Paramedic Care: Principles & Practice Volume 5 Special ...

Paramedic Care: Principles & Practice Volume 5 Special ...

Paramedic Care: Principles & Practice Volume 5 Special Considerations/ Operations Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chapter 11 Hazardous Materials Incidents Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Topics Role of the Paramedic Incident Size-Up Specialized Terminology Contamination and Toxicology Review Approaches to Decontamination Hazmat Protection Equipment Medical Monitoring and Rehabilitation Importance of Practice Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Introduction Hazardous materials are shipped throughout the United States by truck, pipeline, railroad, and tankers Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Hazardous Material Any substance which may pose an unreasonable risk to health and safety of operating or emergency personnel, the public, and/or the environment if not properly controlled during handling, storage, manufacture, processing, packaging, use, disposal, or transportation. United States Department of Transportation Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Role of the Paramedic Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Role of the Paramedic EMS agencies should train all of their personnel in how to respond to hazmat incidents Responsibilities include: Size-up the incident, assess the toxicological risk, and activate the incident management system

Evaluate decontamination methods, to treat and transport exposed patients, and to perform medical monitoring of hazmat teams Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hazmat Standards OSHA publication CFR 1910.120 Hazardous Waste Operations and Emergency Response Standard (2004) EPA regulation 40 CFR 311 Mirror regulation of CFR 1910.120

NFPA standard 473 Standard Competencies for EMS Personnel Responding to Hazardous Materials Incidents Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Levels of Training Awareness level Recognition EMS Level I (operations level)

Patient care in cold zone EMS Level II (technician level) Patient care in warm zone Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Incident Size-Up Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Incident Size-Up IMS and Hazmat situations Priorities for a hazmat incident are the same as for any other major incident Life safety Incident stabilization Property conservation Quickly determine if open incident or a closed incident Basic IMS at a hazmat incident Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

2009 by Pearson Education, Inc. Upper Saddle River, NJ Incident Awareness Every emergency site has the potential to be a hazmat incident Inspect the scene from a distance Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Transportation Maintain suspicion of the presence of hazardous materials at any vehicle accident Railroad accidents Volume Number of cars involved Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Fixed Facilities Facilities where dangerous substances are produced or stored Chemical plants Other facilities Rural areas Many communities have some kind of fixed pipelines Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Terrorism The terrorist may use any variety of chemical, biological, or nuclear devices Weapons of mass destruction Lack of predictability about when or where an attack might take place Look for potential clues Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Recognition of Hazards Placard Classifications Absence of a placard does not mean the absence of a hazmat threat Regulations vary Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Placard Classifications

Diamond shape Indicates hazmat classifications Color code Hazard class number UN number Use of symbols Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Hazard Classes and Placard Colors Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Placard Classifications Several shortcomings of placards Quantity may not be sufficient to require placard Dangerous placard Does not indicate substance present Lack of placard

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ NFPA 704 System Identifies hazardous materials at a fixed site Uses diamond-shaped figures divided into four sections: Red Flammability Blue

Health hazard Yellow Reactivity White Specific information Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Identification of Substance Emergency Response

Guidebook Shipping papers Material safety data sheets (MSDS) Databases Hazmat telephone lines (CHEMTREC, CHEMTEL, Inc.) Poison control centers Toxicologists References

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Emergency Response Guidebook Should be carried on every emergency vehicle Lists more than a thousand hazardous materials Specific emergency

procedures Shortcomings Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Shipping Papers Contains the most accurate information about a transported substance Bill of Lading May not be with driver if they have left vehicle

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Material Safety Data Sheets Present at fixed facilities Data Should be posted in easily accessible location Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Monitors and Testing Air and gas monitors Determines the percentage of oxygen in the air Measures the presence of explosive gases, carbon monoxide, and toxic gases Litmus paper Measures the approximate pH of a liquid Colormetric tubes Suction the air and search for specific chemicals

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Other Sources of Information Textbooks, handbooks, or technical specialists Computerized database CAMEOComputer-Aided Management of Emergency Operations Local or regional poison control center Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

