Hazards and Safety in the Biomedical Industry

Introduction:

The world can be a very dangerous (or safe!) place, depending on where you wander into, and, for the most part, living in Canada affords us many simple guarantees that we may take for granted. For instance, in the United States, the prevalence of workplace injury is about 3 times what it is in Canada or Europe^{1, 2, 3}. Why the difference?

In Ontario, we hold businesses to standards set by the provincial and federal governments; basic working awareness and education, essential material handling education, and, heaven forbid, measures that dictate what happens if somebody is hurt are all excellent advantages Ontarians have protecting themselves while at work. Direct, basic safety measures must fall under the Occupational Health and Safety Act⁴. This protects the employee and sets out standards of practice for both employee and employer regarding action, asking questions, ensuring an employee is suited to the task, personal protective equipment (PPE), and other specific requirements based on the method of possible injury. In general, this is more than adequate to prevent harm in situations where the employer is just, fair and reasonable and the employee is following instructions, is sound of mind, does not have malicious intent and is aware of what can hurt him. If the employer or employee does not do these things, legal recourse is possible because of the nature of training and sign-offs (sign here if you’re not going to blow up the building or burn your eyes with that acid).

Material handling safety standards are covered by WHIMIS⁷ training and if an employee has any involvement with affected materials, the employer must include this training as a requirement to work. This ensures that people working with a variety of agents, chemicals, or substances know how it enters the body, what PPE to wear, what to do if it gets imbibed, and how to store it. Substances always have to be marked, the source has to be verified, it has to been disposed of properly, and it has to be locked away securely.

In situations where an accident or injury does happen, Workers Compensation through the Workplace Safety and Insurance Board (WSIB), as set out in the Workplace Safety and Insurance Act allows for rehabilitation, lost time compensation, and back to work programs.^{5, 6}

Modality specific governing bodies oversee technologists, nurses, doctors, and other practitioners, these bodies make sure doses are not exceeded, they know what they’re doing from a diagnosis/treatment standpoint, and malpractice/complaints are tracked. Physicians are overseen by the College of Physicians and Surgeons of Ontario⁸, dentistry practitioners are kept in check by The Royal College of Dental Surgeons of Ontario⁹, and physiotherapists have their own college too called … you guessed it… the College of Physiotherapists of Ontario¹⁰. What is common between all of these governing bodies is that they handle licensing, auditing, complaints, malpractice, and education of their practitioners to ensure the quality, reduce the liability, and uphold the prestige of being able to call yourself one of these people. The results of the findings of these bodies will be upholding of membership, ability to work in differing capacities at healthcare facilities, accreditation¹¹ for their own practices, and ability to process patients’ claims properly through the Ontario Health Insurance Plan (OHIP).¹² The equipment upkeep requirement set out by these groups vary, but one commonality they must abide by is having to keep regular preventative and repair documents ready for audits. This includes summaries of condition of units, assessment of facilities, accepted or denied repairs and any necessary certification reports. Any technologist from TRH Services is also a part of and is similarly overseen by their own association called the Ontario Association of Certified Engineering Technicians and Technologists (OACETT¹⁴). Our staff are aware of all of the above workplace safety standards and practices and will abide by them when they are on site. Additionally, they may raise concerns if there is a lapse in any of these practices so potential hazards or incidents are less likely to occur. The concerns raised will usually be directly related to your equipment that is being serviced, but if something is noticed in the facility itself or activity of the staff, we try to make note of that too.

Specific Hazards

Now, where do these injuries actually come from? There are a number of major hazards that any problem situation can fall under. Electrical, mechanical, ergonomic, chemical, biohazard, temperature, radiation, psycho social and miscellaneous¹⁵ are all categories that adequately encompass most situations encounterable. The type of equipment that this article will speak to is very broad, but for your consideration, there are items related to:

Medicine: Medical examination rooms, waiting areas, drug use and access, patient monitors, anaesthetic equipment, treatment tables or operation chairs, patient transport and continuous/non-continuous monitoring, scales, implanted devices, diagnostic ultrasound equipment, X-ray or MRI equipment, non-medical electronic equipment, accessories, reprocessed equipment, and all related items or situations that are directly attributable to the visit to the office, recovery, rehabilitation, and follow-up process
Dentistry: applicable items above as well as hand tools: drills, scalers, accessories and water source/flushes
Physiotherapy: applicable items above, as well as weightlifting equipment, ultrasound equipment, interferential/TENS units, rehab objects, force measuring/exerting equipment, wax bath, and acupuncture

All of these disciplines have general, shared building items like doorways, furnishings, flooring, bathrooms, and hallways that may have hazards as well. There are specific pieces of equipment not mentioned here that are too numerous to list. If you are unsure about if your equipment could pose a hazard, or want a general assessment, make special note to mention you would like a facility assessment outside the areas where your equipment to PM is located. While we are a biomedical company primarily, we offer many related technical (electronic, mechanical, or otherwise) services that you wouldn’t expect.

