Posted By Administration,
Tuesday, March 12, 2019
When CNN’s article regarding the JAMA radiation letter first hit the CANA newsfeed on February 26, 2019, we knew immediately it would be a big deal. And yes, the story has become a many-headed hydra of confusion, concern, and misinformation, accompanied by increasingly scary rumors.
We constantly field concerns from suppliers about cremated remains placed inside keepsakes, from crematory operators and embalmers about their cases, from families about their options, from regulators about all of the above, and from you — in the middle of it all — trying to serve your families, comply with regulations, and protect your staff.
CANA has curated several of the most useful questions in one place to counter some of the fear, anger, and rumors. And it’s all publicly available, so please share this resource far and wide, bookmark it for later reference, come back to check for updates, and, most of all, DON’T PANIC.
Where it started.
The radiation misinformation saga began with a research letter, titled Radiation Contamination Following Cremation of a Deceased Patient Treated With a Radiopharmaceutical and published on February 26, 2019 in the Journal of the American Medical Association (JAMA). In the letter, Dr. Nathan Yu (et. al) discussed a case study of a business in Arizona that cremated a 69-year-old man with pancreatic cancer in 2017. The deceased had been treated with an intravenous radiopharmaceutical for a pancreatic tumor and died five days later. When the medical staff became aware of the cremation, they notified the crematory and the cremation chamber, equipment, and staff were all tested for exposure to radiation. The equipment was found to have traces of contamination, as was a urine sample from one crematory operator (but it was a different isotope from the one used in the patient’s treatment). The contamination levels were below the limits set by the US Nuclear Regulatory Commission. In conclusion, because this is only one studied instance, researchers recommend further testing for more data and better understanding.
CNN was the first major media source we found to bring the letter to the general public awareness. To round out the story, the network solicited the opinion of Dr. Daniel Appelbaum, chief of nuclear medicine and PET Imaging at the University of Chicago Medical Center. He said, "If there are reasonable and fairly straightforward and simple things that we can do to minimize radioactivity, why not do that?” Applebaum also acknowledged the need for better understanding and regulations that keep workers safe. In the case of crematory operators, the doctor recommends "robust enforcement of mask and gloves and handling techniques."
Where it went.
Other media outlets picked up the story and it spread quickly, with information traveling like a game of telephone. My mother’s church group argued against cremation for spreading radiation in the community. One CANA member’s staff are expressing concerns about “the crematory operator who died from radiation” (when none have). Each of which are exaggerated concerns about what we know.
Because while the case study is new, the knowledge about radiopharmaceuticals and brachytherapy is not. And the medical community is quick to reassure that there is Low Risk of Radioactive Contamination from Cremation When Proper Safety Procedures Followed. CANA is aware that these concerns and fears are rooted in a lack of awareness and understanding, so we want to provide information to help.
What we know.
At CANA’s second Alkaline Hydrolysis Summit, we invited Jeff Brunette, Health Physicist and Manager of Radiation Safety at the Mayo Clinic, to talk about nuclear medicine and its impact on death care. His full presentation is available as a free, on-demand webinar for you, your staff, and anyone to access anytime on CANA’s Online Learning platform, but here are some highlights:
Nuclear medicine, as administered by a medical professional, is very different than a nuclear warhead. These treatments are administered at doses for safe and healthful diagnostic imaging and cures, not mass devastation.
- These treatments have known efficacy windows which range depending on the use. Diagnostic imaging (e.g. PET scans) can take 20 minutes to 67 hours to clear the system. Radiopharmaceuticals can take 3-12 days (this is where the case study falls). Radiation oncology, like brachytherapy, implants treatment into the body to deliver targeted doses over a treatment window and these isotopes can take weeks or months (or longer) to decay to acceptable exposure levels.
- The variations in the length of radiation are due to different materials (called isotopes) used in treatment and their half-lives (i.e. how long it takes the radiation to degrade to half its original mass).
- Safe levels are determined by federal regulation. For the US general public, this is anything up to 100mrem in a year (excepting medical treatment — a full-body CT scan provides approximately 1,000mrem), while for people who work with the substances it’s 5,000mrem each year. A fatal dose is more than 500,000mrem. And we are exposed to radiation by taking an airplane, using the microwave, and from nature (both Earth and space).
- Radiation treatments also vary in strength. Alpha waves are stopped by paper, or blocked by your skin. Beta waves are blocked by soft tissues and thin metal of aluminum. Gamma waves travel much farther. Distance from the radioactive material also changes exposure — the medical community measures the potency at one meter to determine when a patient can go into public spaces. In most of the cases described above, treatment is outpatient (even the implanted seeds) meaning the person can leave that day.
