Health and Safety

Health and safety main

Post Bag September 2015

The much-used phrase “If it’s not written down it did not happen” is frequently bantered around in everyday life, and no place is it more commonly used than in our arena. There are times when it is used to drive home a salient point to clinicians, for example with regard to the assessment and treatment of patients; the rationale behind this being that the patient record must reflect all the actions and pertinent negatives which took place so that a full picture can be presented either for the patients GP, at the hospital or at a subsequent investigation.

Another reason why patient treatment records must be completed fully and accurately is that they may be audited and the content reviewed, inspected, or examined to check for compliance with best practice. Through the audit process it may become apparent that a particular piece of manual handling equipment is extensively being used across the Trust or that a piece of equipment is rarely being used, either because something else is better suited or it was not considered. If the carry chair was used to move the patient, but it is not recorded, then as far as the audit is concerned “it did not happen”.


(A conversation between two old chestnuts)

”Are we going to get our meal break at the time that we are given at the start of our shift, Fred?”

“Well, George” he replied, “It all depends upon what we are actually doing at the time when our meal break is due to start.”  Fred had read the ESOP 25, the new document that explains what actions are to be taken in EOC / HEOC with regard to allocating calls to crews. 

“What is ESOP 25?” enquired George. “Aah, you might well ask” Fred responded, relishing the idea that for once he was in a position to pass on some useful information to his new crew partner. 

“When we come clear from the call which took us past ourallocated meal break start time, we are to be sent to the nearest agreed facility within our own EOC area and are not to be allocated any further calls until after we have completed our meal break.”

George thought about this for a few minutes, mulling over the possible scenarios that might delay having his chip-butties on time. “What if we are tasked to take a patient from the hospital A&E department to the Burns Unit  and our meal break starts while we are still travelling there?” he asked Fred.

“That’s straight forward, George.  If we are carrying out an inter- hospital transfer and go past the start of our meal break en route; after handing over our patient and greening up at the burns hospital, we will not be assigned to any further calls, but will be sent to the nearest agreed facility within our own EOC area and stood down there for our meal break.”

“But what if we take our patient to the nearest A&E department and while we are in the hospital, our meal break comes and goes?” pushed George. “You know what I am like if I get hungry”. Fred smiled “That’s okay too George.  If weattend to a patient and convey the patient to hospital and subsequently go past the start of our meal break, then we will be sent to the nearest agreed facility within our own EOC area after handing over our patient and greening up at the receiving hospital.”

Fred could see that George was still not convinced that a robust system was in place that would ensure his chip-butty-buddy got his fatty-fries at a reasonable time during their shift.

“Look at it this way, George” said Fred, tempting his mate to take a more active role in the discussion; “What do you think will happen if we are sent to a patient in the Town Centre and it is a minor injury that does not need attendance at hospital?”  “Well” said George,” I presume that if we are dealing with a patient but do not convey the patient to hospital, but go past the start of our meal break while we are dealing with the patient….  our Control Centre will send us to the nearest agreed facility after completing all documentation and greening up on scene.” “Spot on” roared Fred, pleased that his crew mate was slowly getting his head around ESOP 25.

“But Fred” quipped George, his mind now in overdrive and trawling his grey matter for a scenario that ESOP 25 did not cover. “What if we are on our way to a stand by point and a 999 call comes into control 5 minutes before our meal break is due to start, and we are the nearest resource?” “That’s dead easy” smiled Fred. “ If, prior to our allocated meal break start time, we are allocated to an emergency call, which ultimately takes us past our meal break start time, we must take the call”.

Fred could see that his crew mate was really digging deep into his brain box. “But what happens, Fred, if we are given a job before the start of our allocated meal break time, set off in the direction of that patient, go past what would have been my fatty-butty time and then get stood down from that call in the middle of nowhere….” Challenges George. (“Yeah, and not a chippy for miles” thought Fred.

“Well in that case” explained Fred, ”If prior to reaching our allocated meal break start time, we are allocated to an emergency call which takes us past the start of our meal break start time and we then come clear from THAT call, we cannot be given any further calls and must be sent to the nearest agreed facility within our own EOC area for our meal break.

