Toxic Avoider

The middle-of-the-night silence is broken by lights and the sound of the dispatcher announcing that Attack One is needed to respond to a distant area of the interstate highway for a motor vehicle accident with injuries. When they confirm their response, the crew is told law enforcement will have a delayed response due to other activity.

Per the regional protocol, an interstate roadway accident includes a ladder truck for scene protection, but Attack One is first to arrive on the scene. In a desolate section of the highway, the crew finds a vehicle that has run off the road and rolled onto its side. A man stands some distance away. He has no apparent injuries but says he was in the car. The weather is poor, with cool temperatures and a steady rain.

Making poor eye contact, the man says he was a passenger and the car was being driven by a man he didn’t know. That man was not injured and was picked up by a passing motorist.

A member of the Attack One crew has walked down to the road to check out the car and assess for scene hazards. He reports back by radio: “Ask the driver what’s in this vehicle. I see a lot of containers and notice a strong smell of chemicals. Is there anyone else in this vehicle? I am backing away.”

The Attack One officer relays the questions, but the man is very elusive in answering about any aspect of the incident. He says no other person is in the car. He says he has no idea what else might be in there and that the driver just picked him up to drive him to the next city. The driver, he says, was named John.

Due to the rainy conditions, the man is placed on the stretcher in the back of the ambulance. The paramedic begins the interview, and the patient remains uncooperative. He says only that he feels light-headed and short of breath and has to go to the bathroom. He specifically denies any injuries. His clothing is wet, but crew members notice an unusual odor to him.

The paramedic asks the man to look at him. “Time to answer some questions straight with me,” he says. “What is in the car? It has chemicals in it, and you smell like some chemicals are on you. We can’t help you unless we get some information.”

The man looks away and says he knows nothing. He wants to get out of the ambulance if the crew has no way of allowing him to empty his bowels in the vehicle.

The man appears to be breathing rapidly, and his vital signs reveal he has a low oxygen reading and slow pulse. He has no signs of injury anywhere and is moving his neck actively, so there is no appearance that the accident caused him any significant trauma. It is also apparent that his abdomen is cramping and that he is going to move his bowels soon whether there is a toilet present or not.

The paramedic is putting together the pieces of something much more complex than an injury from a vehicle accident. The ladder truck has now arrived, and the information about the unusual nature of the car has been passed on. Law enforcement is not on the scene yet. The scene is at least a 20-minute ride from the closest hospital, there are no public restrooms nearby, and the patient has signs of poisoning and a smell of chemicals on his clothes. The pieces suggest this was a rolling meth lab, whether this man was the only occupant or not.

The Attack One crew decides to have the man step back out of the ambulance and go to the bathroom, and they’ll peel his clothing off and leave it outside the vehicle. There is a concern he could have weapons on him that are not obvious, or something in his pockets.

The paramedic announces his plan to the man, telling him he’ll have to go to the bathroom on the ground but the crew will shield him with some sheets as he does so, and they assist in removing his clothing, which they will bag up and leave at the scene. The man only resists when it comes to the disposition of his clothing, insisting they take it to the hospital.

The crew initiates the plan, and the paramedic backs away to talk to the officer from the ladder truck. They call for a hazardous-materials response and additional law enforcement. The paramedic says the man may not be hurt but appears to be very ill from some form of toxic exposure, and they will need to get him en route to the hospital rather than wait for law enforcement to arrive. The officers agree they will manage this as a rolling meth lab incident.

Well away from the apparatus, the patient moves his bowels. He had to be encouraged to completely disrobe, then removed several items and insisted those go with him to the hospital. He will not let anyone see what those are, but says they’re not chemicals or weapons or anything else dangerous. Of course one of the members sneaks a peek, seeing they are large stacks of currency, nothing else. Rather than discuss the cash’s origin, the patient is allowed to keep it in a “red bag.” The remainder of his clothing and belongings are bagged and turned over to the ladder company officer for disposition once law enforcement arrives.

The patient is placed in the ambulance and in a sheet, and it is noted that his breathing effort is increasing, so he is started on supplemental oxygen. He has a congested cough and a slow pulse rate. The crew initiates a nebulizer treatment with both albuterol and ipratropium. Once the man is completely undressed, an examination reveals no injuries, and he insists he was not hurt in the accident. His pupils are constricted, and he still has the smell of chemicals on his hair and skin. The Attack One crew member opens the exhaust in the patient care area and places the ventilation system on high output. The driver’s cabin is closed off. The crew members have put on full turnout gear, including goggles and double gloves. An intravenous line is placed in a large antecubital vein, and a liter of fluid pressure-infused.

The patient has signs of poisoning, with symptoms consistent with poisoning due to nerve agents. These include organophosphate toxins and characteristically produce a chemical syndrome that includes salivation, lacrimation, overactive bowel and bladder, constricted pupils and slow heart rate. This patient demonstrates many of those findings.

The paramedic believes the best site for this patient’s care is the regional trauma center, which has a well-prepared decontamination area, close presence of law enforcement and the ability to manage trauma if the patient is found to have any injuries. He moves away from the patient to notify the ED staff at the trauma center about the clinical, security and decontamination needs of this unusual encounter. The paramedic wants law enforcement or security present on arrival and to move the patient immediately into the decon area, as they are not able to clean him any further in the field. He reports several times that no injuries are obvious, the patient has respiratory issues that are being managed, and the biggest safety concern is contamination with a hazardous material of some type that could affect the ED.

