 Small quantities are nor-mal in the cell. Its half life in the blood is about oneand a half minutes.

In recent years several comprehensive reviews ofthe toxicity of formaldehyde have appeared.7679The main effect of exposure to low concentrations isto irritate the eyes and the upper respiratorytract,80 85 though other parts of the respiratory sys-tem and the skin may also become sensitised.8688 Aconcentration of 10 ppm begins to be unbearable, giv-ing rise to burns in the nose, trachea, and eyes accom-panied by intense lacrimation, coughing, palpitations,and a sensation of thoracic and cephalic oppression.Concentrations of 50-100 ppm produce pulmonaryinflammation and oedema and ultimately death.89The North American Contact Dermatitis Group

have ranked formaldehyde as tenth in a list of thosechemicals causing most skin reactions.90 Allergic der-matitis caused by contact with formaldehyde has beenfound in the medical sphere among nurses handlingthermometers sterilised in 100 g/l formaldehyde solu-tion,91 personnel using disinfectants containing for-maldehyde,92 and patients whose injuries have beendressed with plaster impregnated bandages contain-ing 100 g/l of melamine formaldehyde resin.93 94 In1966 Blejer and Miller described an outbreak of con-tact eczema in a haemodialysis unit where a 20 g/lsolution of formol was used to sterilise open tanks.95Specific sensitisation of the respiratory tract is alsopossible, though this is much less common than sensi-tisation of the skin.9697 In recent years the auto-mating of sterilisation processes, better ventilation,and greater awareness of the need to use protectivesystems has reduced the incidence of such cases.98 99Formaldehyde is known to be highly reactive with

nucleic acids and proteins,100- 102 and several studies

Gestalhave shown its mutagenic effects on various micro-organisms,'03 107 arthropods,'08 110 cell test sys-tems,Ill-116 and mammals.1 17 Since squamous cellcarcinomas of the nasal passages of rats and miceexposed to 6-15 ppm of formaldehyde were observedin the United States,118 - 120 there has been contro-versy world wide as to whether formaldehyde is or isnot carcinogenic, 21 - 124 and there have been numer-ous studies of morbidity'25 and mortality' 26 - 135among groups of workers subject to occupationalexposure to formaldehyde. No abnormally high ratesof mortality from nose or lung cancer have beenobserved in these groups, but there have been reportsof higher than average mortality from tumours of theprostate, skin, kidney, brain, mouth, colon, bladder,and bone, and from leukaemia. Most of these studiesare open to the criticism that the small number ofsubjects prevented significant conclusions beingreached-for example, in the case of nose cancer-but a much larger study has recently been carried outby Acheson et al, who found no evidence of higherthan average rates of mortality from any of thetumours mentioned in earlier studies (including nosecancer) and concluded that formaldehyde is not car-cinogenic in man.'36 Further research on this subjectis nevertheless still needed before definitive conclu-sions can be arrived at.The attitude of official bodies to formaldehyde has

exhibited the same incoherence as scientific publi-cations. In 1981 the National Institute forOccupational Safety and Health declared for-maldehyde to be a possible carcinogen,137 and inApril 1982 the United States Consumer ProductsSafety Commission responded to numerous com-plaints regarding the irritant effects of formaldehydein the respiratory tract and its possible carcinogenicpotential by banning the use of urea-formol foams asinsulators in the building trade.138 A year later theban was lifted by the Court of Appeal on the groundsof the incorrectness of the documentation presentedby the CPSC regarding evidence of the health hazardposed by the chemicals given off by the foams.'39 InMay 1984 the Environmental Protection Agency nev-ertheless included among its priorities reviewal of theuse of urea-formol resins in housing.140 Similar situ-ations have been created in other countries. A WorldHealth Organisation working party recently recom-mended that because of its possible carcinogeniceffects, formaldehyde concentrations at work shouldbe reduced as much as possible, and that as a pro-visional limit workers should in any case not beexposed to concentrations in the air of more than 0-5mg/m3 for a mean eight hours a day in a workingweek of 40 hours.76ETHYLENE OXIDEThe bactericidal properties of this colourless gas were