“But can our control centre take us off that original call” asked George “and just drop another call of equal or higher acuity on us, because we are no longer on a call and are the nearest resource?”  Fred sat back and sighed. “You really have NOT read ESOP 25 have you, George?” he teased.  “Once we are past our meal break time and we come clear from the call that took us past our meal break start time, it is chip-butties and egg-banjo time”. He could see that the penny was slowly dropping and the curtains were raising a hope of understanding. “Mind you” added Fred “while we are still making our way to the patient, and we have gone past our meal break start time, our control Centre can contact and ASKif we would be prepared to accept a further call of a higher nature, even though we would be pushing our butties further away…..  we can accept the newer call or we can decline it and remain in the original call. No pressure. It’s all there in ESOP 25”.

“Well it sounds like a good system, Fred, but does it work the same when we are due to finish our shift?” asked George. “Yes mate. If we are on the way to a patient, but before we reach the location we go beyond the end of our shift, our control Centre have a higher acuity call come in and we are the nearest resource” explained Fred “they can contact us to ASK if we would be prepared to accept the newer call even though it would make us late off work. We can accept or decline the call. If we decline the call then we carry on with the job in hand”….

“Where my copy of ESOP 25?” asked George.

Swinging the Lantern

“We’ve never had it so good,” remarked Thelma, pressing the command button. “No more stooping or struggling with awkward or heavy patients thanks to these ‘ere air bags. “Too right” replied Louise as she gently applied support to the elderly gent’s shoulders while the Mangar smoothly lifted him off the ground to a height where he could step forward and make his own way to his armchair. Louise had been her regular crew partner for more than 15 years and both had experienced the stresses and the pain that resulted from physically shifting or lifting patients, often by grasping the waistband of the clothing or the trouser belt. “Same with the handling belt” remarked Thelma, “it’s so much easier for us when assisting a patient of providing that little bit of reassurance while they walk across the room”.

There had been a lot of changes since Marty had mysteriously left the depot garage after his day shift on 21 October. Rumour had it that he was depressed; some thought he had injured his back once too often shifting patients, but inwardly Thelma and Louise had this feeling that Marty was on a sabbatical, doing research into the prevention of musculoskeletal injuries and how the ambulance service could prevent lower back disorders being the main cause for early retirement amongst otherwise fit individuals.

“The smell of the grease paint and the roar of the crowd, that’s what life is all about” commented Pete, recalling his days in the circus. “We used to take risks, but they were calculated, we knew what we were doing, we’d practiced time and time again, till we got it right”. His crew partner Anthony, wasn’t the same outwardly type of character as Pete. He had watched and noted how his partner appeared slick, sometimes mystical in the way he pulled off certain manoeuvers or techniques, but inwardly he was dreading the day it might all go Pete Tong. The guys over in procurement had secured a supply of “widgets” to make it safer when breaking off the top of ampoules, but Anthony had seen Pete showboating too many times by holding the small glass bottle in one hand and cracking the top off with his thumb. “I hate it when you do that” he remarked “Even though it takes my breath away, I’d rather you use the widget”.

Seeing a clown dangling from a truck with his braces snagged on the door handle, reminded Chrissy how close his crew partner Graham had come recently when they responded to a call in an unlit part of the county. “This is madness” remarked Graham as he opened the nearside crew-cab door intending to step out and walk towards the dark garden. Instead, he lost his balance and fell forwards still grasping the door handle with his right hand which resulted in him twisting around and landing on the muddy ground on his back. “This Suggs !” he hollered; “Why can’t they put the street lights back on so I can see where I am going?” Trying to stifle his desire to laugh out loud, Chrissy came around the front of the ambulance and offered his hand to Graham who was wet, muddy and far from impressed. “They keep telling us to exit the vehicle backwards, Graham” he said. “Maybe if you had you wouldn’t be in such a mess now.”

Bill was fairly wide of girth compared with his crew partner Ben, and this was why they were always arguing about which one would survive the longest if they fell overboard and ended up in the North Sea on a winters night. This was rather a futile discussion considering neither had any intentions to go cruising or joining what Bill referred to as the gin Palace Brigade. Aside from the perils of the deep, they would also discuss the hazards associated with patient’s houses and how Ben might not notice the odd vase or planter on the stairway. Bill had become quite tactful in the way he related his concerns to patients and their family members, when asking them if they minded while he moved them out of harm’s way. Neither of them had encounter a Monet hanging on the wall or a Greek Urn on the stairway, but as Ben always reminded Bill, “It’s not the financial value I am worried about, it’s the sentimental value if it gets broken” to which bill invariable replied “Yes, and the increased risk of snagging the carry chair on it or worse still if we trip over the Greek urn”.