The patient improves with the nebulizer and supplemental oxygen. His pulse oximeter reading, originally in the 90% range, increases, and he coughs less frequently. He begins to discuss a little of what happened, saying he got light-headed and probably passed out. He continues to insist someone else was driving and left the scene, but the story lacks credibility with the crew. His cardiac monitor shows no irregular heartbeats and a rate that’s actually slowing.

Hospital Course

The transport takes about 20 minutes, and on arrival at the trauma center there is no one to greet the ambulance.

The EMTs are ready to load the patient into the ED, but the paramedic stops them. There is a state highway patrol car in the parking lot but no security to greet the crew, and the decontamination room door is not open.

“I don’t want any of us to go into the main ED,” the paramedic says quietly to the other crew members, “because we might all be contaminated. We don’t want the ED staff and other patients to get sick. Stay here while I call again.”

Standing outside the vehicle, the paramedic calls the ED and asks to talk immediately to the charge physician or nurse.

“We are outside the doors of the decontamination room and will stay here with the patient until your staff is dressed appropriately and ready to manage him,” he says. “The state highway patrol officer needs to come along with security to help make sure this guy doesn’t suddenly feel better and bolt.”

The charge nurse and physician take about two minutes to place protective gear on, then open the decontamination room. Security staff circle around behind them, and a state highway patrol officer, in the ED to interview a different patient, stands in the decon room entrance to receive the report on the law enforcement details. The charge nurse says they misunderstood the original call, not hearing the paramedic well because he was maintaining a low volume so the patient could not hear. They were prepared for a trauma patient, not a contaminated one.

The patient is placed in a warm decontamination tub and cleaned rapidly with warm water. After this he is transferred to a regular ED cart and for security purposes left in the decontamination room. His cardiac monitor shows an ongoing slow heart rate. His respiratory rate has decreased, and oxygen saturation is OK on nasal cannula. He is started on doses of atropine for presumptive poisoning with organophosphate chemicals.

The Attack One crew members remain outside to prevent contamination inside the building. The ambulance is isolated in a corner of the parking lot. They remove their turnout gear and protective gowns and goggles and bag them outside. They each shower off and don hospital gowns. They contact Incident Command at the scene and are told to wait until the scene is fully evaluated before they clean their vehicle and return to service.

The report comes from the scene about an hour later, after a complete evaluation of the car and contents. The law enforcement people feel sure the patient was the only person in the car, and the car was full of chemicals used for production of illegal substances. Most containers are not marked, so complete analysis will take hours. Incident Command directs the crew to clean the vehicle, get a full evaluation in the ED, turn over their clothing to the cleanup crew, and stay out of service through the end of shift.

The ED staff assist in cleaning the vehicle, and the ED physician evaluates each of the Attack One crew members. In the end, the ED director expresses gratitude to the crew for their concern and ultimate actions that assured the safety of all ED staff and patients at the trauma center.

The patient is treated in the ED decontamination room until he’s thought to be thoroughly cleaned and no longer coughing or at risk for vomiting. Law enforcement takes control of the large sum of money that was in the patient’s possession, and the patient remains completely uncooperative in identifying the chemicals in the car. He is identified as the driver of the car, which had been stolen. He recovers slowly over two days in Intensive Care, then is released to jail.

Case Discussion

Safety for public-safety workers includes a reliance on excellent communications. The National Incident Management System (NIMS) gives a structure to communications and personnel organization in emergency operations. Communications between law enforcement, fire and EMS personnel are very important for safe operations at incident scenes and allow each discipline to perform the operations needed for mitigation. In EMS operations, the next phase of communications is between the field and the hospital personnel who will care for the patient. Information must be passed that provides for an efficient transition of care.

The Attack One crew had little information that the victim was contaminated with hazardous materials. After they became suspicious, they attempted to reduce the patient’s exposure and the risks to themselves. The patient was cleaned as well as possible before removal from the scene. Transportation was provided in a manner that protected the crew as much as possible. The receiving ED was notified but did not take adequate actions to prepare, so the Attack One crew leader had to stop the process and insist the ED and personnel be prepared before interacting with the patient. The crew members then reduced their own exposure risks and avoided moving a contaminated patient, cot and EMS crew into the ED.

The current illegal drug production and distribution system is full of hazards for police, fire and EMS. Small “labs” can be anywhere, fixed or mobile. They are producing new substances faster than those substances can be identified. It is necessary for EMS providers to understand the major syndromes that identify toxins. In this case the crew matched the patient’s symptoms to the likely chemicals.

Some chemical testing can be done at the incident site, and some in the emergency department. In this incident both sites attempted to perform the necessary testing, and the Attack One crew provided the communication link. Unfortunately, the person most knowledgeable about the chemicals was not cooperative.

In a potential hazmat incidents, victims require evaluation and sometimes care at the scene, then a coordinated approach to transportation and communication with the receiving ED. The integrated process of field and hospital testing is crucial in some incidents where hazardous materials are involved. When needed, emergency workers may use the regional poison control center for coordination of toxicology information.

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. Contact him at jaugustine@emp.com.