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Occupational hazards in hospitalsfirst made known in 1929,'"' and since 1962 it hasbeen widely used to sterilise medical material. Atpresent it is the disinfectant gas most widely used tosterilise plastics and other materials that cannot besubjected to heat. Its acting at room temperature alsomakes it economical. Its disadvantages, however,include its being explosive, which makes it necessaryto mix it with inert gases; its remaining impregnatedin the material being sterilised (it dissolves in rubber),which means that the material sterilised must sub-sequently be ventilated; and its toxicity, concen-trations of 50 000- 100000 ppm being lethal in a fewminutes. 142

In the United States more than 2000 million kilosof ethylene oxide are produced yearly. Although lessthan I% of this total production is used for industrialor medical sterilisation, this use constitutes the great-est health hazard, with an estimated 100 000 healthworkers at risk in the sterilisation services of UnitedStates hospitals. Whereas other industrial applica-tions use ethylene oxide in closed circuits or outdoors,sterilisation involves open processes carried out inclosed premises.143 The areas of greatest risk are ingeneral the sites where ethylene oxide chambers areemptied, the most dangerous moment being when thedoor is opened.

Exposure to ethylene oxide, usually either contactwith the skin or inhalation, may produce either localor generalised effects. The exposed individual'sdefensive reactions are hampered by the typical lag ofseveral hours between exposure and the appearanceof symptoms, and by the fact that the gas is imper-ceptible to smell until quite high concentrations arepresent (700 ppm).144 Contact with insufficiently ven-tilated materials containing ethylene oxide (such asgloves, face masks, overalls, tampons, endotrachealtubes, or anaesthetic masks) produces irritant cutane-ous lesions, 145-.149 conjunctivitis and cornealburns,1 50 and, after exposure to high concentrations,cataracts.'51-153 Repeated contact may give rise toallergic sensitisation.154 Generalised effects mayinclude acute poisoning, the seriousness depending onthe intensity of exposure. Mild symptoms includenausea and vomiting155 and irritation of the eyes,nose, and throat, whereas in the more serious casesthere may be respiratory problems (dyspnoea,cyanosis, and pulmonary oedema), which may beproduced by just a few minutes exposure to concen-trations of 500-700 ppm.144 Other symptoms mayaffect the heart, the nervous system (with headaches,sleepiness, weakness, lack of coordination, and con-vulsions),144 the blood'56 and anaphylaxis.157Chronic ethylene oxide poisoning may cause en-cephalopathy, polyneuritis, and neurovegetativelesions.158 Exposure during gestation has beenreported to induce premature deliveries144 or abor-

515tions.l59There are no data suggesting that ethylene oxide

has teratogenic effects in man, and the resultsobtained with laboratory animals are con-tradictory.'60 161 As an alkylating agent, 162 manystudies have confirmed its mutagenic action in micro-organisms, arthropods,164 plants, 165 166 and thecells of man 167 168 and other mammals. 169 170 Thefrequency of chromosomic and chromatinic anoma-lies in lymphocytes is also known to be higher amongpeople chronically exposed to ethylene oxide thanamong the general population. '7' - 175 Rats exposedto ethylene oxide atmospheres have been observed tosuffer from leukaemia and mesothelioma, 17'1 and sub-cutaneous innoculation in mice increases the inci-dence of fibrosarcomas. l76 The epidemiologicalstudies conducted among people are neverthelessinsufficient to enable definitive conclusions regardingits possible carcinogenic action, for whereas Hogstedtet al'77 178 reported an increase in both general mor-tality and mortality from tumours (especially leu-kaemias), a study carried out in the United Statesfound no such effect.'79 Uncertainty regarding theduration and intensity of exposure hinders the draw-ing of conclusions, and further epidemiological stud-ies are required.The degree to which an individual has been

exposed to ethylene oxide may be measured biologi-cally by its alkylating haemoglobin and binding tohistidine to give N-3(2-hydroxyethyl) histidine.180Legally established tolerable limits vary from onecountry to another. In 1971 the American Conferenceof Governmental Industrial Hygienists proposed 50ppm as the mean allowable concentration in theworkplace,'8' but information gathered concerningmutagenic and possible carcinogenic effects has led toa legal threshold limit value (TLV) of 10 ppm and aproposal in 1982 for a reduction to 1 ppm,'43 thesame level proposed in 1983 by the Occupational andSafety Health Administration.182 In the USSR thelimit is 0 5 ppm. After comparing the alkylating andmutagenic potential of ethylene oxide with that ofionising radiation, Calleman et al proposed a TLV of0-25 ppm, which would be equivalent to the maxi-mum allowed dose of 5 rads of radiation a year.'80

In the light of the data now available, it may beconcluded that whenever possible sterilisation byethylene oxide should be replaced by sterilisation byy rays or propyl oxide.