What's the risk?
The US Nuclear Regulatory Commission has set specific levels (mentioned above) to regulate emissions and uses. In the case of cremating a body treated with nuclear medicine, the Commission and medical community agrees that the potential exposure is too low to record. Though cremation volatilizes the radiation treatment, Brunette says even extreme cases are not likely to exceed the limits set for safe exposure due to the combination of medically accepted isotopes, their half-lives, and treatment use. He explains it with an analogy: taking a daily recommended dose of aspirin is fine (around 325 mg) but taking a year’s worth at once (118,625 mg or more than three bottles) is fatal.
Canadian Nuclear Safety Commission has their own rules and regulations and reviewed them extensively last year. CANA recommends their comprehensive Radiation Protection Guidelines for Safe Handling of Decedents as a great resource to learn more about the isotopes in question and safe handling procedures, even for non-Canadians.
Ultimately, Brunette argues that radiation is a limited concern because the levels you will encounter on the job are small, and not very common. Your bigger concerns are the activities that your staff do every day: musculoskeletal injury from lifting, exposure to disease during embalming (HIV; Hepatitis B & C; Tuberculosis; MRSA), and exposure to harsh conditions during cremation operations (heat, noise, dust or chemicals).
How can we operate safely?
CANA recommends asking all families for detailed medical information to properly understand and respond to potential risks. Just as you ask about the presence of pacemakers, ask about nuclear medicine treatments.
Paul Harris of Regulatory Support Services encourages all funeral home, crematory, and cemetery owners to ask the pertinent questions of their families. Cause of death is the first indicator that a case is at risk for radiation therapy, but all families should be asked in the case of death unrelated to their ailment. In many cases, families may be unaware or not understand the procedures the decedent has undergone. In these cases, you may need to ask for a Health Insurance Portability and Accountability Act (HIPAA) release form (in the US, rules in Canadian provinces vary) to contact the medical provider yourself. Asking the radiologist for information on the treatment and about the specific isotope and its half-life is the best way to determine when (or if) it is safe to cremate or embalm the body.
The medical community also recommends installing a simple radiation detector to quickly alert staff to the presence of radioactivity (some states require them in all morgues). Brunette recommends a pancake Geiger-Mueller counter which can be acquired cheaply (particularly if you have them left-over from the old nuclear-powered pacemaker days) and built into your case acceptance procedure. The Arizona Bureau of Radiation Control recommended a combination metal/radiation detector, such as the MetRad, which one school in considering adding to their intake process curriculum.
Mostly, Brunette recommends the following steps to reduce exposure:
Awareness: Talk to families, ask the radiologist, consider purchasing and/or installing detectors.
- Protection: Wear appropriate PPE when potential for contact with body fluids, cremated remains, or AH fluids.
- Disposal: Drain blood and body fluids during embalming directly into the sanitary sewer system and don’t aspirate unless necessary.
- Proximity: Maximize distance to the body and minimize time in close vicinity to the body.
What we do next.
The medical community should do what Drs. Yu and Applebaum say: research. Learn more about these situations so everyone can make informed choices about safety. In the long-term, this will serve us better than knee-jerk reactions and blanket rules to refuse all cases who have ever been treated.
Our professional community should continue to do what you do best: serve your communities safely and compliantly. Enforce PPE, add this to your list of questions for families, do your due diligence. You should review your existing policies, processes, and procedures to ensure that you are screening for the use of radiopharmaceuticals and staff are taking proper precautions. Inform yourself and staff with basic information about diseases that could indicate potential treatments and which isotopes are used. Know who to contact with questions like your local hospital’s radiology department (or the decedent’s doctor) or regulator.
Mostly, DON’T PANIC. Now that the public is aware of this issue, this is an opportunity to educate our communities and ourselves with good information from reliable sources. CANA will periodically update this post with new knowledge, so bookmark this for later.
Sources of information referenced in this article:
Barbara Kemmis is Executive Director of the Cremation Association of North America.
processes and procedures
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Posted By Administration,
Tuesday, January 2, 2018
Happy New Year from CANA!
As we lay 2017 to rest and get used to writing 2018 on our paperwork, we asked a few CANA members what resolutions they have for 2018 and each said the same thing: I don't believe in New Year's Resolutions.
Instead, they strive to improve the performance and service of their company throughout the year by supporting their staff's professional development, by protecting the safety and well-being of their operators and their image, and by caring for themselves and their colleagues the same way they care for our communities everyday. These goals aren't something we can do in one day, but something we can continue to strive for throughout the year.