Electrical

This subject is one that is so prevalent in our modern life yet so little is known about what is safe or not using common sense or common knowledge. Simply put, electrical danger happens whenever any path is formed from an electrical source to a patient and may cross their body in such a way or intensity that causes discomfort or damage to tissue. The problem with electrical hazards, and why it is such a danger, is because electricity is an invisible hazard that is hard to immediately protect yourself from. All electrical devices that have preventative maintenance (PM) performed on them will undergo an electrical safety test that ensures that the device is not at risk of shocking your patient or practitioner.¹⁶

Electrical Sources

There are many sources of electrical hazards that can be roughly categorized as damage, defect, bridging and induction.

Damage is pretty straightforward. This can happen due to breakage in the cable, causing the metal to be exposed when it is normally safely behind insulation. This is usually obvious, but the exposed portion may be too small to immediately see, or the exposure may be hidden under a desk (a metal one) and the desk suddenly becomes like a big wire. A device that has this problem may cause unexpected operation of unknown effect. Internal damage to a cable will cause that which it is connected to operate in an abnormal fashion, and the entire safety of the device itself can be called into question because a cable does not meet expected standards. TRH, as part of the PM procedure, ensures that the device is within allowable limits, the accessories or cables are free of shock or abnormal operation hazard, and will be expected to last until the next PM due date, which usually is in one-year increments.

Defect¹⁸ is the result of inadequate standards or actions performed during the material sourcing, manufacturing, assembly, distribution, receiving, operation¹⁷, or servicing. This source of hazard is greatly minimized when the device is connected in some way to accreditation, servicing, or safety checks, which work in a chain; if a qualified practitioner is overseen by a qualified body, that qualified body expects qualified service personnel to identify if the equipment meets manufacturing and operating standards. TRH will identify that each piece of equipment, regardless of how you obtained it, is certified by the basic standards that the Canadian government deems necessary to allow it to be sold and/or used in clinical or residential situations. Devices that do not meet standards can be verified or confirmed to be operating within a larger scope of related guidelines but will be made note that they do not technically pass certification standards.

The third category of electrical hazard occurs during what is known as shorting or bridging. You may be aware, but shocks also happen if another medium, such as water bridges that path. Spillages are very dangerous where an electrical device is concerned – you are essentially sticking your finger in a wall outlet when you touch water that’s in contact with power. This is especially concerning because it can turn an otherwise perfectly functioning and protected machine into a patient, fire, explosive, near miss, or equipment failure hazard¹⁹. Regular facility service checks, practice guidelines, and common sense largely takes care of this hazard. All devices are assessed to be safe with regards to this bridging/spill and if they are not, the hazard is identified and will usually follow with a recommendation of corrective measures including changes to room construction, electrical wiring, inclusion of special wall plugs or the relocation of equipment.

Finally, there are situations where electricity can be transmitted invisibly through the air to metal you normally would not expect to have electrical activity. These are most commonly found where the power enters the facility (or a circuit panel), large compressors or motors are stored, or overhead transmission wires. These situations historically have only arisen in rate high power applications, but basically, power, when looped in a coil, will induce magnetism which will, in turn, create a varying intensity of electrical shock. For this reason, they are very low in risk factor, if your building was built and set up properly.

Electrical Effect

The effect of electrical impact on the human body may be shocking to you. Standard household power is 120-220 volts, 15 amps at 60 hertz. The higher value is the line coming into your house, which may also be used for large appliances like refrigerators and washing machines. The lower value will come out to your plug socket to power most household and commercial devices. Voltage is the force of the power, amperage is the rate and hertz is the frequency (faster waves). The specifics of electrical values need not concern you, but it is noteworthy that the frequency we use for transmission of electrical power is very effective in activating (or deactivating) human muscles²⁰, and, interestingly, it may cause you to move suddenly in an unexpected direction, or even grip a power cord more tightly and not let go. We take special care to ensure that the risk of somebody coming into contact with live electrical power is eliminated with respect to the devices we have been brought on site to test. Should the electrical ‘leakage’ be noted to be excessive, the unit is either failed and immediately communicated to the staff and a ‘high leakage’ sticker is placed in a visible location if the client wishes to continue using the device.

Harm to a person from standard power depends on how it comes into contact with a person. A Smaller surface area like a break in a cable will cause a sharp shock that a person will flinch from and is largely not a life or death situation because it shorts out a very small portion of tissue. If the site is largely bare and the width of a finger, there is a chance of a burn or scar because the furthest points on the metal will traverse the whole of the tissue. If the metal-body contact is large, such as a treatment table or frame, where the body will create a path from one end of the person to another, the electricity may contract muscles painfully, damage organs, scar internal nerves or vasculature. It’s also noteworthy that electrical damage to tissue may not appear until even weeks later.²¹ The most concerning of these many horrible things is organ damage, and specifically, cardiac changes. Ventricular fibrillation can be induced in between 211-743 micro amps (μA) and even as low as 40 (μA) in certain situations where the cardiac tissue is directly targeted.¹³ There are general values that we make sure the unit has to pass our electrical tests, but special measurements are made for units with a large metal surface area, direct to the chest region (ECGs), or may involve a unit which a patient is sure to use in a state of undress.