2009 by Pearson Education, Inc. Upper Saddle River, NJ Other Sources of Information CHEMTREC Maintains a 24-hour, toll-free hotline 800-424-9300 CHEMTEL, Inc. Maintains another 24-hour, toll-free emergency response communications center 800-255-3024 Supplies the names of state and federal

authorities that deal with radioactive incidents Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hazardous Materials Zones Your main priority at a hazmat incident is safety Request help right away and establish command Evacuate people from the area around the incident

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hazardous Materials Zones Establish zones Hot (Red) Warm (Yellow) Cold (Green) Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Specialized Terminology

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Specialized Terminology Boiling point Flammable/ explosive limits LEL UEL Flash point Ignition

temperature Specific gravity Vapor density Vapor pressure Water solubility Alpha radiation Beta radiation Gamma radiation Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Contamination and Toxicology Review Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Contamination and Toxicology Review Threshold limit value/time weighted average (TLV/TWA) Threshold limit value/short-term exposure limit (TLV/STEL) Threshold limit value/ceiling level (TLV-CL)

Lethal concentration/lethal doses (LCt/LD) Parts per million/parts per billion (ppm/ppb) Immediately dangerous to life and health (IDLH) Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Types of Contamination Primary Direct contact Secondary A contaminated person or object comes in

contact with an uncontaminated person or object Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Routes of Exposure Respiratory inhalation Topical absorption Parenteral injection Gastrointestinal ingestion

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Routes of Exposure Click here to view an animation on poisons. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cycles and Actions of Poisons Acute effects Delayed effects Local effects

Systemic effects Biotransformation Synergism Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Treatment of Common Exposures Treatment ranges from supportive care to specific antidotes Before administering specific pharmacological treatment, at least two sources should agree on the medication

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Corrosives Brush off dry particles Flush liquid corrosives with large quantities of water Tincture of green soap may help in decontamination Irrigate eye injuries, possibly with proparacaine hydrochloride to assist

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Corrosives If the corrosive has been ingested, do not induce vomiting If the patient can swallow and is not drooling, give the person 5cc/kg water up to 200 cc Support the ABCs Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Pulmonary Irritants Cannot be decontaminated Remove patients clothing Flush exposed skin with large quantities of water Irrigate eyes with water Tetracaine to reduce eye discomfort Treat pulmonary edema with furosemide and albuterol Support the ABCs Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

2009 by Pearson Education, Inc. Upper Saddle River, NJ Pesticide Actions Blocks acetylcholinesterase (AChE) causing: SSalivation LLacrimation UUrination DDiarrhea GGastrointestinal distress EEmesis Involuntary muscle

contraction Pinpoint pupils Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pesticide Treatment Remove all clothing and jewelry Maintain and support ABCs Suction if needed Administer atropine 2 mg IV push until SLUDGE symptoms resolve If an adult has seizures, administer 510 mg

of diazepam If the patient can swallow, give 5cc/kg up to 200 cc of water Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chemical Asphyxiants The most common chemical asphyxiants include: Carbon monoxide Has a high affinity for hemoglobin and displaces oxygen in the red blood cells

Cyanides Inhibit cytochrome oxidase that enables oxygen to create adenosine triphosphate (ATP) required for muscle energy Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Treatment for Chemical Asphyxiants Decontamination is usually not necessary Remove from the toxic environment Remove patients clothes to prevent trapped

gases Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Treatment for CO Exposure Oxygenate patient Hyperbaric therapy is necessary in some cases Increases the displacement of carbon monoxide from hemoglobin molecules by oxygen Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

2009 by Pearson Education, Inc. Upper Saddle River, NJ Treatment for Cyanide Pasadena, Lilly, or Taylor kit Administer amyl nitrate ampules Prepare and administer sodium nitrite 300 mg IV push over 5 minutes Follow with an infusion of thiosulfate, 12.5 g IV push over 5 minutes Repeat at half doses if necessary

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Treatment for Cyanide Cyanokit Hydroxocobalamin Binds cyanide from cytochrome oxidase Forms cyanocobalamin (Vitamin B12) Excreted by the

kidneys Courtesy Dey, L.P. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hydrocarbon Solvents Support the ABCs Decontaminate the exposed area Do not induce vomiting If the patient can swallow and is not drooling, administer 5 cc/kg up to 200cc of

water Seizures 510 mg diazepam Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Approaches to Decontamination Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Approaches to Decontamination