So from our experts to you:
And there's a hand, my trusty friend!
And give us a hand of yours!
And we'll take a deep draught of good-will
For auld lang syne.
We look forward to seeing all that you accomplish in 2018 and continuing our support of our members and the industry throughout the year.
Heffner Funeral Chapel & Crematory, Inc.
I don’t do New Year’s resolutions. When I’m motivated over a topic, I make a commitment and set timelines for accountability to follow through, timelines for myself included. These timelines may or may not coincide with January 1st.
As much as I’m flattered to be asked to contribute to CANA’s Cremation Logs and make recommendations for staff training in the new year, I’m not even sure I know what “improving staff training” means. I also flinch at the word “training” – I think we train dogs and we educate people.
Heck, for some employers, any training would be perceived as an improvement. My guiding principle, from the book Good to Great, is that you get “right people on the bus and wrong people off the bus.” If the wrong people snuck on the bus, either by acquisition of a firm, marriage to a relative or simply a wrong hire, then no amount of training will change the person. Instead, you need to do some top-grading and weed out the low performers.
Great people in end-of-life care sincerely want to do all they can for a family in grief. Every year they want to enhance their skills to serve. They want to be the very best informed and most knowledgeable caregiver they can possibly be. If those are not obvious traits, than the wrong person is on the bus!
Top-grading is probably an excellent resolution. The right staff will rise to the top and the opportunities for improvement will be natural. The problem is, it may start with the owner – it’s up to management to decide what talents they need and what skills they’ll teach or have others teach for them by sending staff to appropriate seminars and continuing education.
In the end, the words don’t matter if there is no downside to refusing to be enlightened – make sure the right people are on the bus and get the others off. Not just January 1st, make a point of doing this continuously.
Larry Stuart, Jr.
Cremation Strategies & Consulting
Generally, I think New Year's resolutions are ridiculous. We try to solve all of our perceived problems at the stroke of midnight only to fail miserably, usually before Valentine's Day. The key to true success is to declare broad-based, realistic resolutions and work on them all year long. Baby steps, if you will. For instance, a cremationist could resolve to focus on improving three important facets of cremation operations: safety, the environment, and the public’s perception of a crematory.
So, for 2018, repeat after me: "I resolve to be an even better cremationist by working to improve Operational Safety, Environmental Impact, and Public Perception regarding cremation.
Working on these three goals in progressive steps will be much easier to accomplish than resolving to “never leave the crematory during the cremation,” because we know that there will be times that, sooner or later, this will happen. Then, you will feel defeated and risk scrapping the whole thing. Instead, implement the following procedures throughout the new year. Here are a few examples of things that will help to succeed with your New Year’s resolution.
- Improve Operational Safety: Don’t bypass or short-cut the cool-down step of the process. If your equipment is meant to cool-down between cremations (and most are) you should never bypass this to rush the process. Typically, operating procedures call for a cool down period between cremations to approximately 600ºF before the chambers can be safely swept out. Waiting until the unit is cool to perform the next cremation also helps prevent premature ignition as you load the next case — which can be extremely dangerous. Waiting can also help to prevent a “run away” cremation; the cremation is better controlled with less heat at the start, and the likelihood of overheating is decreased. And remember, regardless of the unit, operators must always wear personal protective equipment to safeguard against harm from the heat.
- Reduce Environmental Impact: No matter how new and advanced your equipment is, failure to operate it properly can and will produce hazardous emissions and harm our environment.
- Scrutinize. Examining the materials included with the remains assures operator safety and reduces the volume of pollutants released into the atmosphere. Often friends and loved ones will place objects in the casket as a token of remembrance or as a personal gesture. Items like stuffed animals, picture frames, bullets, plastics, etc., are not meant to be cremated and could damage the unit, cause unnecessary toxic pollution, or even compromise the safety of the operator.
NOTE: In some parts of North America, the operator is not legally allowed to open the casket prior to cremation due to regulatory laws. Confirm compliance with all relevant laws and take reasonable action to ensure the safety of yourself and your community.
Any new policy implemented in effort to improve operator safety and improve environmental impact will help to paint cremation in a better light with the public. News stories that feature cremation fires or YouTube videos that show dark billowing smoke being emitted from a cremator stack do more harm than just to the environment and the safety of the operator. They tarnish our credibility and creates a negative perception with the public.