Thelma and Louise continued to use the handling aids but misjudged a bend and drove off a cliff

Marty met up with his mate Emmet and designed equipment to reduce accidents in the future

Anthony failed to shut the ambulance door fully and was ejected during a high speed run

Pete toed the line with regard to safety and became an instructor at the ambulance training school

Bill and Ben took early retirement and secured employment with Pickford’s removals. Neither have yet encountered an unknown Picasso or Monet.

Graham and Chrissy have got their act together and still refer to the past as Madness

Marty returned to front line duty but has never driven faster than 88 miles per hour, especially if it’s raining and there is a risk of thunder or a lightning strike.

“What’s a Greek Urn?” asked Bill one day; “About two drachmas a day, retorted Ben”.

Return To Work Interviews

I am often contacted by members of staff and asked for my opinions with regard to return to work (RTW) interviews, the process and what, in my humble opinion should be taking place. In a nutshell there are numerous reasons and justifications for the RTW interview but to avoid the laborious task of spelling out every chapter, section, sub section or paragraph, it is important to look at the overall situation and to consider the possible knock on effects if we did not carry out the RTW interview robustly.

When an employee returns to work following an absence due to illness or injury ( or even a sabbatical) there are numerous “black holes” that are waiting to snare us at a later date if we fail to conduct the RTW interviews appropriately and that includes ensuring they are carried out in a timely manner. So, having laid the groundworks, let’s look at what should happen in an ideal environment.

Drive Safely

The key issue here is that all DRIVERS are required to drive their vehicles, regardless of being on a routine or emergency call, to the expected standard of a professional driver. This expected standard includes taking into consideration and making allowances for fixed, moving and environmental hazards.

These hazards include, but are not limited to:
Other road vehicles going in the same direction
Other oncoming road vehicles
Cyclists, horses and pedestrians

Additionally, the driver must take into account:
tall trees dropping water and leaves onto the road
tall trees casting shadows across roads preventing ice from melting or rain water from drying
High buildings casting shadows across roads (ditto)
Hump back bridges to go over or under
Single and multiple bends to negotiate
Changes from multiple to single lane carriageways onto unmade road surfaces

And finally the driver must take into account the changes in the weather. Previous dry spells allowing oil to gather in road surface dimples, Wet spells bring the oil to the surface and create a surfactant agent. Frost, ice and snow on roads reduce traction and hide the road edge & road markings. Add to the list any rain fall, hail or snow and vision is further reduced.

Taking all this into consideration (and not wishing to teach anyone how to suck eggs) our ambulance drivers are also acutely aware that they are responsible for the safety of their crew partner. Place a patient in the rear saloon area and that will increase the driver’s responsibilities ten-fold.

Throughout this piece I have referred to the driver’s responsibilities and what the public expects of them. The over-riding consideration that one should expect of ANY driver is that they can safely stop their vehicle within the distance that they can see ahead. With the removal of street lighting in numerous parts of our region, our drivers rely heavily on their vehicle headlights at night and in reduced visibility. To drive with main beam on would be advantageous, but the presence of oncoming traffic and other road users may prevent this. In this situation one would expect the driver to drive on dipped headlights. When driving on dipped headlights the distance of clearly illuminated road ahead is substantially reduced therefore I would not expect or encourage ANY driver to drive as fast on dipped as they might on full main beam.

Given that our Trust covers some 7,500 square miles which includes numerous rivers, estuaries and lakes, our rural drivers often encounter ground mist and fog which drivers within towns and cities may not.  Some crews will benefit from borrowed lighting which comes from Clubs, Pubs, entertainment centres, cinema foyers and petrol station forecourts; but others will be travelling down A / B roads that are in total darkness, and some across dirt tracks.

I would suggest that only our crew know what road conditions they are experiencing while out on the road and that any additional pressures placed upon them by a third party to drive faster or to explain why they do not appear to be travelling faster, could be the catalyst for a road traffic accident to happen.

We are all painfully aware of the Stop Clock Targets that the current government places upon the NHS and the fines which are doled out like toilet roll paper; and the sad part is that we are not judged upon the level of clinical care that we provide to our patients.