CYTOSTATICSCertain oncolytic agents have long been known toproduce contact dermatitis and blisters, and elemen-tary precautions have always been taken to avoidtheir contact with the skin of the patients to whomthey are administered and the nurses responsible for



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their administration. Modem studies, however, haveshown that the mutagenic hazard presented by cyto-statics (found by Hoffman'83 in the urine of nursesand technicians who had prepared or administeredantitumour agents) is not limited to physical contactbut also includes the inhalation of vapours andmicrodroplets given off during the preparation andadministration of cytostatic solutions, and thesemutagenic effects are reinforced by smoking. Immu-nological alterations have been observed in the lym-phocytes of the peripheral blood of both patientstreated with cytostatics and the staff who had pre-pared and administered the drugs.'84-187 To elimi-nate these risks, cytostatics should be prepared andreconstituted in vertical laminar flow chambers usinga laboratory coat, gloves, and a face mask, and thesame rules should apply to the handling of the urineof patients treated with these substances.188-190

ANAESTHETIC GASESThe first reports of harmful effects of anaestheticgases among health workers are those of Hewitt(1893), Kirschner,'91 and Perthes (1925),192 all ofwhom described acute effects. Hirsch and Kappurssoon pointed out that although acute poisoning isinfrequent, the likelihood of chronic poisoning can-not be neglected,'93 and cases of chronic poisoningwere described by Werthmann in 1948.194 Never-theless, this problem was generally ignored until in1967 Vaisman carried out an epidemiological study ofSoviet anaesthetists,'95 since when a variety of disor-ders have been attributed to anaesthetic gases.'96 - 198Following Cascorbi,'99 we shall classify them intothree main groups: changes in behaviour and the abil-ity to perform psychometric tests, diseases of theorgans for the biotransformation and excretion ofxenobiotics, and faulty cell replication.

Changes in behaviour and the ability to performpsychometric testsBruce et al found that volunteers exposed to traceconcentrations of anaesthetic gases (50-500 ppm ofN20 with or without 1, 10, or 15 ppm of halothane)suffered alterations of perception, cognition, andmotor skills.200202 Neither Smith and Shirley,203nor Frankhuizen et al,204 nor Venables et al,205 how-ever, have been able to reproduce their results, whichare furthermore questionable as regards their statisti-cal significance'97 and the surprising finding thatnitrous oxide alone was more deleterious than whenaccompanied by halothane.202 Occupationalexposure to traces of anaesthetic gases has not beenobserved to give rise to neuropsychiatric disor-ders.206 - 208 Quimby et al found that rats exposed to10 ppm of halothane for eight hours a day, five daysa week from birth to the age of 60 or 135 days, made

Gestalmore mistakes than controls in specific tests but thattheir relative learning rates were similar.209 210Again, however, these results and their statisticalsignificance have been questioned.197 Present knowl-edge suggests that no acute behavioural alterationsare produced by concentrations of nitrous oxidebelow 8-12% or by less than 0 1% of halo-thane.2' 1213A finding that may or may not be relevant to the