Improve Public Perception: The easiest resolution is to assure that your facility is always clean and tidy. As cremation becomes even more popular, so will the public’s desire to visit crematories before deciding on which firm to use, which will increase your visitation and witnessed cremation services. Open and clean facilities with an engaged and knowledgeable staff are going to win every time. Clean your place daily. Wipe up any spills with a sanitary solution of 1:10 bleach and water as they happen. Sweep the floors and mop as appropriate. Dust off all surfaces on a regular basis. Treat your crematory like a funeral home is treated. It should be a showplace just as nice as any other room in your business.
- Resolve to get CANA Certified: Even if you are not an actual operator, the knowledge, information, and insight presented at a CANA Crematory Operations Certification class will not only improve the safety of your operation, our environment, and public perception, it will improve the service of funeral professionals toward their families.
As a fellow cremation professional and so-called expert, I will join you in the resolution to implement strategies and programs to help increase the safety of the crematory operator, lessen the environmental impact of cremation, and to continue to educate the public with facts, science, and emotional realities, all in the hopes of improving their perception of what goes on inside a crematory. Happy New Year!
Market Director for Manitoba / Northern Ontario, Service Corporation International
Ours is a difficult job. We meet people at the worst moments of their lives and guide them through this period of initial hurt until their mother, child, grandfather, loved one is laid to rest. And then we say goodbye. They continue on their grief’s journey, we take the next call. Our journey stops, or never stops as the phone keeps ringing, without any satisfying conclusion.
So in 2018, I want us all to make a New Year’s Resolution to take better care of ourselves.
I need to take my own advice here. We are too often a profession in which we put others’ needs before our own. This work selects those who have so much to give and who are determined to carry on through terrible situations. We continually respond in a professional and dignified way to national tragedies, horrific accidents, or acts of violence and serve our communities while grieving ourselves while our own family awaits our return.
We must take care of our mental and spiritual health and watch for warning signs in ourselves and our colleagues. We must know when it’s enough and when to reach out and ask for help. That may mean reaching out to a colleague for help with a difficult case, or for professional help to avoid or cope with a breakdown. Yes, was as death care providers can hurt too.
Your network inside the profession, your social groups outside, your hobbies and passions, your family and friends all serve important functions to ground you in life when our career surrounds us is death. This year, let’s resolve to celebrate these groups, to take stock of our physical, mental and spiritual health, and to reach out to others when we need it or we feel they do.
The CANA network is one of the most powerful benefits of attending a CANA event and membership with the association. CANA provides the space where cremation professionals can share important conversations with people who get you and your business. Consider connecting with CANA and other industry experts at the 2018 Cremation Symposium for topics that inspire innovative thinking.
Not a member? Join your business to access this article and all archives of The Cremationist plus advice, tools, techniques, and statistics to help you understand how to increase your cremation success -- only $470.
Ernie Heffner shares 40+ years of professional funeral service. He has a diverse background in the operation of end-of-life care related enterprises including funeral homes, cemeteries, a monument company, 10 funeral business relocations and 5 new replacement facility constructions. Ernie has received national recognition and has been a featured speaker on numerous occasions for a variety of state and national industry organizations, related industry organizations as well as his local public speaking engagements for community education.
Larry Stuart is a graduate of Kent State University and is a past member of the Board of Directors of the Cremation Association of North America (CANA) as Supplier Liaison. Through his experience Larry has seen first-hand the negative impact that poor crematory maintenance and improper operating procedures can bring about. Larry has spoken at numerous industry events and has conducted crematory operator training classes across North America with a mission to advance the safety of cremation facilities and their employees and to more positively impact our community and our environment.
Michael Sheedy has been a funeral director for over 20 years and currently serves as President of the Board of Directors for the Cremation Association of North America (CANA) and is a member of the Ottawa District Funeral Association. In his tenure with Pinecrest Remembrance Services, he has been part of the creation of Ontario’s first full service facility with onsite visitation and receptions.
processes and procedures
tips and tools
Posted By Paul Harris,
Thursday, September 14, 2017
Updated: Wednesday, September 13, 2017
Opioid abuse is not only causing an alarming number of deaths among users, but its effects also now stretch to those who simply come into contact with the drugs. This has led to a nationwide effort by public safety agencies to revise policies and procedures to minimize the risk of exposure to these very powerful drugs.
According to the Centers for Disease Control and Prevention (CDC), fentanyl is a synthetic drug 50 to 100 times more powerful than morphine and heroin. Fentanyl acts quickly to depress central nervous system and respiratory function. Exposure to just a quarter of a milligram may be fatal – and some of its analogs are even stronger at even smaller doses. In September 2016, the U.S. Drug Enforcement Agency issued a critical statement to the public and law enforcement personnel warning of serious effects after unintended contact with carfentanil which causes major effects at just one microgram.