There are significant non-patient effects of electrical malfunction and those are damage to equipment and the possibility of starting a fire. Equipment damage can cause a device to not monitor the patient properly, result in high or no output of energy (motor, ultrasound applicator, treadmill speed), or increase the chance of shocking mentioned before through damaged or shorted components. The problem with this is that if it occurs, it may not be discovered until your next service call, which is why preventative maintenance is important to resolve the environments and check the manufactured protections that are designed to prevent this. Should a device malfunction in any way (even once), it is highly advised that you discontinue operation and have an assessment done on the device at your earliest convenience. There may be pressure to keep a device in service, but it is far better to be safe than sorry. This is recommended if your building has a power surge and there are devices connected directly to the wall without a surge protection power bar in between the two. A visit for a purely electrical safety visit will not incur the same sort of cost that a regularly scheduled PM visit will, and will take almost no time at all.

The last point to be made about effects is comfort level of the patient. It is not uncommon for conditions to arise that will give apparent shocking such as atmospheric changes giving rise to static electricity, malfunctioning devices that are supposed to apply a current, and very low level of electrical interaction that not being felt physically. If lead wires of an accessory to a device appear to be shocking, we are able to test and confirm that the wires are good or not. In all of these cases, while the result may not cause somebody immediate pain, injury or complaint, their comfort level determines how safe they feel at your practice, and may decide to seek services elsewhere without informing you why. This point is so minor but it certainly is something that should be addressed if at all possible. Static shocking is something that device grounding can address²², and is tested on all electrical devices that PMs are performed on. Eliminating this concern can be done by advising you on the source, what sort of materials may be causing it, or what can be done to minimize impact.

Electrical Protection

How can these scary concerns be addressed? Thankfully, the manufacturers of your lovely equipment go to great lengths to ensure they don’t get sue— err to make sure you don’t get hurt! Each and every item that is manufactured or imported for use in Canada has to be approved by an organization such as the Canadian Standards Association (CSA²³) for electrical devices, Federal Communications Commission for communicating devices (FCC²⁴) and Conformite Europeenne (CE²⁵) for aspects relating to the enclosure, materials, and mechanical operation. If the item was assembled elsewhere and is imported generally it may need further certification because it is lacking CSA, FCC and/or CE approval. European, Australian and United States have similar authorities (ULC/UL26, ETL²⁸, etc.) but in all cases, there needs to be a number that is relatable back to CSA/FCC/CE. If there are no standards organizations listed, or they have been rubbed off, then CSA/CE needs to test, pass, sticker, and otherwise confirm, in writing, that the device is safe to use on/with/around patients. If these things are not done, depending on what body oversees your practice, it may be possible to fail an audit, reaccreditation, be subject to fines, or will be held entirely liable in the case of an accident or incident. TRH, through its years of exposure to all variety of devices, has a database of models and equipment types, experience with what to look for, and the expertise to verify that your devices are either compliant or non-compliant. Should there be a bulletin or safety issue of the device resulting in noncompliance or danger, we are able to inform our customers that those devices need to be taken out of service immediately.

Manufacturers abide by an endless amount of veritably unknown groups that only seem to only communicate in acronyms (CSA, ESA, IEEE, ISO, UTL, Cisco, NEC, NFPA, WTF, LMAO, etc.). These groups certify, approve, test, audit, and keep careful track of all aspects of device and components such as material source, manufacturing process and quality of end result, security, the validity of output and measurement, transportation, storage and life cycle analysis²⁷. A device or component needs to be proven to pass under all conditions and will do so for all revisions and repeated manufacture. The accompanying or consumable components also need this process applied to them and (along with the main device) need to be trackable. Should there be a recall on affected serial or lot numbers of your devices or accessories, it is our responsibility to inform you immediately and replace the affected products if we sold it to you or know you are in possession of it. The cost of this is normally covered by the manufacturer, insurance, or related companies.

While these basic manufacturing and incoming inspections are good for life, that does not guarantee safety should there be damage/fault from the power source or decay over the life cycle of the unit. For this reason, there are a series of internal and external protections put in place in case of a fault. The first is a limit on ground resistance, which is how much impedance to current flow there is from safe points on the device to what is called ground (or earth). What this means, put simply, is that if the power coming into the device somehow bypasses the normal flow (shorting the wall-outlet power directly to parts that can contact a patient), it will go through the lower resistance to flow, the earth, instead of the higher resistance, the patient. The second is fuses²⁹: if for some defect, damage, or source surge reason, the current may be higher than intended and will damage the equipment (or be applied to the patient); it will flow through the fuse enough to melt it and shut off power to the device instead, if it has fusing. The third is encasement. Proper encasement ensures that the electricity is contained inside insulated, non-conductive material where live power shouldn’t have a path. Including International Protection Marking or Ingress Protection (IPX³⁰) and National Electrical Manufacturers Association (NEMA³¹) ratings which say how durable the enclosure is to water getting in, durability, and electrical safety; all covered under the IP code³². Insulated wires, accessories, covers, and membranes for buttons, screens, and other electrical interfaces are all included in this measure. All devices are tested for these features and failure results in a non-compliance sticker. Repairs or accessory replacement may be required for the device to be marked compliant, but sometimes this is done at the discretion of the customer if the failure reason or value is minor.