toxicity of anaesthetics is that among United Statesdoctors, whose overall suicide rate is 15% higher thanthat of the general population,21425 anaesthetistsare the second most suicidal subgroup (behindpsychiatrists), with a rate three times that of the con-trol group.216 217 This has been confirmed by Lew ina study of the causes of death among members of theAmerican Society of Anesthesiologists,2'8 which hasnamed suicide as the major health risk amonganaesthetists aged under 55.219 220Diseases of the organsfor the transformation andexcretion ofxenobioticsHepatic diseases-Since the introduction of halo-thane in 1956, occasional cases of hepatic necrosisafter its use as an anaesthetic have beenreported,22' 222 and repeated anaesthesia under halo-thane is now regarded as an aetiological factor thatcannot be ignored.223 Subanaesthetic doses of halo-thane, isoflurane, diethyl ether, fluoxene, enflurane,and nitrous oxide have been found by some authorsto cause hepatic alterations in animals,224- 227whereas others have observed no such changes evenafter lengthy or intense exposure228 -230; controversyon this point continues.'97 231 232 In operatingtheatre staff temporary rises in hepatic transaminaselevels have been reported,233 and also jaundice234and hepatic cirrhosis,235 whereas in the United StatesCohen et al found that the incidence of hepatic dis-eases was above average among female operatingtheatre staff236 and dentists using general anaesthesiathree hours a week or more.237 An increase in thefrequency of hepatic diseases has also been observedamong anaesthetists in Czechoslovakia238 andEngland and Wales.239

Kidney disease-Certain epidemiological studieshave reported a higher than average rate ofkidney disease among anaesthetists, womenespecially216 236 238; Chang et al observed ultra-structural changes in the kidneys of laboratory ani-mals chronically exposed to low levels ofhalothane240; and Dahlgren found moderate tempo-rary alterations of kidney function in Swedish healthworkers exposed to methoxyflurane.24Faulty cell replicationAbortion and congenital malformation-In Vaisman'sreport attention was drawn to the high rate of abor-



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tions among women working in operating theatres inthe Soviet Union. 195 The same phenomenon was sub-sequently observed by Askrog and Harvald inDenmark242 and was confirmed by Cohen et al in theUnited States and Canada,236 where the abortionrate among pregnant women working in operatingtheatres was 17- 1% whereas that of other pregnanthospital workers was only 8-9%. Other investigatorshave reached similar conclusions,238 243 244 thoughthere have also been contradictory reports in whichno increase in the spontaneous abortion rate wasobserved among doctors and nurses exposed to ana-esthetic gases.245 246 Of the various dangers attrib-uted to chronic exposure to traces of anaestheticgases, the risk of abortion among women working insurgical departments is the only one recognised by theUnited Kingdom Department of Health and SocialSecurity.247A more surprising finding has been that abortions

are twice as common among the wives of UnitedStates dentists administering general anaesthesia atleast three hours a week as among the wives of thosewho use only local anaesthesia (18% v 9%),237though Askrog and Harvald had already reported asimilar phenomenon among the wives of Danishanaesthetists.242 This suggests that anaesthetic gasesmay affect spermatogenesis, and such alterationshave indeed been observed in animals,248 -251 butWryobek et al found no changes in either the mor-phology or the concentration of spermatozoa pro-duced by anaesthetists working in three San Fran-cisco hospitals (though the modem gas extractionsystems in these centres may have meant that theseanaesthetists enjoyed better than average protec-tion).252

Several studies have reported that women exposedto anaesthetic gases during gestation run a greaterthan average risk of giving birth to children with con-genital malformations.236 253-256 Tomlin found thatthe central nervous system and musculoskeletal sys-tem were especially affected by this abnormal inci-dence of malformations,244 whereas Pharaoh et alobserved higher than. average frequencies of con-genital cardiovascular malformations and stillbornbirths and a smaller average size among live new-born babies.245 Baltzar, however, found no suchdifferences.257 The validity of many of thesestudies237 242 244 256 257 has in any case been ques-tioned258-262 on the grounds that most were carriedout using retrospective postal questionnaires. Fer-standing,260 Axelsson and Rylander,26' and Tan-nenbaum and Goldberg262 have been especially crit-ical, pointing out numerous methodological flawssuch as the lack of criteria for exposure or outcome,poor survey response rates, selection bias, lack ofvalidation of outcome, recall bias, and lack of control

517of potentially confounding variables.262 These criticsemphasise the need to carry out suitably designedprospective studies to determine whether or notexposure to trace concentrations of anaesthetic gasesentails a real risk of abortion or congenitalmalformation.

