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Attack One responds to a person down and finds a young male in the bedroom of an apartment. First-arriving police officers had found no one else on scene. The patient is motionless on the bed, not breathing, and has no pulse. There are no signs of trauma, but emesis is present on the bed and floor.
The crew immediately applies a defibrillator but finds no rhythm. They initiate cardiac compressions, as well as bag-valve mask ventilation. An endotracheal tube is quickly inserted, and emesis noted in the throat and airway. An intravenous line is placed in an external jugular vein, and drug therapy begun.
At that point one of the police officers walks back into the room. "This is likely a suicide," he says, "with potassium cyanide." He'd found a note, composed and printed on the young man's computer, detailing his frustration with his life and a girlfriend.
An immediate decision is needed. At this point the only people in the apartment are the five public-safety personnel, but an engine crew is about to enter. They are directed to wait outside and asked to secure the entrance to the apartment. The patient is reassessed: no signs of life, asystole and no response to initial therapy. His skin is cool, and rigor mortis is not present. The emesis has a foul smell and blood in it.
By protocol, the crew can stop resuscitation here and call medical control, and the crew leader asks that this be done. Based on the history and apparent clinical condition of the patient, the public-safety personnel could be at risk. A rapid search of the apartment for further information could be worthwhile, though, before the premises are turned over to hazardous-materials crews. So the crew leader asks that a crew member seek information in the room that typically holds the most clues for EMS: the bathroom.
The crew, careful not to touch anything, inspects the bathroom. The toilet and floor have further emesis, without obvious blood. On the sink is an empty jar, approximately 8 oz., labeled as potassium cyanide. No other bottles or containers are found. The wastebasket is empty. The kitchen and the room with the computer yield no further clues.
Attack One and the police now must safely evacuate, leaving potentially contaminated materials inside. The engine crew is asked to secure the perimeter, including the patient's auto (identified by the police officers). They bring the crew five sets of dry decontamination bags, then set up for wet decontamination outside the building. Hazmat is called for assistance, and law enforcement supervisors and the medical examiner are called to the scene. Attack One's medical control confirms the decision to abandon resuscitation, and sets up to do evaluations of the public-safety workers.
Contamination Management
Two Attack One crew members were directly exposed to the patient's emesis and are considered most contaminated. While the bathroom is considered a high-risk site, the kitchen is not obviously contaminated, so the five emergency workers remove their outer clothing in the apartment's "dirty" room, clean themselves grossly in the kitchen, then go through wet decontamination at the apartment's outside entrance and don the scrub suits in the dry decontamination kit. The last person out is the Attack One crew leader, who briefs the hazmat team that's ready to enter the apartment.
To prevent any inadvertent exposure, Command needs to collect information to track the pathway of the chemical jar. The police are quickly able to identify the victim's vehicle, parents and worksite. The victim worked at a chemical laboratory, and a conversation with his supervisor identifies that lab as the likely source of the bottle, and that the victim's last workday was the day before. The pathway of the chemical would include the victim's vehicle, apartment (particularly the bathroom and bedroom) and body.
The medical examiner allows the hazmat crew to collect the necessary materials in the apartment, then collaborates on how to package the body for transport to his office. The hazmat crew also collects specimens of the emesis from both rooms. A rapid test with the team's analyzer reveals high levels of cyanide.
The Attack One crew and police officers go to the ED, where they want to take one more warm shower to feel appropriately cleaned. Then they're screened and cleared.
The hazardous-materials team is placed in charge of the toxic apartment site. They secure the cyanide jar. An industrial cleanup team, contracted by the building's owner to come in and completely strip and clean things, finds cyanide residue in the bedroom and bathroom and the victim's car. Investigators hypothesize that he had opened the jar in the automobile, carried it into the bathroom, ingested it there, then moved to the bedroom, where he vomited more forcefully, causing the bloody emesis. The victim is autopsied in a contained environment by the medical examiner, and his death formally attributed to the cyanide ingestion.
Case Discussion
This victim's suicide note was found in a timely manner, but the direct information about his method of choice was found in a location that frequently holds clues to patients served by EMS. The bathroom is often the "clinic" for the patient and their family. In appropriate clinical situations, and with permission of the patient or family (and their assistance if needed), checking the patient's bathroom will often yield information regarding medications, bleeding, self-treatment and ability for self-care.
In this case, providers made a rapid decision to abandon the resuscitation attempt, localize the contamination, decontaminate the exposed workers and prevent further exposures. The "trail" of the chemical hazard was traced, and its threat contained. Rapid decontamination of the rescuers included removing all clothes, medical equipment and shoes. The cardiac monitor was contaminated, as was the airway kit, and both were removed as part of the overall cleanup.
What is the extent of EMS's responsibility for hazards related to a patient's emergency medical care? Overdoses can represent one such type of encounter. This is an excellent topic to discuss with your department's legal advisor. Incidents where there is immediate threat to others, such as a toxic exposure, require the fire/EMS provider to identify the likely "pathway of danger" for the material and address its containment. In this incident, the ingested material was a well-known high-level toxin. The rescuers were exposed immediately and unknowingly, but took fast corrective action and underwent decontamination. The area was sealed, the contamination contained, and cleanup initiated. The medical examiner's office participated in decision-making that kept its personnel safe as well.
EMS personnel should remember there is a pathway of danger involved in other overdoses as well, including farm chemicals, other industrial chemicals and carbon monoxide. The ED must be advised if the patient is to be transported, and so must the medical examiner, with the message passed to funeral home personnel, if events move in that direction. For carbon monoxide poisonings, the source must be identified and stopped, the building ventilated adequately and occupants not allowed back in until the threat is mitigated.
author: By James J. Augustine, MD