A Call to the Hall

Attack One responds to a report of persons ill at a bingo hall. Three individuals had reported suddenly feeling ill to the facility’s staff, which had called 9-1-1. The Attack One crew arrives on scene and enters the site, prepared to call for additional help and evacuate the building if any unusual substances are detected. They find their first victim outside the hall, complaining of shortness of breath. The other two persons are in an office just inside the front door, so the crew carefully enters the building, noting no unusual odors. Bingo activities are ongoing.

The Patients

The first patient is a 50-year-old female who complains of sudden onset of shortness of breath. She tells the crew she was playing bingo and abruptly felt an onset of wheezing and throat irritation. She began coughing, and now has a headache and some nausea. On exam, she has audible wheezes and decreased air movement.

The patients inside are a 55-year-old male and a 39-year-old female, both with cough, nausea and headache. The female has vomited once. Both were playing bingo and had similarly abrupt onsets of symptoms.

Scene Management

The first victim is assessed, then started on a nebulizer treatment with albuterol. Her wheezing begins to improve, and her oxygen saturation improves with supplemental oxygen and the nebulizer treatment. Her throat irritation clears, and her headache only occurs with coughing. No further symptoms develop.

The second and third victims are moved outside the building, and their coughing resolves. The female vomits once, then her nausea clears. The male becomes nauseated, but only after seeing the female victim vomit. He feels better after removal from the building.

As care is being administered to these patients, another nine victims emerge from the building, stating they are having problems with coughing and eye irritation. The Attack One crew calls for additional fire and EMS resources and the regional hazardous-materials team. The crew suggests that the bingo game be stopped immediately and all persons removed from the building. Initially, the management team rejects this suggestion, since there is a significant amount of money “on the table.” The crew insists, however, and the management team makes the announcement. The building is evacuated.

Organization of the Incident

Incident command is established. The hall is the only functioning business in an old strip mall. It measures 50´ x 75´. On this cool afternoon, the heating system is functional and there have been no recent problems or repairs. The business has been stable, no threats have been received by management, and no unusual events have occurred during the day. The crews press the 12 victims for information about the onset of their symptoms. All affected persons had been in one area of the hall, sitting at adjacent tables. Victim No. 1, the first to have symptoms, was near the middle of the victims’ positions.

Medical Decision-Making

There are no immediate threats to life identified. There are several reasonable explanations for victims’ symptoms, including irritant vapor exposure, carbon monoxide exposure or the release of another hazardous substance. The first three victims had headaches and nausea, but also respiratory symptoms. Others had coughing and eye irritation. This would suggest an irritant vapor exposure.

The first victim is transported to the hospital, accompanied by one member of the Attack One crew. The other Attack One crew member organizes the other victims and starts them on high-flow oxygen from a manifold. This exacerbates coughing in some of the victims, so he fits the oxygen manifold with a nebulizer, and the victims are treated with saline and albuterol.

The crew member who went to the hospital stays with the patient until the emergency-department staff evaluates her. They find no evidence of highly toxic exposure and no carbon monoxide in her blood. At about the same time, the regional hazardous-materials team completes a sweep of the building, finding no carbon monoxide or other toxic substances.

The victims at the scene are managed until their symptoms are cleared with the nebulizer treatments; they’re then released with appropriate discharge instructions.

Organizing Patient Assessment

Many fire and EMS organizations use triage systems that result in patients being numbered in sequential fashion. The Emergency Assessment box (see Figure 1 on page 46) represents the results of that triage process in this case. The crews triaged 12 patients, and categorized them by compromise of the ABCDE body systems.

Case Discussion

The Attack One crew organized a moderate number of patients, initiated treatment and then organized available information to successfully manage the incident. They approached the scene cautiously in anticipation of a hazardous-materials incident. As with many incidents involving vapor exposures, the victim-count here increased as time progressed. The initial concern, with the cool temperatures and older structure, was that carbon monoxide caused the problems. But the localization of the victims, the predominant respiratory complaints and the throat irritation made it much more likely an irritant gas exposure.

The crew activated the regional hazmat team, which participated in management and in ruling out highly toxic substances. A critical management step in hazardous-materials exposures is facilitating communications between the scene and the hospital. This is most successfully accomplished by having a crew member stay with the patient until medical decision-making is finished in the ED. This individual should have direct two-way communication with Incident Command (and/or the Hazmat and Treatment Sectors), so each can share information resulting from field and hospital testing. Some exposure incidents will only be managed in a timely fashion if the hospital and field crews have linked together in identifying the hazard.

What if the patients here had more headaches, nausea and lightheadedness? Carbon monoxide would then be a more likely agent, and victims would be triaged and transported for hospital treatment. Carbon monoxide would likely be detected in the structure, and more important, hospital assessment would identify carboxyhemoglobin in the victims’ blood. Those with serious symptoms, such as altered levels of consciousness, could be taken to centers with hyperbaric chamber capability.

In this incident, victims could be treated at the scene, discharge information coordinated with medical control (and the treating hospital), and further transports were not needed. With the hazmat team ruling out a highly toxic substance, the building was ventilated, the crews did a thorough search for other sources of odor, and then the bingo cards were put back into service. The source of the problem was not identified until…

The Lucky 13th Patient

The final segment of this incident occurred later in the day. The Attack One crew was called to a home for a patient short of breath. This patient had been at the bingo hall that day, and when she opened her purse that evening, she was greeted with a big burst of pepper spray. Apparently, she was in the middle of the area where the victims were seated that afternoon when she hit a winning streak. She stated she had stuffed some winnings into her purse, and it appeared she accidentally activated the bottle of pepper spray she often carried. She did not open her purse until she arrived home that evening, and the exposure caused her symptoms. She was also treated with a nebulizer and recovered quickly.

Learning Point: Management of a Multiple Casualty Incident Due to Irritant Gas Exposure