Chronic exposure to anaesthetic concentrations ofnitrous oxide or halothane has been reported toincrease the resorption and congenital skeletal mal-formation rates among rats exposed duringgestation263-267 or to reduce the weight and lengthof hamster fetuses,268 but no such effects have beenobserved at subanaesthetic levels.267 269-271 Neitherhave changes been observed in the fertility of animalsexposed to subanaesthetic doses,248 269 272 or inexposed chick embryos.273280 Mutagenic effects onbacteria have been observed by some28' 282 but notby others.283 284 To sum up, there is at present noconclusive experimental evidence that chronicexposure to traces of anaesthetic gases-or even shortexposure to high concentrations285 has any adverseeffects on gestation in animals.

Malignancies-Chloroform286 287 and trichloro-ethylene238 have been found to be potentiallycarcinogenic (causing hepatic carcinomas and kidneytumours) for experimental animals exposed to largedoses introduced by mechanisms different from thoseinvolved in the occupational exposure of man. Withthe exception of a study by Corbett,288 however, theresults of which he was unable to reproduce,289 thereis no experimental evidence that low concentrationsof halothane, nitrous oxide, enflurane, isoflurane, ormethoxyflurane are carcinogenic.290294

Bruce et al detected an abnormally high rate ofmortality from lymphoid and reticuloendothelialtumours among anaesthetists during the period1947-66,216 but a subsequent study failed to confirmany relation217; Cohen et al observed a greater inci-dence of cancer among female anaesthetists in theirnationwide study236 but found no difference betweenexposed and unexposed subjects in their study ofdentists237; and although Corbett et al reported anabove average cancer rate among anaesthetic nursesin Michigan,288 serious doubts have been raised as tothe validity of both this study and Cohen's.258 259The suggestion that anaesthetic gases may act astransplacental carcinogens is not supported by thestudies of Knill-Jones et a1243 and Pharaoh et a1245 inwhich the incidence of cancer is no greater among thechildren of female anaesthetists in England and Walesthan among those of other women, though adifference between the two groups has been claimedby Tomlin.244 In view of these studies it cannot beconcluded that there is a risk of cancer from chronicexposure to traces of anaesthetic gases.



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Other risks, and preventive measures

Irritation of the respiratory tract has been reportedafter chronic inhalation of ether, and laryngitis andattacks of asthma after exposure to halothane andenflurane respectively.295 Personnel long exposed tonitrous oxide have been reported to sufferneuropathies296-298 recently shown to be caused bythe ability of nitrous oxide to oxidise vitamin B12,thus impeding the synthesis of methionine, folate, andthiamine.299 -303

To prevent abnormalities caused by exposure toanaesthetic gases it is necessary to make anaestheticand surgical staff aware of the risks and to urge theintroduction of efficient gas extraction systems (levelsof 130-7000 ppm of nitrous oxide and 10-85 ppm ofhalothane have been detected in the region where theanaesthetist breathes).304-306 Good practice codesshould be adopted to reduce atmospheric pollution,routine inspections of equipment should be carriedout, and routine checks on pollution levels in theaffected areas and personnel should be performed. Inthe United States, where (without counting surgeons,

dental staff, and vets, whose exposure is intermittentand variable) about 50000 people, 35% of themwomen, are occupationally exposed to anaestheticgases (anaesthetists, anaesthetists's nurses, operatingtheatre nurses, and technicians),305 hospital regu-

lations limit pollution in operating theatres to 25 ppmof nitrous oxide and 1-2 ppm of halogenatedagents.307

Drug addiction and psychic problems

The risk of health workers becoming addicted todrugs arises because of the stress and anxiety to whichthey are subjected at times and because of the readyavailability of suitable drugs.308 It is quite commonfor attempts to be made to overcome the pressures ofoverwork, stress, and affective strain by excessiveresort to stimulants, whose use may alternate withexcessive consumption of coffee or tobacco and theuse of sleeping pills, alcohol, or other drugs. Severalstudies have confirmed that alcoholism, drug addic-tion, and depression are more common among doc-tors than among the general population,309315 as

are visits to the psychiatrist.3'6 For example, of the5925 patients admitted to the psychiatric wards of theMayo Clinic between 1956 and 1963, 93 were doctors(one in every 64 admissions),3'7 and in 59% of thesecases the cause was either alcoholism (16-6%) or drugaddiction (34 4%). Almost all these patients had useddrink or drugs as a defence against acute anxiety.Similar findings were reported by Murray after exam-ining admissions to psychiatric centres inScotland318: there were significantly higher than aver-