Since leaving the box, the device and accessories may crack or fray, and circuit board components may fail at any point due to the reality of manufacturing probability of failure. For this reason, a standard or extensive, regular inspection is required to ensure that no harm can result electrically on a patient or passer-by. Electricity is hidden away from us quite extensively (and with good reason!); for this reason, you need indirect and specialized devices to detect fault and danger. Over the longer term, we may recommend a full servicing of the device, which will involve internal inspection of circuit boards to prevent random (but predicted) future failure. To extend the useful life of your devices; ensure that units are free of dust, filters are not blocked, and there are no fluids intruding in the sides of the device. This may require partial disassembly, in which case TRH would need to service it and PM after repair. Should your device be tested and is no longer reliable enough to recertify, there may be the option to qualify for the equipment buyback program, in which we will make use of parts of the device for other repairs and/or dispose of anything that is of no use to anybody³⁴.

Mechanical Source

Mechanical hazards are anything physical that can impact with force, puncture, rub, or scrape that causes pain, bruising, cuts, or discomfort. These can be blunt, sharp, rough, pointy, or even smooth in nature that may still cause harm. The injury can result from trip, fall, gravity, stationary situations, or user caused situations. These incidents can also be pneumatically, electrically or mechanically driven in nature with or without user input. Manufacturers typically go to great lengths to ensure that their products are the safest and most comforting things to deal with, and any deficiency in this department is caused by either age, normal wear, misuse, or neglect. The best way to properly identify that there is a possible issue is to imagine yourself where the patient is on, say, a treatment table³⁵, what they might be feeling, the positions they might be in and, if possible, actually place yourself physically in their spot and think what they might be doing and why. You also have to consider all body types, mannerisms, weights, and physiques. There are a number of major, broadly applied principles that go into preventing all these causes and they can be addressed forthwith. All of the things listed or alluded to here are things that TRH staff are trained to look out for and know features to look for that implies a failure in one or more of these conditions that are not apparent to the naked eye. While customer attentiveness is appreciated and helpful, it is by no means a replacement for having a trained service technician evaluate the reality of what is actually going on.

Mechanical Wear, tear, and age

Aged equipment becomes a problem as the protective padding separating the patient from the device degrades through use, cleaning agents, and time. Older (ancient) equipment may just not have been designed properly or before patient/manufacturing standards were less strict. Through use, vinyl, plastic, leather, and other types of materials will have grooves made in them, crack, or lose their safety efficacy. To stop these things from happening, ensure the following is done:

Be mindful of surfaces that come into contact with patient’s skin and what repeated use will do to these
Assess the cleanliness of surfaces and accessories to see if they’re appropriately clean and done so with manufacturer recommended cleaning agents or chemicals
Lubricate joints, articulating surfaces, clean rust and check weld joints
Check if cleaning procedures are being followed up with a wipe and dry, ensuring no build up in cracks or creases
Check if stoppers, brakes, levers, springs, pistons, and other safety features are present and how effective they are in performing their intended purposes
Physically place yourself in the patient’s position and thinking “Am I okay to use this on myself?”

Over time, your equipment is just going to slowly break down and you may not be able to check these things yourself at a quick glance, or even from the outside. Bolts, washers, joints, brakes, springs, levers, pistons, motors, assemblies, covers, membranes and other miscellaneous things may need to be replaced regardless of how great you are at treating the equipment or how often it gets used. TRH technologists have repeated and unique exposure to perfectly operating equipment as well as disastrously maintained equipment and can easily see even the most minor problem features which may be present that are not immediately present. These checks are part of the PM procedure and all done in a timely and efficient manner. It is strongly recommended that all equipment that you use in any capacity or frequency have basic preventative maintenance performed on it (used once a month, kept in storage, ‘probably going to throw it out’, etc.). Whether you decide to address issues, affect a repair, or have the full maintenance done to the equipment in question, it is very important to at least know what condition your stuff is in regularly.

Mechanical Misuse

It is almost impossible to objectively evaluate your own practices, procedures, and way of doing things, so, for this reason, it is imperative to seek guidance from external sources. Firstly, you should always have an open and honest dialogue with patients, admin, technicians, and other staff members so that they feel comfortable critiquing practice and equipment. There have been many instances of staff members being afraid to step forward and address safety concerns because of fear of reprisal and that their boss is all-seeing and all-knowing, which seldom true (except for my boss). For normal practitioners, regardless of experience, misuse does occur for a number of reasons: a difference between product manufacturers/models, not reading the manuals or habit. Habit is the strongest of all the sources of misuse because if something is easier and ‘seems right’, regardless of whether it is, cognitive forces³³ have a peculiar way of allowing you to convince yourself everything is going to turn out great. This is the reason why there are bodies governing practitioners and facilities of all disciplines, which point to equipment servicing companies like TRH to evaluate and enforce specifications and regular/full assessment since we are the ones that most closely deal with and are experienced in the nuances of what to look for. Setting the equipment up to its standard state (levers, brakes, leveling objects, and otherwise calibrating a device) is something we recommend to do each time unless requested not to. In some cases, this may require longer time on site, because if things are left well enough alone, they should remain where they were originally set.

