Exclusive - EMS Magazine - 01-01-92
Incident Case Review - Toxicology
"MIXING IT UP AT THE MALL"
By Clark Staten, EMT-P, I/C
You are the Paramedic Officer in charge of an advanced life
support ambulance in a largely residential neighborhood of a
Mid-Western urban area. It has been a normal early December
shift, for the most part, since you began your shift at 0800
hrs. this morning. The weather is partly cloudy, and the
temperature is 38 degrees. You and your partner have checked
and cleaned all of your equipment, washed the ambulance, and
responded to one call for a 87 year old female that was found
in cardiac arrest when the family woke up this morning. No
one had spoken to her since the night before and she was
cool, in asystole, and had post mortem lividity. She was
soon pronounced DOA by your medical control authority and is
now a brief memory in an otherwise uneventful morning.
At approximately 1142 hrs., while returning from getting fuel
for the ambulance, the radio crackles to life, "Ambulance
18... Ambulance 18...respond now to a report of fumes in the
building at 7601 S. Cicero Rd. ...that's 7601 S. Cicero Rd.
in the shopping mall ... got it Ambulance 18?" You grab the
microphone and acknowledge the call; "Message
received...Ambulance 18...you got anything more on that?"
Both you and your partner began to wonder what "fumes in a
building" means.
Your partner starts flipping switches for the emergency
lights and siren, as you grab the clipboard and begin to fill
out the preliminary information on the run report. The radio
beeps and says, "Ambulance 18... the wind is out of the
Southwest at 8-10 miles per hour...you are getting a
preliminary Haz-Mat response there...Ambulance 18". You set
the clipboard in your lap, and acknowledge the call. You and
your partner begin to hypothesize on the source of the call;
your partner says, "I'll bet it is carbon monoxide...we've
had a bunch of that already this year". You agree, thinking
about a recent carbon monoxide incident that killed a family
of ten while they slept.
Upon arrival at the shopping mall, you note that the reported
address is that of a popular fast-food restaurant, which is
connected to the rest of the mall by a hallway. Two fire
suppression companies are already on the scene, but you don't
see any of the firefighters. One of the first things that you
should consider when responding to any reported hazardous
materials incident is:
(Editorial note - "*" indicates the correct answer)
( PICK THE BEST ANSWER -ONLY )
(1)
A> Call Chemtrec (1-800-424-9300) and get advice
B> Go on in the building and see if there are any
patients
C> Assess the true nature and severity of the incident *
D> Look for the firemen, and ask them what to do next
E> Call dispatch for a EMS disaster plan
Among the first and one of the most important pieces of
information that you will need to effectively manage the
medical response to a hazardous material event is:
(2)
A> Understanding of your jurisdiction's Haz-Mat plan
B> Identification of the product that is involved *
C> A history and physical of the striken patient
D> The location of your "Hazardous Material Response
Guide" book
E> The patients' vital signs
Back to the mall...
A Fire Lieutenant comes out of the building, pulls off his
SCBA mask, and yells at you, "Hey, Ambulance 18... we've got
people down in there!" "They were attempting to clean the
floor and walls with a mixture of cleaning products...there
are fumes". On your rig radio, you overhear the Lieutenant
reporting, "Engine 38 to the fire alarm office...we have a
confirmed Haz-Mat...give me a Level One Hazardous Materials
Response". Do you?
(3)
A> Immediately get your "jumpkit" and drugbox and hurry
into the mall
B> Put on your fire coat, boots, helmet and gloves - then
hurry into the mall
C> Call for an EMS Disaster plan
D> Ask the Lt. what cleaning products were involved *
E> Request the immediate response of an EMS Supervisor
(4) One of the most important pieces of equipment that MUST
be used if you want to enter the mall, that has been
described above, is?
A> Cardiac Monitor w/ defibrillator
B> Oxygen cylinder and positive pressure ventilator
C> Your portable radio
D> Your "turn-out" gear
E> Your Self-Contained Breathing Apparatus *
You watch, amazed, as a fully "suited-up" firefighter
stumbles from an entrance to the mall, dragging a 24 year
old, seemingly unconscious male. You hear the Lieutenant on
the radio, "Engine 38 to Ambulance 18... report to the West
entrance of the building...we've got a patient for you!...
got that Ambulance 18?".
The activity at the scene seems to be accelerating.
You acknowledge the transmission on your portable radio, as
you and your partner are donning your "turn-out" gear.
Several other fire suppression units are arriving on the
scene. You have not been issued any self-contained breathing
apparatus. You note that a firefighter has begun to
administer oxygen to the unconscious young man with a
positive pressure ventilator.
Assuming that you haven't already "blundered" into this
potentially contaminated area, as you might have been
inclined to do prior to this question, do you now?
(5)
A> Again ask the Lieutenant of Engine 38, on the radio, if
the products involved have been identified *
B> Immediately follow the directions of the Lieutenant,
report to the West entrance, and begin treating the
patient
C> Ask the dispatch center about the Estimated Time of
Arrival (ETA) of your EMS Supervisor
D> Request an EMS Disaster Plan
E> Request two additional ambulances and go to treat the
patient
(After performing the answer to #5 above), you are loading
your ALS equipment on your stretcher. A transmission comes
over your portable radio. "Ambulance 18...Ambulance
18...Battalion 19 to Ambulance 18...the products involved are
ammonia and household bleach...mixed in unknown quanities",
the Chief of the 19th Battalion advises you. Battalion 19
must now be on the scene and has assumed command of the
incident. "Message received... Battalion 19...bleach and
ammonia", you entone into your portable.