age rates of alcoholism, drug addiction, functional

Gestal

neurotic depression, and affective psychosis amongdoctors. Perhaps because of the high prevalence ofdepression, suicides are two to three times more com-mon among doctors-psychiatrists especially318than among the general population.313 319-321 Mar-ital and sexual dissatisfaction is also more prevalentthan among non-doctors,316 322 323 though thedivorce rate is no higher than average.324-326Work, which as a channel for the fulfilment of the

individual may favour his or her psychic wellbeing,may also prove psychically deleterious owing to theindividual's own traits (personality, social conflicts,etc), to the working environment (group relations), tothe nature of the work itself (disagreeable or alien-ating jobs, overfast workpace, excessive workloads,changes of shift), or to promotion.

CHANGES OF SHIFTChanges of shift originate personal, family, and socialproblems.327 The resulting lack of synchronisationbetween exogenous stimuli328 (the periodic variationof light, sound, heat, and atmospheric ionisation) andendogenous clocks329 330 gives rise to disorders dueto dysrhythmia. In such cases the human organism,which is programmed for daytime activity, receivesstimuli opposed to its physiological requirements, theconsequence being a characteristic disorder featuringinsomnia, irritability, dyspepsia, spacial and temporaldisorientation, and eventual corticosuprarenalexhaustion.33' Night work goes against the genetic,professional, and social characteristics of the humanspecies. Working while in a state of nocturnal "dis-activation" requires double effort and hence producesgreater fatigue than day work, and this fatigue isincompletely eliminated because daytime sleep is lessrestful than night sleep. This state of chronic fatigue isexemplified by the slowing down of motor responsesto optical and acoustic stimuli and by decreasedefficiency at work. Digestive dysrhythmia is alsoobserved, and there is greater dependence on tobaccoand alcohol among night workers than among dayworkers.The family life of the night worker is likewise upset,

since unless the hours kept by the rest of the familyare made to fit in with his he himself must either fit inwith theirs or live apart. Socially, night work resultsin greater insularity (nightworkers have fewer friends)and less participation in group activities (sports,union or political work, or cultural pursuits), thoughit is also true that morning and afternoon shifts like-wise have their social disadvantages. Thus the morn-ing shift allows the midday meal to be shared with thefamily and leaves time for other family and socialactivities, but since it begins so early may also provefatiguing. The afternoon shift prevents social life,since contact with the children is limited and there are



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Occupational hazards in hospitalsno evenings out, but sleeping hours are normal andworkers with alternating shifts regard it as allowinglost sleep to be made up. It is the night shift thatcauses most problems due to its consequences forfamily life and social activity.332

Emotional stress is one of the main health hazards forhospital personnel, especially for the studentor young graduate nurse, and derives from contactwith the dying, with seriously ill children, and withsorrowful, anxious, and suicidal patients. Working inintensive care units also gives rise to situations that,depending on the personality of the individual, maycause pathological psychic disorders.336 337 In thiscontext the relation between doctor and patient ispassive, with the doctor and nurse being under theconstant pressure of having continually to takeinstant decisions that are critical for the patients'lives. This highly stressful combination of greatresponsibility and continuous attention to patients'needs, which is further exacerbated by a work patternthat does not allow relaxation during breaks andleisure periods, ends up by producing exhaustion andreduced operational capacity.336 338 339 Signs ofstress among intensive care unit workers includepsychosomatic disorders (mainly affecting thedigestive system), anomalous social reactions, varioustypes of neuroses and depression, and even derelictionof duty.340 Psychopathological stress likewise tendsto increase when health work becomes monotonous,boring, and "meaningless" while retaining itsdemanding nature. In all these stressfulcircumstances, however, the effect on the healthworker depends largely on his attitude to the situationand on his resources for coping with it.337 341