Mechanical Neglect

As well intentioned as most people may be, there are those who do cut corners, skip steps, and do not follow the advice of people who have the best intentions for the outcome of the safety of your patients. For this reason, we can and will fail devices and products that do not meet our guidelines, see evidence of misuse or track a record of lack of maintenance (or equipment abuse). For the most part, we rely on governing bodies to read between the lines, but there are instances where it may be necessary to report practitioners to their respective colleges and accreditation groups. At TRH, we try our hardest to give the greatest value to our customers which may include: equipment exchange/buyback, discounts, free warranty and servicing calls, rental accommodations while equipment is being repaired, and extensive advice including part sourcing, all in an effort to encourage full and proper repair and maintenance.

Mechanical/Electrical/Hydraulic/Pneumatic actuation

Certain devices will have their operation controlled by levers, dials, or control panels that will activate other types of units. The commonality between these things is a mechanical effect: a cast saw blade with a faulty bearing, an elliptical with an off-balanced flywheel or a treatment bed with a weak piston will all produce physical impacting as a result of their condition. These modalities or applications are critical because they may fail without any prior warning, as is the nature of high pressure, speed, or torque items. These items are normally not problematic if they don’t show external decay and properly give the full range of motion but they do need to be assessed for the nuances of their characteristics. TRH techs are usually able to predict the useful life of such items and consult service documents to determine when the predicted replacement component age should be.

Mechanical Effect

A lot of the impacts of most of these hazards will be completely unbeknownst to you. It may persist for years before you get any indication of it, if at all. The reason for this is because people will grin and bear it and either think it’s normal or will never come back. This should be a powerful thought to you because it is entirely possible that patients are suffering discomfort over time or will leave your practice without ever telling you why. This is why putting yourself in their shoes and having service personnel evaluate your equipment is critical even if you feel the benefit is not immediately clear to you. We’re mostly in the business of dealing with equipment and technology, but the sheer number of customers we have gives us some insight on what works and what practices lead a business to not be as successful.

The more typical things will be intermittent or frequent scratches, odd muscle/tissue displacement, puncture, bumps, joint bending, or rubbing tissue after brief to prolonged use of equipment. This can cause bruising, cuts, rashes, infection, clothing damage or aching. You may think you’re on top of things but the unique situations may be the only thing to bring upon these above effects, and it’s those times you lose customers, mostly without being aware, since they leave swearing to never come back. It is especially important to be aware of these effects because hazards negatively impact the patient experience and the road to rehabilitation; if you’re treating a musculoskeletal condition, a fracture, or anesthetizing somebody, the last thing you want to do is impede that treatment by putting their chest at some odd angle or introducing a hip joint pain.

Mechanical Protection

Almost all of these things can be prevented by replacing worn assemblies, padding, and bumpers, but there are some instances where one has to get creative. If a situation arises that causes discomfort there are ways of adhering padding to a surface that didn’t originally come with protection, which is most commonly required for older equipment or accessories. TRH has resources, sources, and experience with making custom application fixes to meet your unique and changing needs. Out of service, unavailable, or discontinued products are not necessarily off limits and we can prolong the use of your devices, provided it is safe to do so. There are certain devices that need calibrating of set points, level, output, dial position and need to be run to the full extent (which it might not do normally, i.e. the max weight on an exercise tool, treadmill, power lift, etc.). These procedures are necessary to perform because if there is a fault at the extremes or the set point, it is likely that your device will be inaccurate or fail prematurely. The result of failures on these devices is sudden falling out of supporting structures, projectiles ejected from an enclosure, destruction of facility components, or sudden entrapment of appendages.

Biological Hazard

It may or may not be obvious, but a few things need to be said about the basics bio hazards so we know what we’re getting into. Germs, bacteria, viruses, disease, illness, flu, infections, pathogens, contamination and sickness are all ways to describe the mechanisms that can cause internal and external conditions that are transferable from person to person³⁶. Antiseptics are substances that kill or otherwise render these unfriendly organisms harmless. A very important thing to always keep in mind is that all antiseptics target broad or specific pathogens based on their ingredients, shelf-life, and application. It’s imperative that you understand these things before using them where you do because the active ingredients can harm tissue, damage surfaces, or be useless to properly sterilize a surface against something you need to sterilize against. Hand sanitizer is not an effective cleaner of surfaces, and Virox shouldn’t be smeared across your palms. TRH can only give a cursory assessment to address bio hazards as this is beyond the scope of our expertise, but we can make suggestions on related impacts of infectious control and protection of equipment from cleaning agents.