A recent White House Commission study found over 100 Americans die each day from opioid-related overdoses. US Department of Health and Human Services reports the greatest numbers of deaths occur in Massachusetts, Pennsylvania, Oklahoma, and Colorado.
For the Employer
Death care professionals know of Occupational Safety and Health Administration’s (OSHA) specific workplace safety standards for bloodborne pathogens and hazardous chemicals. Although opioid exposure poses a serious health risk, OSHA does not currently have an opioid exposure standard. However, under the OSHA's General Duty Clause, an employer aware of the risks of exposure to opioids who doesn't provide training could be cited in the event an employee is exposed and requires medical treatment. This article is not a substitute for actual training, rather to provide some guidance based on recommendations to law enforcement and emergency medical service (EMS) personnel.
To address this safety challenge, follow the same process used for other workplace hazards. First, perform a hazard assessment (or include it in your annual workplace hazard assessment) to identify the tasks that expose or may expose employees to the drugs. For example, assessing the remains and surroundings before transfer to a stretcher, searching pockets for material before moving the remains, removing and storing the deceased's clothing and personal effects, etc. The assessment should also include personal protective equipment (PPE) best suited to protect workers against unintended exposure.
Exposure Control Plan
After the assessment, create an exposure control plan. This includes developing the work practice controls such as policies and procedures when employees know or suspect the drugs are present on or near the remains. The exposure control plan must also include a training program. Training will include the hazard assessment, all written procedures for minimizing exposure, use of proper personal protective equipment (PPE), recognizing effects of the drugs, and procedures for obtaining medical assistance in the event of exposure.
Of course, not all unidentified substances found on or near human remains will be an opioid drug or even dangerous. Unfortunately, it is difficult to determine the risk of an unidentified substance by sight. Thus all material should be considered hazardous until identified. When unidentified material is suspected to be an opioid, or is an employee exhibits symptoms of exposure, notify the local law enforcement agency immediately. Given recent advisories to law enforcement and EMS agencies, this may result in a hazmat treatment for the material, especially if staff develop signs of exposure at the funeral home/crematory.
The signs and symptoms of opioid exposure will depend on the purity, amount, and route of administration. The onset of symptoms can range from immediate to being delayed by minutes, hours, or even days. Watch for:
- Altered Level of Consciousness: Excessive drowsiness; difficulty thinking, speaking or walking; confusion; lack of response to pain or someone’s voice; coma; seizures; pinpoint pupils.
- Breathing: Trouble breathing – may sound like snoring; slow shallow breathing; blue lips and fingernails; respiratory arrest.
- Altered Vital Signs: Slowed heart rate; low blood pressure; dizziness; cold, clammy skin.
- Airway: Choking or vomiting.
For the Employee
Observing standard operating procedures in every case ensures the safety of you, your colleagues, and your loved ones. Contribute to a safe and healthy work environment by wearing necessary PPE, participating in risk assessment and planning, and notifying your superior of any signs of non-compliance or exposure. Keep yourself informed about the potential for contamination—reading this article is a great start!—and stay alert for dangerous situations.
This article is not a substitute for actual training, rather to provide some guidance based on recommendations to law enforcement and emergency medical service personnel.
The CDC issued guidelines to protect law enforcement and EMS personnel from exposure to fentanyl or any drug in the opioid classification. Recommended personal protective equipment: respiratory protection, gloves, eye protection, coveralls, shoe covers, and protective sleeves.
Complete information may be found at the CDC website: https://www.cdc.gov/niosh/topics/fentanyl
Industry Partners’ Resources
For more information on this and related topics connected to the opioid crisis, take a look at:
Members can read the full article in Vol. 53, No. 3 Issue of The Cremationist.
Paul Harris is President and Compliance Director of Regulatory Support Services, Inc., a company founded in 1994 and specializing in regulatory compliance consultation to the death care profession. He holds a North Carolina Funeral Service license and prior to joining the company was the Executive Director of the North Carolina Board of Funeral Service from 2004 until early 2012. Additionally, Paul served as the OSHA compliance officer for a large North Carolina-based funeral home and has eighteen years of first-hand knowledge of regulatory compliance issues.
CANA members receive a 10% discount on annual contract for OSHA and other training, services, and guidance with Regulatory Support Services.
Not a member? Consider joining your business to access tools, techniques, statistics, and advice to help you understand how to grow the range of services and products you can offer, ensuring your business is a good fit for every member of your community – only $470!
processes and procedures
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