Assault

Human life undoubtedly includes a degree ofaggressive conduct, whether this be innate oracquired. The necessity of continual adaptation to achanging environment forces such conduct on us,especially in a society as competitive as ours. In thissection, however, we shall limit our considerations tothe urge to harm some person (or some object thatrepresents or replaces that person), the harm causedbeing the sole aim of the aggressive act. Innateaggressive behaviour needs no stimulus, but therealso exist socially acquired forms of aggression thatare triggered by external stimuli such as frustration.The patient and his relatives should therefore never befrustrated, since they may become aggressive.342 -

Frustration may be produced when the behaviourof health workers is unfitting or is not what isexpected, in short when they forget their role. Healthcare involves a social group comprising the health

519worker, the patient, and the latter's relatives andfriends. To paraphrase Berard and Gubler,sometimes it achieves its purpose, the curing of thedisease; generally it manages to provide relief; and italways provides assuagement.346 Each member of thegroup has his own status and accompanies theexecution of a particular function with a behaviourthat is expected by the others. Each status and role inthe group has its complement: husband and wife,father and son, health worker and patient. The rolesof the health worker and the patient are defined by theambient culture and certain aspects are evenregulated by law.347 The role of the patient ischaracterised both by rights such as exemption fromhis responsibilities and the right to receive aid, and byobligations such as his obligation to wish for his ownrecovery and to cooperate in his treatment.348 Thestatus and role of the health worker are characterisedby impartiality (giving each patient the attentionrequired by the gravity of his illness), byconfidentiality (using the patient's body and theinformation he knows regarding the patient solely forthe patient's cure), by affective neutrality (avoidinginvolvement in the patient's affective problems), bydisinterested altruism, and by technical and scientificcompetence.41 Criticism of the health worker'sbehaviour will come from the patient's relatives andfriends, the commonest criticism being that little timeis devoted to Social Security patients.349 The patientshould be convinced that a diagnosis has beenattained or at least that everything possible is beingdone to attain it. The harmonious course of therelation between doctor and patient, each with hisstatus and role, is fundamental for achieving theobjective, health.350352 If disrupted the results maybe pathogenic not only for the patient but,paradoxically, for the doctor also.353

For the doctor, the pathogenic consequences of abreakdown in his relation with the patient may bephysical (injuries), anatomopathological (heartattacks), or functional or psychosomatic (ulcers). Thesources of the patient's aggressive conduct may beclassified in three categories: those arising in thecontext of his relation with the doctor, those arising inhis own family and working environment, and aresidual group of other social sources. Aggressionmay take the form of physical assault or verbalattacks and be received either by the health workerhimself or by his family or possessions. Verbal assaultis undoubtedly the most common but cases ofphysical attack are by no means rare and areoccasionally reported by the daily newspapers.When faced with patients known to be mentally ill,

awareness of the possibility of apparentlyunmotivated fits of violence puts the doctor on hisguard. The most dangerous are the paranoics,



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especially the hypochondriacs convinced that they aresuffering from a serious illness because the doctor istreating them badly (there is usually another healthworker encouraging such patients). Femaleerotomaniacs convinced that only the doctor'sshyness prevents his declaring his love for themgenerally limit themselves to verbal assault but thedoctor should avoid being left alone with them.Hysterical mythomaniacs put about false rumoursand reports whose truth they believe in once they haveuttered them. Excited schizophrenics andhypomaniacs can also be aggressive (thelatter-usually verbally-on being told the truthabout their condition, which it is sometimes wiser tokeep to oneself). Assaults by drug addicts and sadistsmay likewise be expected. Assaults by sane patientsare much more dangerous because they areunexpected; and are much more important becausetheir unexpectedness means that the doctor wasunaware of how he had frustrated the patient.354

Finally, a different type of "assault" to whichhealth workers are exposed is their being sued formalpractice by their patients.355 -358 Though nonewould wish to deny patients this right, it should bepointed out that widespread abuse of its exercise mayprove detrimental to health care by inducing healthworkers to practise medicine on the defensive, withgreater importance being given to what it is legallysafe for the doctor to do than to what is beneficial forthe patient.359 Paradoxically, there are grounds forthinking that the spate of malpractice cases currentlydisturbing United States doctors' peace of mind is inpart due to the very success of modem medicine: thefact that the act of healing is now a commonplace hasresulted in a tendency for any failure to beimmediately attributed to negligence on the doctor'spart rather than to the intrinsic limitations of his art.ReferencesThe following are the most important of the references cited in thetext. A complete list may be obtained from the author on request.