With increasingly rising populations and popularity of frequented facilities, as does this result in an increase of popularity of your local bacteria and virus friends! Most of illness and disease that emerges from transfer of germs is addressed almost entirely by numbers: how frequent is a contagion introduced to a surface, how often does a person come into contact with potential surfaces, how many different people interact with a surface, how long it is there, what temperature the room is, and how often that surface is cleaned. Biohazards are one of the easiest hazards to combat, but in order to do so, you need to be vigilant — the one time you decide not to clean up before you leave for the day is the one day that a disease carrier leaves behind something… and the one time that a vulnerable person comes in contact with it afterwards³⁷.

Biological Source

Pathogens are older than time itself and emerge from the constant struggle to make a life on planet earth. These organisms exist and will exist in large amounts in certain biomes and regions because they aren’t inherently bad, and provide a vital role in making up the world that we live in; they’re just another form of life like plants. You have bacteria in your gut that help you digest certain compounds, viruses play a role in evolution, and some are just opportunistic; stumbling upon a human by mistake. Infrequently, things like flu or large outbreaks will jump across large populations of people, dormant, until it affects people especially vulnerable to it, or it happens to grow strong enough to be noticeable. More commonly they will come from viruses or bacteria that are removed from their ordinary environment to infect a person, where they will proliferate and spread from that person to others in a less widespread sense (usually quarantined). When it comes to devices like autoclaves and ultrasonic sterilizers, it is important to only operate the device if you have been fully instructed and know what to look out for. Sterilization strips are valid for various temperatures and settings and certain aspects of the cycles may be missed or rendered invalid due to inexperience.

Biological Effect

Due to how numerous and intricate pathogens are, it’s hard to give a comprehensive explanation on what this will do to any given person. Somebody may be immune to it, while another will have an immediate reaction and will fall noticeably ill. There are even some people that get these viruses and bacteria that will remain infected for a long time before it’s discovered that they have them inside their bodies. There are types of people who are especially vulnerable to infection because they have compromised immune systems and will react much more strongly than others and become sicker quicker even from basic germs. The only thing beyond this really worth knowing is that it’s vital that as little possible transfer of pathogens occurs because we must assume the worst-case situation happens (a super sick person is going to infect a really vulnerable one).

Biological Protection

As mentioned before, there are a number of products suited toward different pathogens and for different surfaces. These are numerous and application/manufacturer specific, but a few basic protocols^{38 39 40} can be adhered to result in the best outcome:

Cheaper is not always better: Trusted brands will have longer shelf life and efficacy.
Your product may damage material: Products that are heavily comprised of single or basic chemicals will corrode screens, plastic, leather or vinyl.
You need to dry things off: The antiseptics are meant for cleaning purposes, meaning that they are applied, the pathogen is killed, and you have to dispose of the bodies. Don’t leave equipment wet to dry on their own!
Germs are sneaky: Cracks, creases, and joints are where they like to hide, and will spread even if the surrounding surface is sterilized.

Your best bet in any situation is to consult the manufacturer of your equipment as well as the company who’s cleaning products you are using to be double sure you know of the applications and limitations.

Chemical Hazards

Chemical hazards encompass any substance that is made up of a chemical compound or element that is present in small to extreme quantities. This includes stored cleaning agents, solvents, solutions, particulate matter, aerosolized compounds or gases. The manufactured items on this list are covered by WHIMIS⁴¹ and extensive documentation is available on how to handle, store, use, and treat contact with anything approved that is searchable. Things that are not covered fall under OHS, fire, or environmental types of safety measures. Like biohazards, TRH is not fully equipped to advise on the particulars on these hazards and it is strongly recommended to fully understand your WHIMIS sheets and supporting product documentation.

Chemical Source

Sadly, the main cause of problems with this type of hazard is improper education, storage, and handling. Broadly speaking, if you do not know the specifics of what chemical you are dealing with, you should not be using it. Any unmarked container needs to be disposed of, and in its place, a substance that is clearly marked and certified should be used and stored appropriately. You should don any PPE to protect your hands, arms, face, eyes, ears, or any other part of your body that may come into contact with this chemical. When in doubt, gear up or ask somebody. Chemicals should not be stored in a cluttered environment such that they may knock over, emit fumes, or be intentionally accessed by patients or clients. Used chemicals need to be disposed⁴² of properly in a manner where their spillage or leakage will not intersect an area where a person may be (physically, in the air, near a sink, etc.). TRH may see a lapse in proper procedures or standards and will make a recommendation as they are observed, but we are not in a position to enforce these recommendations.

Chemical Effect

The outcome of a chemical coming into contact with a person depends on the nature of the specific chemical. It can be inhaled, imbibed, or enter the body through the skin. Regardless of how things have worked for you in the past, some individuals may even lose consciousness by being in the proximity of certain substances, and it is very important to keep in mind the extremes: like how some people react violently to slight exposure to peanuts. Chemicals can also damage equipment resulting in premature failure, damage, annoy patients, or discolor clothing.