During winter months it is even more important that the mandatory roadworthy checks are carried out on vehicles at the commencement of our duty period. Tyre pressures and tread depths, anti-freeze and screen wash should all be at the correct levels, the vehicle windows should be properly cleaned and windscreen de-misters serviceable.

Our drivers need to keep alert to the projected dipped beam distance of clear illuminated road ahead. That distance is the distance in which we should be able to safely stop if there is someone or something on the road. If we are going too fast to stop within the distance we can clearly see on the road ahead, we are driving too fast.

Check your vehicles. Drive safely. Get there in one piece and be able to carry out your role. Remember that low winter sun can be hazardous and that road conditions can change rapidly in the shadows where the sun does not shine.

Stay Safe and Keep The Shiny Side Uppermost.

Jeff Pittman



[All information can be found in the Ferno User Manual]

  1. Operators need strength, balance, co-ordination and common sense to safely use the chair
  2. Operators should have been trained in the operation of the chair
  3. Training records should be kept and annual refresher training is recommended
  4. Operators need to have read and understood the user manual instructions
  5. Untrained operators can cause injury or be injured.
  6. Permit only trained operators to operate the chair
  7. Improper use of the chair can cause injury.
  8. Use the chair only for the purpose described in the manual.
  9. An un-restrained patient can fall off the chair and be injured.
  10. Before use ALWAYS ensure the two safety rings are positioned over the hinges
  11. ALWAYS Use restraints to secure the patient to the chair
  12. There is an adjustable handle to enable correct posture for the operator
  13. The tracks can be attached for descending stairs
  14. Using the chair on stairs requires a minimum of two operators.
  15. Use additional help when needed.
  16. If available a third person should act as guide for the foot-end operator
  17. When using as a TRACKED chair the rear handle SHOULD be raised to the highest position
  18. Ensure the route down stairs is clear of obstructions
  19. It is NOT recommended to use the rear handle highest position when using as a carry chair
  20. The chair can be used as a carry chair to move patients up stairs.
  21. The tracks should be removed from the chair when moving a patient up stairs.
  22. Prior to folding the chair for stowage or using as a carry chair the tracks MUST be removed
  23. It is recommended NOT to carry the patient with the rear handle FULLY EXTENDED
  24. Do NOT exceed the safe working load of 200Kg / 32 stone
  25. Water under pressure or steam can penetrate joints, flush away lubricant, cause corrosion.
  26. Use caution when cleaning moving parts and hinges.
  27. Do not use abrasive materials to clean the chair
  28. Clean and disinfect the chair prior to lubricating
  29. Only lubricate parts that are indicated in the user manual
  30. Do NOT lubricate the track belts as it will result in a loss of friction.


Jeff Pittman

East of England Ambulance Unison 20106

Branch Health & Safety Officer

30 November 2015



Air-Con or Con-Air

The idea of using air-con or recycled air has never appealed to me. Perhaps it goes back to my younger days when I lived on a very hot island and we had to acclimatise as quickly as possible and this was best achieved by the use of slatted windows, fly screens and natural shelter. The “luxury” of air conditioning was restricted to the pilots and cabin crew that flew back and forth, who due to their limited time on the island had limited chance to acclimatise.

In recent years I became sceptical about the air-con units in buildings (reported risks of Legionella) and this distrust was also applied to the recycled air in passenger carrying airliners. Don’t get me wrong, I have flown more times than I can remember and have no fear of flying, in fact I include the flying part within any holiday as part of it, with the holiday starting the minute the suitcases are checked in at the airport.

It was on a recent short haul flight that events got my mind thinking about what if anything was going on within the aircraft recycled air system and whether this could account for head colds and chest infections which often occurred after a holiday abroad. You only have to watch CNN or BBC World News to see people around the globe wearing ‘smog masks’ as they walk along streets or while travelling on public transport to get an idea that something somewhere is affecting people’s health and I wanted to know if travelling on aircraft increased that risk.

On this particular flight, just after take-off as the aircraft levelled out and the cabin crew were about to commence the refreshments service, that an announcement was made which informed everyone on board that “a passenger on this flight has an acute allergy to nuts, so please do not eat any nuts or any food containing nuts, as the particles can be recycled around the cabin”. My immediate thoughts were that I hope the passenger has got their Epi-pen with them. Almost immediately, to my left was another member of the cabin crew serving a different passenger with his drink and asked him “Would you like nuts with your drink?” This was a tad surreal especially with it being within seconds of the initial announcement being made.