To reduce or remove hazardous substances from people and/or equipment Can be accomplished by physical or chemical means Serves several purposes: Reduces the dosage of the material Reduces secondary exposure Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Methods of Decontamination Dilution

Application of large quantities of water to the person Water may be aided by soap Absorption Use of pads or towels to blot up the hazardous material Commonly used during environmental cleanup Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Methods of Decontamination

Neutralization One substance reduces or eliminates the toxicity of another Rarely used by EMS Isolation/Disposal Separate the patient or equipment from the hazardous substance Establish zones Items that might contain or trap a hazardous substance should be removed Destroy or store contaminated substances Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

2009 by Pearson Education, Inc. Upper Saddle River, NJ Decontamination Decision Making Recall the priorities of incident management Life safety, incident stabilization, and property conservation Environmental considerations form a major concern only in cases where there are no life threats Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.

2009 by Pearson Education, Inc. Upper Saddle River, NJ Modes of Operation Fast-break Decision Making Conscious, contaminated victims will often selfrescue May try to leave the scene entirely EMS units must be prepared for gross decontamination Two-step process Implementation Critical patients and unknown or life-threatening

materials Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Modes of Operation Long-Term Decision Making Occurs when patients remain in the hot zone and have not self-rescued Advantages Better opportunity for thorough decontamination Better PPE Less chance of secondary decontamination

Greater consideration of the environment More detailed research of the actual hazardous substance Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Field Decontamination Decontamination method and type of PPE depend on the substance involved When dealing with unknowns, do not attempt to neutralize

Brush off dry chemicals Apply large quantities of water with green soap if available Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Two-Step Process Step 1 Remove patients clothing and jewelry Step 2 Wash and rinse the patient with water and soap

Repeat Pay attention to difficult areas Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Eight-Step Process 1. Rescuers enter the decontamination area at hot end of corridor and mechanically remove contaminants 2. Rescuers drop equipment in a tool-drop area, and remove outer gloves 3. Decontamination personnel shower and

scrub all victims and rescuers using gross decontamination. (Victims can be moved to step 6 or step 7) 4. Rescuers remove and isolate their SCBA (continued) Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Eight-Step Process 5. Rescuers remove all protective clothing (Victims who are still clothed have their clothes removed) 6. Rescuers remove all personal clothing

7. Rescuers and victims receive a full-body washing 8. Patients receive rapid assessment and stabilization before transport Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Transportation Considerations Field-decontaminated patients may still need to undergo a more invasive decon process at a medical facility Transport to facilities capable of performing

more thorough decon procedures Stretcher decon pool Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hazmat Protection Equipment Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Hazmat Protection Equipment Level A Highest respiratory and splash protection Fully encapsulating Level B Full respiratory protection Non-encapsulating, but chemically

resistant Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hazmat Protection Equipment Level C Uses an air-purifying respirator Nonpermeable suit, boots, and eye and hand protection Level D Structural firefighting gear

The level of protection needed depends on the chemical or substance involved Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Medical Monitoring and Rehabilitation Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Medical Monitoring and Rehabilitation Entry Readiness Blood pressure Pulse Respiratory rate Temperature Body weight ECG Mental/ neurological status

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Post-Exit Rehab Complete decontamination Post-entry monitoring Measure and document the same parameters on the flow sheet

Fluid replacement Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Heat Stress Factors Take into account: Temperature and humidity

Prior hydration status Duration and degree of activity Level of protective suit used Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Importance of Practice Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ Importance of Practice

Put on and take off Level B hazmat protective equipment Set up and practice decon Two-step process Eight-step process Identify a simulated chemical, determine the correct PPE, and establish the proper decontamination methods Monitoring methods and flowsheets Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Summary Role of the Paramedic Incident Size-Up Specialized Terminology Contamination and Toxicology Review Approaches to Decontamination Hazmat Protection Equipment Medical Monitoring and Rehabilitation Importance of Practice Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. 2009 by Pearson Education, Inc. Upper Saddle River, NJ

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