Chemical Protection

Proper storage eliminates most of the hazard potential, including clearly marked containers and any and all locking mechanism afforded by the particulars of the environment. PPE is mandatory for workers needing to use it, should always be accessible, and not be damaged/expired in any way. The final measure that is not always present around chemicals is the means to rapidly treat an exposure. This measure will vary based on the chemical in question, but the most common treatments available are eye wash stations for eye exposure, first aid kits for a chemical burn or related effects of exposure, EpiPens for allergic reactions, suction and ventilation solutions for choking and esophageal obstructions and readily available oxygen for certain inhalation types. Again, it bears repeating that having a full understanding of the substance in question is imperative, as some chemicals are worsened by use of eyewash water, inducing vomiting (some first aid courses of action), and some burns being worsened by the quick application of water.

Temperature Hazards

Hazards relating to temperature extremes are not as prevalent as other types but there are still some things to keep in mind broadly as well as in specific applications that are easily addressed but are very time and attention sensitive. Overheating and correct temperature monitoring is part of some device’s checks, but not all. With respect to temperature monitoring and regulation, TRH’s equipment is calibrated to be highly accurate not only for long term stasis but temperature increases during device operation.

TemperatureSource

There are both intended and unintended extreme hot and extreme cold situations to be aware of. For intended heated situations in therapeutic or interventional applications, you have warming baths: water heated pads for pain or therapy, wax, hypothermia treatment, freeze guns or freezers. Unintended situations arise when thermal regulation of an electronic device is unchecked but also occurs when equipment is run for a long period of time, especially when there are powerful bulbs involved.

TemperatureIntended

In all of these listed situations, it’s important to follow the manufacturer’s guidelines on operating temperature and adjust the dial accordingly. All heating solutions should be monitored for temperature to ensure that your device did not suddenly lose thermal regulation and that it is an appropriate temperature for treatment that meets medical or therapeutic guidelines. An example of what can go wrong is that if you adjust the dial to be hotter than usual, then change the water from sludgy dirty water to pure distilled water, you may be much over or under temperature (depending on the device)

TemperatureUnintended

Temperature regulation is attained in heating elements by having the temperature sensed and the current to the temperature generator shut off when the target value is achieved. When temperature is unregulated in its generation, there should be some kind of alarm of shut-off regulator; if this is not present or defective, fire, burns or explosions may result. For certain devices, TRH checks these alarms and feedback loops for any defects, usually testing the device at its extremes, if permitted.

TemperatureEffect

The most obvious effect of high temperature is immediate or gradual 1st, 2nd, and 3rd degree burns⁴³. Something that will also cause a negative effect is higher than normal temperature that will affect things like hydration, cause long term tissue or nerve weakening, loss of fertility or causes cell death. For certain devices, a technician will check if there are especially hot areas that will cause apparent or actual burning (or burning sensation).

TemperatureProtection

The best way to protect against unintended temperature abnormalities is to ensure your equipment is regulated and measured and alarms in some manner if it is outside your intended temperature range. If the temperature is unavoidable, then your next option is to introduce thermal barriers between the heat and the patient, making sure not to enclose the heat source which could result in fire. The next on your solution list is to introduce extra cooling to the heat source or some form of heat sink and generally making sure the heat source is free of dust and is properly ventilated. Finally, shutting off the unit in between treatments and making sure power is off when the unit is finished being used for the day. If these additions to the normal equipment are required, TRH Services has the ability to research, source, install and evaluate that the solution meets your needs or guidelines.

Radiation Hazards

RadiationSource

Radiation is a broad term, but largely has its root in electromagnetism as it relates to light, and in particular, high energy light. Lasers, x rays, discussion surgery, ultrasound, UV light therapy and magnetrons are devices that utilize high energy light or voltage sources to accomplish diagnostic, surgical, or therapeutic goals. There are some common safety elements to be aware⁴⁴ of generally, regardless of whether you are directly or indirectly involved in these procedures. All of the aforementioned sources of radiation require some form of education or training in the hazards and should not be attempted or in any way independently operated by somebody who is not under direct supervision of somebody with those qualifications. You should never be in charge of output changing or watching a patient when treatment or therapy is being affected, regardless of what you are asked to do by a trained professional. The negative effects of background exposure to this radiation are highly dependant on frequency and length of time you are in its area of effect and should always be at the back of your mind when you’re working in and around this type of equipment. Any patient that is affected by a diagnostic procedure or treatment needs to be assessed and verbally confirmed to not have any condition that is impacted by exposure a confirmation that they are feeling well before and after procedures. Finally, it is imperative to be aware at all times what the state of the equipment is and if it is outputting currently, and that all dials, displays, lights, and noises are being made at the right times. Operating the equipment, you may only have a basic understanding of what the machine does or how it works and not be fully familiar with what things look like when they’re not working, and for that, TRH can help. By ensuring all buzzers, lights, indicators, and patient safety switches are operating properly, your device will not suddenly behave incorrectly without you knowing.

