Case Review: Families to the Left

The Attack One crew arrives at the junior high school and finds many of the students outside. The principal had set off the fire alarm to evacuate the building after a group of about 20 students and teachers had suddenly started coughing and choking near the school’s cafeteria. It’s just before noon, and media trucks are on scene almost as quickly as the hazardous-materials team. The Attack One crew is assigned to perform triage. They report to the front of the school and begin work on those with symptoms.

Three individuals are complaining of shortness of breath, coughing and burning eyes. All can speak in full sentences, and they report they were exposed to something near the school’s cafeteria that immediately caused irritation. One 12-year-old student has asthma, and she says she went to her locker and took several puffs on her inhaler, but it’s not relieving her symptoms. A teacher who stayed in the area to help move students away now complains of a persistent cough, and another student, 13, complains of coughing so hard “it made me throw up blood.”

The Incident Commander suspects a release of pepper spray and has instructed crews to close off the building, but not disrobe the exposed or lay out a decontamination area. There are no obvious smells on the victims’ clothes, so the Attack One crew sticks with that plan. They assemble the rest of those having symptoms and do a quick check on each. With a lot of students and faculty milling around, they cordon off an area of the front lawn upwind from the school for those feeling ill. One crew member is assigned to establish a separate area in the warm zone for performing a pre-suit evaluation of members of the regional hazardous-materials team. Hazmat team members will then enter the building in protective suits and analyze for hazardous substances.

The Attack One crew continues the triage process, gathering information from victims about where they were when their symptoms started. They relay this information to command, and then to the hazmat team leader—it is vital to locating the source area and establishing the incident’s cause. The crew leader contacts the regional poison control center to report the incident, the likely source and the victims’ symptoms. In combination with medical control, the crew decides to send the most symptomatic patient—the student who’s wheezing—to the hospital. The poison control center will coordinate any information exchange with other hospitals, if needed, and also with the broader healthcare community. The transport ambulance will take the girl to the local children’s hospital, and its paramedic leader will remain on the radio there to share information from the hospital and relay any questions between the scene and emergency department. The rest of the victims are not in distress, but the Attack One crew, medical control and Incident Command decide to keep them at the scene and provide symptomatic care until the nature of the exposure is identified by the hazmat team.

At this point, the triage area converts into the treatment area. The Attack One crew huddles with their counterparts from other ambulances assigned to the incident to organize a transport area and operation, should it be needed. The two victims complaining of difficulty breathing receive albuterol by nebulizer. The young victim who had been coughing and vomiting blood is carefully examined. There is no sign of blood in her mouth and no ongoing nausea, abdominal pain or signs of distress. Another student calls the paramedic aside and quietly reports that this student “gets nervous easily” and has a habit of “sticking her finger down her throat to make herself vomit when she wants to get out of class.” Knowing this allows a little extra reassurance for the girl from the treating EMTs and another teacher who is helping the ill students. All other victims receive assistance in rinsing their eyes with bottled water, drinking some fluids to soothe any sore throats, and eating a little food.

Family Notification and Reunification

The media is reporting live on noon broadcasts, and parents are quickly arriving at the scene to see if their children are ill. With the assistance of school personnel, responders establish a communication system to let parents know, both on the scene and over the phone, the status of each child. The Attack One crew assigns an EMT to track all patients in the triage area, collecting their names, triage statuses and school identifications. Using a simple black marker, he marks each patient with a triage number on the back of their left hand. These numbers are applied only by the EMT doing the tracking; that way there is no misidentifying who has and hasn’t been triaged.

As parents arrive, they are greeted by school personnel, and if they have a child in the triage area, they are guided toward that part of the grounds. There, another school authority confirms the child they’re searching for, and the parents are allowed into an area adjacent to the triage area, where they can talk with their young ones. Crews in the triage area dramatically reduce parental concern by recognizing family needs and, where possible, allowing family members to assist in calming patients and sharing information. Siblings are also allowed to stay in the family area, another effective method of comfort. To keep some order in the triage area and avoid mixing family and patients, family members are constantly reminded that “families to the left” would be appreciated.

The school system has worked with local fire/EMS to learn the Incident Management System. This allows school leaders to provide timely assistance to emergency responders in crises, and assign a public information officer (PIO) to work with those of other agencies. Under the plan, the school system establishes a communication center for parents to facilitate family reunification. The school uses its phone systems and personnel, armed with appropriate parent and guardian names, to relay information about those involved in the emergency. They can tell the adults if their children are safe at school, being evaluated by emergency personnel, or have been removed to a certain hospital. On this day, they inform hundreds of parents that their children are OK; about 17 that their children are being evaluated; and one that their child is in stable condition and going to the children’s hospital for further evaluation.

