White powder triggers lockdown of ED, as fire and police respond
White powder triggers lockdown of ED, as fire and police respond
EDs need quick, appropriate response to unidentified substances
In a scene reminiscent of the anthrax scares of 2001-2002, an unidentified male walked into the ED at Fort Sanders Regional Medical Center in Knoxville, TN, on the afternoon of Wednesday, Aug. 22, and then exited the ED after leaving behind a bottle containing white powder.
The event triggered a lockdown of the ED, which was quarantined by the local health department, but the substance was found to be harmless within several hours. The ED reopened that evening.
While the hospital would not comment for this article, a news release issued that day stated that "proper precautions were taken to lock down the unit, and the appropriate authorities were contacted." In this case, that involved the ED contacting the local 911 center, which in turn triggered involvement by the health department, the fire department, and the FBI. (The FBI web site has a detailed description of proper procedures and coordination between the agency and local health and safety organizations. See the resource box, at the end of this article.)
While the Fort Sanders news release did not provide much detail on the "proper precautions" it took, Dan Hanfling, MD, FACEP, director of emergency management and disaster medicine for Inova Health System in Falls Church, VA, recalls a similar incident about 10 years ago at another facility that he says is a prime example of what not to do.
"A disgruntled apartment renter decided to take out his frustration on his landlord," he says. "The landlord had received a letter in an envelope containing a white powder. When he opened it, his eyes started to run, and he decided to bring it to us."
When he showed the envelope to the triage nurse, she opened the note and said, "My goodness, you're right! My eyes are watering, too!" says Hanfling. "She closed the envelope, put it in a bag, and walked him through the ED into one of the interior patient care rooms — after which the doctor and nurse assigned to that patient did the same thing [by opening the envelope, smelling it, and having their eyes react]." Both the landlord and the staff members who treated him went through decontamination. Finally, he says, the authorities were alerted, and it was determined that the powder was an industrial-grade cleaning product. The landlord was evaluated, observed, given follow-up information, and released.
In a proper response, Hanfling advises, the staff should be alert to and recognize any potential issues, particularly an agent that could pose a threat of contamination. "The first thing that should happen is the person who finds such a substance ought to alert those around them that it looks suspicious," he says. "If it is possible to gather it up without any further dissemination, for example, if it is in a closed bottle, walk it outside, take the person who delivered it along with you, as well an anyone who might have come in contact with it, and have a quick, cursory examination to determine what it is." If the container is open, he adds, everyone should be kept away from it.
Move it outside
Getting a source of potential contamination out of the ED should be a primary concern, adds James J. Augustine, MD, FACEP, director of clinical operations at Emergency Medicine Physicians, an emergency physician partnership group based in Canton, OH.
"The thing to do is to immediately move it outside and conduct all containment activities outside the building," Augustine says. "Don't let anyone else near it, and don't do anything to disturb it." Ideally, he adds, you should tell the person who brought it in to turn around and walk it outside.
One of his facilities also had a similar incident, Augustine says. "A couple of years ago, this guy walked in and said he was going to commit suicide by using the bottle of cyanide he had with him, and this really was cyanide," he says. The nurse did a "very appropriate thing," Augustine says: She had a technician accompany her, and they walked him outside the doors of the ED, where she could continue the interview and leave the container outside.
"All those interactions need to take place outside," Augustine emphasizes. "There, they could secure the bottle of cyanide, question him about where had been, and initiate care for him, including decontamination."
Is an ED lockdown, such as the one that was initiated in Knoxville, an automatic response to discovering a potentially dangerous substance? Not necessarily, argues Hanfling.
"Our ultimate response [during the aforementioned incident] was for all intents and purposes a lockdown," says Hanfling. He notes that ultimately the fire department, the U.S. Postal Service and the police responded to calls, and this gridlock, combined with concern about the offending agent, led the ED to stop taking patients. "We've come a long way since our experience and the numerous white powder experiences that occurred in 2001-2002," he says. "The fact is we realize that for the most part a less draconian dragnet needs to be put in place."
If you can isolate and remove the substance, identify those who have been in contact with it, and allow the proper authorities to investigate, then a lockdown may not be necessary, he says. "The problem with a lockdown in the ED is that it is so disruptive," Hanfling says. "There are probably ways around having to shut the whole ED down, assuming there has been a somewhat expedient response to the material and its evaluation."
Hanfling asserts that "999 out of 1,000" of these cases prove to be hoaxes. "The 'out clause' is that when in doubt, you can certainly cease standard operating procedures until you are confident there is no risk posed to staff or patients," he says.
Augustine agrees you should have other options available short of a total shutdown. "You should be able to adapt your operations," he says. For example, if something "dirty" comes in the door, you may have to close that entrance and then use another one, Augustine says. "It's the same as if a door broke," he says. "You don't close the ED; you use another door."
In addition, EDs today often are designed in such a way that the entrance for "HAZMAT-contaminated" is separated from the ambulance or walk-in entrance, Augustine says. "This way, it will not affect routine ambulance arrivals or walk-up arrivals," he says.
Under what circumstances should a lockdown be called? "If a person is acting in such a way that the staff feels he has done other [violent] things, or put others at risk — or if there is greater concern for the larger area, you should lock down the ED," Augustine advises. "For example, if someone became angry and dumped piles of white powder around the entire building, then it's best to keep everyone in place until the HAZMAT team can come in."
Who you notify, and in what order, also depends upon the nature of the event, Augustine continues. "If it is a potentially legal issue, call the police," he advises. "If [the individual with the substance] just wants to harm himself, you can call the HAZMAT team that serves your hospital, and should already know who that is." They, in turn, can assist you in identifying the material and containing it, but they are not responsible for disposing of it. "That will be the responsibility of whatever HAZMAT company services the hospital — the company that handles all of its hazardous waste," Augustine explains.
Finally, he says, whatever the incident, you should always follow the "golden rule of response." "The teaching line we use in drills is, 'We will protect this house,'" Augustine says. "Whether it involves a patient, a bottle, or an envelope, the object is to protect the hospital by containing the offending object outside until an appropriate cleaning can be done or the hospital is otherwise prepared to manage the situation."
In other words, any containment activities should take place outside the mainstream. "That's an 'all-hazards' teaching," Augustine says.
Sources/Resource
For more information on dealing with suspicious substances in the ED, contact:
- [email protected].
- Dan Hanfling, MD, FACEP, Director of Emergency Management and Disaster Medicine, Inova Health System, Falls Church, VA. Phone: (703) 776-3002.
www.fbi.gov. On the left side of the page, under the heading "Learn About Us," click on "National Security Branch." On the right side of the page, under the heading "Inside the National Security Branch," click on "Protective Clothing" and "Working with the FBI lab."
In a scene reminiscent of the anthrax scares of 2001-2002, an unidentified male walked into the ED at Fort Sanders Regional Medical Center in Knoxville, TN, on the afternoon of Wednesday, Aug. 22, and then exited the ED after leaving behind a bottle containing white powder.Subscribe Now for Access
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