I Gestal JJ. Occupational hazards in hospitals: risk of infection.Br J Ind Med 1987;44:435-42.

2 Freeman NT, Whitehead J. introduction to safety in the chemicallaboratory. London: Academic Press, 1982.

5 Link UJ. Electrical safety in hospitals, a current review ofprin-ciples and practices. Eire, Pennsylvania: American SterilizerCompany, 1976.

Gestal30 Braestrup CB, Vikteriof KJ. Manuel de radioprotection dans les

hospitaux et en practique generale. Geneve: OrganisationMondiale de la Sante, 1974:vois I, 11, III.

34 Department of Health and Social Security. Guidance on the safeuse of lasers in medical practice. London: HMSO, 1984.

37 Steward T. Problems caused by the continuous use of visualdisplay units. Lighting Research Technology 1980;1:26-36.

44 Fisher AA. Contact dermatitis in medical and surgical person-nel. In: Maitach HI, Gellin GA, eds. Occupational and indus-trial dermatology. London: Year Book Medical Publishers,1982:219-28.

54 Organizacion Mundial de la Salud. Limites recomendados porrazones de salud en la exposicion profesional a determinadossolventes organicos. Ginebra: OMS Ser inf tecn 1982;664:9-43.

76 Organizacion Mundial de la Salud. Limites de exposicion pro-fesional que se recomiendan por razones de salud: substanciasirritantes de las vias respiratorias. Ginebra: OMS Ser inJtecn1984;707:39-76.

77 Gonzalez Ferradas E. Formaldehido: toxicologia e impacto ambi-ental. Madrid: Ed Mapfre, 1986.

78 Gibson JE. Formaldehyde toxicity. London: Hemisphere Pub-lishing Corporation, McGraw-Hill International Book Com-pany, 1983.

136 Acheson ED, Gardner MJ, Pannett B, Barnes HR, Osmond C,Taylor CP. Formaldehyde in the British chemical industry.Lancet 1984;ii:61 1-6.

143 Gennart JP, Dutrieux M, Lauwerys R. La toxicite de l'oxided'ethylene: revue de la litterature. Archives des Maladies Pro-fessionelles de Medicine du Travail et de Securite Sociale1983;4:269-74.

189 Riesgos y prevencion en el manejo de soluciones citostaticas. Mal-aga: Sociedad Espaniola de Higiene y Medicina PreventivaHospitalaria, 1985:2. (Serie documentos tecnicos.)

197 Ferstanfing LL. Trace concentrations of anesthetic gases: a crit-ical review of their disease potential. Anesth Analg1978;57:328-45.

198 Edling C. Anesthetic gases as an occupational hazard: a review.Scand J Work Environ Health 1980;6:85-93.

262 Tannenbaum TN, Goldberg RJ. Exposure to anesthetic gasesand reproductive outcome: a review of the epidemiologic lite-rature. J Occup Med 1985;9:659-68.

311 Modlin HC, Montes A. Narcotics addiction in physicians. Am JPsychiatry 1964;121:358-65.

313 A'Brook MF, Hailstone JD, McLaughlan IEJ. Psychiatric ill-ness in the medical profession. Br J Psychiatry 1967;113:1013-23.

322 Scheiber SC. Emotional problems of physicians: I nature andextent of problems. Ariz Med 1977;34:323-5.

324 Fine C. Married to medicine: an intimate portrait of doctors'wives. New York: Atheneum, 1981.

332 Leonard R. Le travail de nuit et les horaries alternants. Paris:Universite de Paris, 1982.

335 McCue JD. The effects of stress on physicians and their medicalpractice. N Engl J Med 1982;8:458-63.

343 Carthy JD, Ebling FJ. Historia natural de la agresion. Mexico:Siglo XXI editores, 1966.

358 Ataz L. Los medicos y la responsabilidad civil. Madrid: EditorialMontecorvo, 1985.



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Documents

Occupational hospitals: accidents, exposure to and assault · Occupationalhazardsin hospitals: accidents, radiation, exposureto noxiouschemicals, drug addictionandpsychicproblems,