RadiationEffect

Consequences of exposure to radiation vary based on the modality but:

Laser therapy will produce high energy UV or IR light that can damage the retina’s cones/rods, cornea and capillaries in the eyes⁴⁵. Higher than usual laser therapy is sometimes used to heat tissue but will not burn unless exposure is outside of procedure parameters (Wattage/wavelength).
X ray diagnosis only involves the application of a beam for about a 10th of a second and total dosage is usually relatable back to how much background radiation somebody would have had to passively get exposed to in order to get an equivalent dose. Exposure levels are acceptable for how often it is likely to occur. People at risk for certain cancers are more likely to develop problems than others but is still ultimately very low and risk advantageous for diagnosis. The safe practice regarding X rays is regulated very well⁴⁶.
-Ultrasound is largely minimal⁴⁷ risk as the sound wave generated only heats tissue but could potentially harm a fetus. Excessive treatment times, older ultrasound applicators or machines, or damaged/uncalibrated equipment will have higher or lower dosage than expected, depending.
UV light (UVB) is used to treat psoriasis and vitamin deficiency⁴⁸ as well as even lower level UV for jaundice in newborns. Tanning beds harm the skin in a similar way to overexposure to a very particular component of natural night which causes melanoma and other forms of cancer⁴⁹
Magnetrons⁵⁰ or pulsed electromagnetic fields affect cell membranes and ions in tissues in a not-fully-understood manner which has impact on tissue growth, growth impediment and other changes. There are varying effects on mood as well. The field is most effective near the center and anywhere inside the coil and doesn’t extend far beyond that. Additionally, as mentioned before in the electrical section, this is called induction and is present in high-energy situations involving coils or power supplies.

Radiation Protection

Laser: goggles and retinal displacement (look away!)
X ray: limit repeated exposure, lead vest, and protective shielding
Ultrasound: distance, proper use of contact medium (ultrasound gel), and warm-up
UV light: avoiding direct exposure
Magnetrons: distance

A lot of these therapies depend on long term exposure; so the less time you’re around them without protection, the better you are off.

Psychosocial Hazards

This final category of hazards draws upon miscellaneous sources, practices, moods, behaviors, temperaments, and ergonomics. This is not normally a huge area of focus for practitioners as there is no immediate cause and effect relationship or even numerics to judge if things are going right. Many let this aspect of their practice fall by the wayside. The problem with this is not only people not coming back (extreme) but it distances the emotional bond between patient and practitioner which will result in lack of reporting of changes in treatment, belief that a treatment is ineffective and will cause others to not seek treatment, and may have side effects of stress/depression or apathy. Hazard wise, there are a few notable categories (negatives):

Excessive or prolonged tones, sounds or vibration
High or low lighting levels and visual distractions from electronic equipment
Unclean equipment, facility structure in poor condition and electrical conditions look ‘sketchy’
Practitioner incompetence, lack of engagement or bedside manner

Psychosocial Source/Effect/Protection

The biggest cause of discomfort in the hospital, physiotherapy or dentistry profession is lack of connectivity with the patient. Due to the high-profile nature of medical practitioners there is this era of reverence that creates a communication barrier because there may be a belief that the staff member is ‘above them’. This makes the patient feel they need to grin and bear things, think otherwise concerning feelings or observations are normal, or lack a curiosity about their treatment.

Psychosocial Annoyance

Repeated buzzing, beeping, door sounds, drafts, lack of privacy barriers, lack of accessible or well-maintained washrooms, lack of building maintenance, lights flashing, uncomfortable temperatures, or lack of stimulating activity during waiting are all easily remediable problems with the proper foresight. Budgeting a little more to interior decorating, doing a monthly self-assessment of what can be done better, or having a company service your building are all great first steps to identifying deficiencies here. TRH is experienced in building maintenance when it comes to electrical, compressed air, gas and miscellaneous activities.

Preparation

Lack of preparation is a rising complaint in clinical settings due to caseload, or the nature of assessment/triage, but knowing the basics about why an individual has come to see you goes a long way in instilling confidence that you know what you’re doing. You may be bang-on after reading the first sentence of the patient summary, but if the patient has formed biases about your competence, they will doubt the validity of your conclusion. Keeping up to date with medical literature, exposing yourself to contrary opinions and schools of thought, thinking outside your discipline, focusing on preventative care, and treating the patient with respect/dignity are a few ways you can impress the patient.

Information Transfer

Your patients should be treated like adults and explained the full scope of what you are assessing or treating and why. They should also be informed about the limitations of these things, reason for delay, forces at work outside of the treatment room, and what reasoning you have behind your conclusions. While you may have assessed patients many times and come to the same conclusion based on the things you’re checking off in your head, they may have only been informed of this information by you, and you should treat the information you’re passing on in the same manner as if you were learning about it for the first time yourself. Think about how you would feel if you didn’t have the training you did and you were briskly told what’s to be done without the reasoning behind it or the science backing your claims?

Follow-up

Due to client or patient volume, you may feel you do not have the time to follow up with how they are progressing in their own time or if they have encountered any issues along the way. Medical expenses, family or personal matters, access issue, or unrelated conditions can all impact the decision-making process they have with regards to following through with coming back to your practice. Contacting the patient for a brief chat about their experience and how things are going is great ‘bedside’ manner, even if it is done through administrative or nursing staff, and not directly.

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