So I began to research aircraft recycled air systems. Was it possible for someone eating peanuts while seated in row 33 to cause adverse effects on someone seated in row 1? How did the air system function?  On the underside of the luggage stowage bins are small manual nozzles which you can pull to activate / push to stop and move them around to direct where you want the air flow to be directed. Are these capable of firing deadly peanut particulates into the airway of a person with an acute nut allergy at 30,000 feet inside a pressurise aircraft? At least there was comfort in knowing that all the cabin crew are trained to a high standard of first aid and the medical equipment includes Oxygen and a comprehensive range of medicine and drugs including medication for the treatment of Anaphylaxia.(I did not learn whether or not the passenger with the “acute allergy to nuts” was actually carrying an Epi-pen).

Bearing in mind that some ‘Budget Airlines’ do not include a meal within the cost of the flight ticket, I then began to consider the knock-on effects that this ‘acute allergy’ might bring about because a high number of passengers travelling on these low cost airlines purchase food and drink in the departure lounge and bring it onto the aircraft when they are called to start boarding. It is most likely that none of these passenger give a seconds thought to whether or not another passenger might have an ‘acute allergy’ to something they have purchased and intend to eat during the flight.

Then there are the larger transcontinental or long haul airlines which include not just a meal but drinks, ice creams, hot face cloths and (if the adverts are to be believed) even hot showers and massages within the price of the flight ticket. The menus on these sky liners are invariably well balanced and prepared in the galley with an option or two. Sometimes the flight is so long that several meals and snacks are served in flight or a refuel stop is made at an intermediary airport. Added to the meals will be the duty free sales and of course the soft drinks, wine, beers and spirits with crisps, nuts and other assorted tasty bites.

At what point therefore should the person with the ‘acute allergy’ inform the airline? It was a bit like bolting the stable door after the horse had bolted with regard to the nut allergy passenger as food and drinks purchased in the departure terminal were already being consumed. If the allergy is actuallyTHAT serious should not the passenger have given adequate and timely notice to the airline staff at the time booking the seats or at the very latest when checking in?

I contacted the Civil Aviation Authority (CAA) and asked them for some information regarding the risk of anaphylaxia on board an aircraft:Unfortunately, cabin crew may not always be informed of a passenger's allergy until passengers have boarded the aircraft. Some airlines will remove certain foods from specified flights if contacted well in advance by the passenger. This does not however address the issue of other passengers bringing peanuts or other nut products on board. Although anaphylactic reactions can occur as a result of inhalation of food particles, they are very rare. It is unlikely that someone opening a packet of nuts four rows down could trigger a reaction, but it might be possible if they were in the adjacent seat.

 So, according to the CAA if a passenger has an acute allergy to peanuts (or some other food stuff) they might react if exposed to it within a seat or two away. But what about the recycled air system? Is it possible for the system to circulate food particles (or aerosol generated bacteria from passengers with an upper respiratory tract infection) around the aircraft which in doing so might place other passengers at risk?

With regard to the aircraft air system I specified the Boeing 737-800 series which is a popular work horse with short haul and low cost airlines. Again the CAA was very helpful and responded:  With regard to the B737 - 800 series aircraft; The circulation of air within aircrafts is segmental and does not travel along the aircraft, research has shown that air movement along the cabin is for no more than 3 rows; any aerosolised nut particles suspended in the air and re-circulated would be removed by the filters in the recirculation system.

This was beginning to look good but I wanted to learn more about aircraft recycled air systems and in particular what was FACT and what wasFICTION. Was this becoming my very own Pandoras Box?

There are references to be found in numerous media sites about aircraft cabin air not being as clean as it should be with exaggerated claims that the recycled air is contaminated with pathogens. So I decided to look into how the air is actually ‘pumped around the aircraft’ and if whether or not that is the correct way to describe it.

The air inside aircraft is apparently a mixture of fresh air AND recycled air with compressed air coming from the jet engines. Although initially the compressed air is hot it does not contain any unwanted particles such as fuel, engine oil or gases. The air is directed into what in the aviation world is referred to as the pneumatic air cycle kit (PACK) and according to one source there are usually at least two packs per air craft.