Incident Resolution

Within a short time, the hazmat team identifies that the exposure is not any high-level toxin. The culprit chemical is likely an irritant spray with capsicum resin, or pepper spray. The source is likely a spray bottle, the area of likely exposure just outside the cafeteria. The team identifies a liquid line along the wall there, suggesting someone sprayed it intentionally (accidental discharges of pepper spray usually do not produce a straight line down a wall). When the team identifies the chemical, the victims in the treatment area are released, the hospital is notified, and the poison control center is briefed.

In the final step, a member of the hazmat team, the command staff, the Attack One officer and school officials walk the entire school to make sure there are no remaining odors, sources or dangers. Once that’s complete, students are allowed back in. The crew members complete patient documentation, the triage and treatment worksheets and the nonremoval releases. Copies of the worksheets and patient reports are passed to command, and a copy of the worksheets (without medical information) given to school authorities. Then the media gets a final briefing.

Pepper Spray

Knowledge of pepper spray products will allow providers to manage victims appropriately without removing a lot of people to hospitals, and without the difficulties of “wet” decontamination for a large group of exposed.

The active ingredient in pepper spray is capsaicin, derived from cayenne and other peppers. The chemical is extracted from the pepper in an organic solvent such as ethanol. The solvent is then evaporated, and the remaining waxlike resin is oleoresin capsicum (OC). An emulsifier like propylene glycol is used to suspend the OC in water, and it is pressurized to aerosolize it as a pepper spray.

Capsaicin is not soluble in water, no matter what volume is used. Ask victims to not rub their eyes or skin, which may cause greater exposure or penetration. No difference has been found between water, milk, antacid solutions, baby shampoo and lidocaine gel in reducing the pain of an exposure. Time after exposure, generally 7 to 15 minutes, is the best predictor of pain control. State laws attempt to control the strength of these sprays and who may carry them; many states restrict products to no more than 10% of the OC active ingredient for standard pepper sprays, 5% in most animal-repellent sprays, and up to 20% in some wildland sprays. All concentrations are effective in incapacitating animals and humans when a spray is directed to the face.

Pepper “hotness” is measured on the Scoville scale. Scoville heat units (SHUs) correlate to the amount of capsaicin present in a pepper or pepper product. An SHU value of 1 million units will produce temporary debilitating results and stop an attacker. Many sprays designed for criminal deterrence also contain a small amount of fluorescent dye. This is invisible to the naked eye, but an ultraviolet light will cause it to fluoresce on exposed skin. This is used to identify an attacker.

Case Discussion

The Attack Crew participated in the patient triage and gathering and reporting of information vital to establishing the cause of this incident. They reduced parental concern by recognizing family needs and, where possible, allowing family members to assist in calming patients and sharing information.

It is important in pepper spray incidents for hazardous-materials teams to provide rapid scene evaluation and chemical identification, though in many incidents it’s difficult to identify the exact chemical used. In this incident, rapid detective work identified the chemical, source and area of likely exposure. This allowed symptomatic victims and others to be managed appropriately without unnecessary transports or decontaminations.

The Attack One Crew knew hazardous-materials exposures often result in multiple-casualty incidents, and important information may come from transporting the most symptomatic patients to hospitals. In this incident, there was an efficient exchange of information between the scene and the ED. This is facilitated if one knowledgeable EMS member from the transporting crew remains on a radio at the hospital. That individual would be aware of who was working the scene, which party had what information, and what questions needed to be answered at any given time. In other incidents the ED can do rapid testing for toxins, and in some cases provide information back to the field that results in patients being treated there and not removed to hospitals. Alternatively, it may discover a substance is unusually toxic, more victims need to be transported to hospitals, and a few EDs may even have to be taken offline to handle incoming patients and provide further decontamination.

The Attack One crew also chose to use the regional poison control center for coordination of toxicology information. These facilities can coordinate information exchange between hospitals and out to the community when doctors’ offices, clinics and other medical facilities may be seeing the aftermath of a large chemical release.

In potential hazmat incidents involving children, victims require evaluation and sometimes care at the scene, then a coordinated approach to transportation and communication with parents. When possible, rescuers should allow parents, teachers and guardians to assist in calming students and facilitating management of those acutely injured or ill.

Learning the Incident Management System lets school officials function effectively with emergency responders in addressing students’ needs. School systems can provide PIOs and communication centers for contacting parents and reunifying families. This can be useful for emergency personnel, as schools often have available phone systems and personnel to make calls, as well as parent and guardian names, and can definitively tell worried parents their children’s status.

James J. Augustine, MD, FACEP, is medical advisor for the Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, and a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton. He is also a member of the EMS World editorial advisory board. Contact him at jaugustine@emp.com.