Simultaneously, another radio transmission blasts through one
of the now busy radio frequencies, "Truck 15 to Battalion
19...Truck 15 to Battalion 19...we have three more
people down in here...we are bringing them out now!".
Battalion 19 acknowledges the transmission and passes it to
you on your frequency. Your mind now begins to go into
"high-gear"... what happens when you mix ammonia and bleach?
Nothing...or does it produce a more toxic end-product?
(6) The combination of (even household strength) ammonia and
bleach can produce an extremely toxic gas called:
A> Anhydrous Ammonia Gas
B> Cyanide Gas
C> Nitrogen compounds
D> Chloramine *
E> Sodium Chloride
(7) The type of reactivity that occurs is due to the fact
that Ammonia gas becomes a ________________ material when
mixed with Chlorine:
A> Binary Reactant *
B> Neutralizing
C> Potentiating
D> Lacrimating
E> Pathogenetic
(8) You should give primary consideration to the fact that
this by-product of combination of ammonia and bleach
produces an agent that is very similar in nature and
action to:
A> WWII Mustard gas *
B> Modern Nerve Gases
C> Organophosphate Poisoning
D> Carbon Monoxide poisoning
E> Sulfuric Acid
Several firefighters have carried a total of four patients to
an area immediately adjacent to the West entrance to the
mall. You and your partner have gathered all of your
equipment and are quickly approaching the firefighters and
patients. The firefighters are providing oxygen by positive
pressure mask to the striken patients. You notice that at
least one firefighter has removed his self-contained
breathing apparatus while working on the patients. The next
MOST APPROPRIATE action that should be taken is:
(9)
A> Begin advanced life support (ALS) procedures
B> Intubate the patients, due to the fact that may soon
experience respiratory failure
C> Have the firefighters disrobe and decontaminate them and the
patients *
D> Begin Intravenous therapy, so that you have the ability
to administer specific antidotes
E> Contact your EMS supervisor on the radio and ask
him/her what to do
The department Hazardous Materials Team has arrived on the
scene and is alerting the firefighters, that are still in the
mall, that the combination of ammonia and bleach can also
produce another undesired effect.
True or False ? T or F (Circle One)
(10)
The combination of ammonia and bleach can react violently
and/or spontaneously explosively. (*T)
The firefighters have begun to ventilate the building, and
you could possibly expect that a faint odor of
(#10)_______________ would be detected in the surrounding
area.
(11)
A> Garlic
B> Almonds
C> Cherrys
D> Ether
E> Herring *
Members of the Hazardous Materials Team have disrobed and
washed the patients with mild soap and water. They have
continued to administer oxygen to them. As they are cleaned
and turned over to you, your next responsibility should be
to:
(12)
A> Begin BLS procedures
B> Begin ALS procedures
C> Adminster sodium thiosulfate, IV push, 5mg/kg
D> Administer Amyl Nitrate Ampules - one every 5 minutes
E> Perform triage *
Next in your treatment of the patients, (after completion of
#12), you could expect to be primarily concerning with the
treatment of:
(13)
A> Cardiac Compromise
B> Dermatological Problems
C> Nuerotoxic conditions
D> Respiratory difficulties *
E> Carcinogen effects
Secondarily, pre-hospital personnel in the above set of
circumstances, may find it necessary to treat previously
decontaminated patients for:
(14)
A> Signifigant systemic poisoning through absorption
B> Cardiac compromise *
C> Long-term Psychogenic manifestations
D> High Blood Pressure
E> Major changes in Serum urea nitrogen
One could logically expect that patients exposed to a
combination of ammonia and bleach could potentially also need
to be treated for the long-term complications of exposure to
chlorine, ammonia, and chloramines. They generally include
all of the following... EXCEPT :
(15)
A> Hearing loss
B> Cytotoxicity
C> DNA Damage & Chromosome aberration
D> Hair loss
E> Neurotoxicity *
F> Delayed pulmonary edema
G> Asthma & COPD
H> Pneumonitis
High flow humidified oxygen should continue to be afforded
the patients, during stabalization and transport. Symptomatic
treatment of cardiac arrythmias should be undertaken.
Narcotics and caffine should be avoided in treating these
patients. Some improvement has been anecdotally shown with
early respiratory symptoms of chlorine exposure, by
administering 3.75% Sodium Bicarbonate solution by nebulizer
treatment. Pre-hospital providers should follow local system
protocals, or treat the patients as determined by a
authorized consulting physician.
After decontamination, triage, treatment, and consultation
with a physician who is knowledgable in toxicology issues,
the patients can be transported to the appropriate definitive
care facility. Only by making appropriate pre-hospital care
determinations, can the patient hope for the optimal outcome
and eventual recovery. Those decisions will be based on good
information resources and procedures that must be developed
and implemented in a minimum of time.
The case study presented above is more common than you might
imagine, and the potential for these circumstances exists
throughout the United States and the world. Are YOU educationally and
operationally prepared for YOUR next Hazardous Materials
incident?
-30-
(Authors note: Reference materials for this case review were
provided by the TOMES (tm) computer-aided Hazardous
Materials database system (c) Micromedex 1987-1992)
Exclusive printed submission to, and initial copyright by:
Emergency Medical Services Magazine
Creative Age Publications
Electronic publication rights respectfully reserved by the
author. 1992 - Clark Staten, Emergency Response & Research
Institute, Chicago IL.