The Hospital Accreditation Standards established by The Joint Commission, and followed by almost all of the nation’s healthcare facilities, mandate that U.S. hospitals should be prepared to decontaminate patients who have been exposed to hazardous materials. However, although thousands of incidents involving hazardous materials occur annually in the United States, only a small percentage of them result in injuries or disabilities requiring hospital care. In most of these cases, moreover, the risk is usually visible to the naked eye.
That is not always true, though, of a new risk now evolving in some areas of the country – so-called chemical/detergent suicide. Suicide itself is not new, but the ways in which individual citizens choose to end their lives has evolved over time – from self-hanging and artery-cutting to self-inflicted gunshot wounds and so-called “suicide by cop” – i.e., putting oneself in a situation in which a policeman or other responder must use lethal force to stop a murder or some other type of horrendous crime. Chemical/detergent suicide first came to widespread public notice in Japan, where in recent years literally hundreds of people have been committing suicide by mixing a sulfur-containing product (e.g., a dandruff shampoo, a pesticide, or even bath salts) with an acid-producing chemical.
Hydrogen sulfide (H2S), a common ingredient in a toilet bowl cleaner, has been the “weapon of choice” used by many of those who decided to take their own lives. A colorless gas with a characteristic rotten egg or sewer gas smell, H2S can cause the death of anyone inhaling just a few breaths of the gas. A number of cases similar to those in Japan already have occurred in the United States and now pose a serious danger to first responders and hospital personnel.
A suicide case of a patient who had ingested rat poison (aluminum phosphide) was admitted in December 2011 to a Northern Virginia hospital. In this case, the ingested agent mixed with fluids in the patient’s airway and gastrointestinal systems to produce phosphine – another deadly gas. The patient later died, but not before the hospital’s emergency department also had become contaminated from what is called “off gassing” – i.e., staff members became ill from inhaling the poisonous byproduct – and the care of other patients had to be quickly moved into a tent outside the hospital.
Another incident occurred in December 2011 at St. Joseph Mercy Hospital in Ann Arbor, Michigan, where hazmat teams had to be called in after it was determined that a patient who had ingested rat poison was “emitting potentially toxic gas.” The patient was then isolated to preclude the contamination of staff members and/or other patients.
Preparedness: How Much Is Too Costly?
The basic elements of almost all hospital preparedness plans and policies begin with an annual hazard-vulnerability analysis identifying external risks – including the threats posed by hazardous materials. These threats normally are associated with transportation or industrial accidents, but not – so far, in most U.S. hospitals – with the mixing of common household chemicals and/or the deliberate ingestion of a pesticide.
At the heart of the typical emergency department line of defense is a hazmat response appendix – usually included as part of the facility’s Emergency Operations Plan. The plan typically details, among other things: (a) alert and notification procedures; (b) the medicines, medical equipment, and other material resources needed in emergency situations; (c) the personal protective equipment (PPE) clothing and gear also required; and (d) detailed specifications related to a “decontamination-corridor” set-up and operations. Many hospitals also follow the OSHA (Occupational Safety and Health Administration) “Best Practices” federal guidelines for hospital-based First Receivers to develop their response plans.
Training hospital personnel to safely and quickly don and doff PPE, set up the decontamination corridor, and carry out the decontamination of both ambulatory and non-ambulatory patients (and those with special needs) not only takes considerable time but also, in most cases, adds significantly to routine ongoing expenses. Many hospitals continue their everyday life-saving work for many years, though, without having to respond to a real-life hazmat incident, so the need for this significantly higher level of preparedness is usually not at the forefront of planning efforts.
Unique Response Needs – None of Them Easy, or Inexpensive
Although patients exposed to chemical/detergent suicide agents may benefit from being decontaminated if the product is spilled on them, the off gassing that results still poses a secondary threat to the treatment team and the facility. Hospitals faced with the need to successfully resuscitate a critically ill patient must decide, therefore, both where and how to provide ongoing care. The most immediate steps taken usually include ongoing use of the PPE required, the rotation of hospital staff (to avoid provider fatigue and/or heat-related illnesses), and the maintenance of “clean air” in the treatment area – none of which is easily, or inexpensively, accomplished.
Some facilities may have the capability to vent contaminated air from a treatment area to an exterior connection. Facilities that are not able to vent to the outside can, however: (a) transfer the patient to another facility that has the capability needed; or (b) provide care at a temporary site outside the facility – a medical tent, for example. Temperature control, lighting, and access to the medical equipment, supplies, and medications needed all must be provided for the tent or any other type of “outside” or auxiliary facility to function properly.
Decedent management is the next procedural task that must be carried out if the patient succumbs to the poison. Here, close coordination between the hospital, medical examiner, and funeral director will help prevent the spread and/or relocation of the immediate danger. Poisonings are not uncommon everyday problems for emergency department clinicians. Even if they were extremely rare, though, it is now obvious: (a) that the threats posed by chemical/detergent suicides cannot be ignored; and (b) that dealing with such threats usually requires both special preparation and early recognition to prevent yet another attempted suicide from becoming a statistical reality.
Craig DeAtley, PA-C, is director of the Institute for Public Health Emergency Readiness at the Washington Hospital Center, the National Capital Region’s largest hospital; he also is the emergency manager for the National Rehabilitation Hospital, administrator for the District of Columbia Emergency Health Care Coalition, and co-executive director of the Center for HICS (Hospital Incident Command System) Education and Training. He previously served, for 28 years, as an associate professor of emergency medicine at The George Washington University, and now works as an emergency department physician assistant for Best Practices, a large physician group that staffs emergency departments in Northern Virginia. In addition, he has been both a volunteer paramedic with the Fairfax County (Va.) Fire and Rescue Department and a member of the department’s Urban Search and Rescue Team. He also has served, since 1991, as the assistant medical director for the Fairfax County Police Department.