So here we are, strapped into our seat waiting for the aircraft to be pushed back from the stand so that its jet engines can propel it along the taxiway and ultimately along the runway up into the wild blue yonder. It’s a hot sticky day so even before the air craft doors are shut we note passengers tweaking the air vents above their heads in an effort to keep cool. With the doors securely shut the air must be delivered equally to all outlets and at the same temperature & pressure; but if it doesn’t go somewhere else it must surely go around and around, or does it?

In reality, according to source, the air leaving the vents above your head is not sent back to the front of the aircraft, it is in fact drawn down into the lower section of the fuselage (the cigar shaped bit that we and cargo occupy) where most of it is vented outside to the atmosphere. The air which is not vented to outside is remixed with more compressed air from the engines and makes its way again through the ‘packs’ to the air vents above our heads. By now I was thinking that I had found the cause of illness but I was wrong. The air that enters the lower section of the fuselage passes through filters that are as efficient AND as expensive as those found in clinical areas.

These filters eliminate all particulates and prevent anything other than clean air from re-entering the occupied area of the fuselage; so why do passengers claim that the air-con has been the cause for their subsequent illness? Again my source has a simple answer which is that air conditioned air is very dry which explains why passengers feel dehydrated. Some of us may have experimented by placing a swab moistened with sterile water behind an oxygen mask in an attempt to prevent prolonged use the oxygen supply from drying out or irritating the patients airway; and if you have will know that this simple act works quite well. So why can’t the airlines humidify the air-con so that it not so dry? The simple answer is that it would take thousands of litres of water and with one litre weighing one kilogramme the reason becomes clear. The amount of water needed to adequately humidify the occupied area for the duration of the flight would be too heavy.

So where is this issue about dehydration leading us? Well, although air conditioning units are generally clean, if not used regularly bacteria may develop within it, which is why aircraft air-con is kept running and serviced at every opportunity. The downside is that the air-con can be responsible for drying out the sinuses which in turn can cause the mucous membranes to crack or split which then becomes a route for bacteria to enter the body. So the current thinking is that it is not the air-con which makes us unwell it is when our sinuses dry out as a result of being in an air conditioned environment and our membranes break down so that bacteria can find it easier to enter our bodies and that appears to be the answer.

The solution? It all comes down to basic IPC. The things which are most likely to be the source of our post-flight illnesses are those everyday objects that we normally take for granted but seem to forget when we go away on holiday; gantry handles, door handles, armrests, trays, turnstiles and toilets door handles. Even airline pilots are known to regularly use hand sanitizer  on the instruments, switches and levers in the cockpit before they settle into their pre-flight routines.

To say that aircraft cannot make you ill is not exactly correct because some people will invariably be poor fliers, who find travel difficult at the best of times and these include people who suffer badly on the roller coaster or the waltzer at the fairground. The problem would appear to be that any mass gathering of people in a confined space will increase the risk of spreading a disease and that includes for example cinemas, theatres, train carriages and aircraft.

There have been reported cases of people contracting malaria at airports even when they have never left the country and sadly these people did not benefit from a timely and accurate diagnosis because they “had not travelled abroad”. So with that in mind, how many times have you discounted foreign travel as a potential source simply because the patient had not themselves travelled abroad? Did you ask them if they had been to an airport terminal or met friends / family from abroad? The actual number of reported malaria cases at UK airports is less than 20 confirmed which is very low when compared with over 650,000 aircraft flights that were tested. However, those 20 were enough to warrant a thorough investigation with intensive research to identify the type of mosquito and from which country that had originated. Pause for thought.

Do I have a pet hate? Yes, but it has nothing to do with aircraft air-con or recycled air.. The recent decision to start charging 5p for every plastic bag that is handed out at supermarkets is, I believe taking the wrong step. From a hygiene point of view I would rather see disposable gloves provided where fresh food products are on sale and for it to be mandatory that all shoppers wear them when handling fresh fruit and vegetables. It works very well in other countries and takes away the worry that the food has just been handled by someone who did not bother to wash their hands after using the toilets.

The old adage “coughs and sneezes spread diseases” still rings true today, so what we need to do is “catch it, bin it, kill it” by using tissues; but most importantly we need to promote the importance of hand washing with soap and hot water as well as the use of hand sanitizers.

Jeff Pittman


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