Blue man’ throws ED into divert, cause remains unknown for 9 hours

Despite preparation, training, manuals, event teaches valuable lessons

When the patient first presented at the entrance to the ED at Greenville (SC) Memorial Hospital on Nov. 9, 2004, his face was blue, with a burning sensation on his face and in his lungs. What transpired between that moment and the time the ED resumed normal functions following a nine-hour divert demonstrates the value of careful disaster planning and the sobering reality that all the planning in the world can’t guarantee a flawless response.

What’s equally important, as the ED director subsequently demonstrated, is the recognition that such plans must be reviewed and updated continually, and every incident should be viewed as a learning experience.

An unknown substance

The patient, who worked at a nearby UPS facility, accidentally spilled a commercial dye on himself, relates Martin Lutz, MD, medical director of emergency services for the Greenville Hospital System (GHS), of which Greenville Memorial is one of four facilities.

"He did not know what it was," says Lutz, who was not present in the ED at the time. "He was lifting boxes, the blue powder came on him, but he didn’t see it. A co-worker told him he looked like a Smurf,’ and their safety officer brought him here." This is a common presentation scenario, when the patient bypasses the EMS system, pre-hospital decontamination, and pre-notification of the ED.

The patient went inside the building and presented to triage, which involved passing through part of the waiting room. The triage nurse at once noted his exposure to an unknown substance and took him as quickly as possible to the closest negative pressure room. Because the facility has four external "decon," or decontamination showers, as well as a decon room, "In retrospect, it probably would have been better to take him outside," Lutz notes — or better yet, he should have been decontaminated at the workplace. But given the ultimate unfolding of events, the failure to decon the patient outside was "good and bad," he says.

In reality, the failure to take the patient back outside once he was in the building may not have been a serious error, notes Kathy J. Rinnert, MD, MPH, assistant professor in the division of emergency medicine at the University of Texas Southwestern Medical Center in Dallas.

"If the negative pressure room is geographically very close, like 3 or 4 feet down the hall, then so what?" she offers. "The overriding concern is you do not want to take someone with a potential exposure deep into the complex or facility. If you do not know what the substance is, you want to be very careful about who you expose this person to, including health care providers."

It’s also critical, Rinnert adds, to leave any equipment you use, including patient care items such as blood pressure cuffs, with the contaminated patient in a treatment room until you have identified the substance.

Protocols come into play

Once the patient was in the negative pressure room, the on-duty staff were familiar with what needed to be done, says Lutz. "We have been using the Hospital Emergency Incident Command System [HEICS] for about 10 years," he notes. As part of their disaster preparation, each of the four campuses of the GHS conducts routine emergency preparedness drills. 

Greenville, in fact, has two specific manuals — HEICS and the GHS disaster manual; both include policies and procedures for hazardous materials. There are separate sections for chemical, radiological, and biological exposures, Lutz adds, and now, following this event, there will be a fourth category: "unknown substance."

"Following our policies, the nursing supervisor went to the manual and made the appropriate phone calls," he relates. The supervisor’s job, Lutz says, was to call the fire department on 911 and request a hazmat (hazardous materials) team, in-house nursing administration, and the on-call administrator who would be the incident commander if an incident command needed to be activated.

"[The administrator] came in from home and assumed a safe position outside the building," Lutz explains. A sample of the powder was taken to the State Law Enforcement Division in Columbia, SC, which was several hours away, for identification — a major cause for the nine-hour divert. The state lab ultimately determined the commercial dye was nonhazardous, it posed no threat to the public, and the patient had suffered an allergic reaction.

Initially, the fire department recommended diverting all noncritical patients. "Until we knew what the substance was, they didn’t want anyone to leave. Using a very cautious approach, the waiting room was closed, and people in there had to remain. The patient rep went around and explained the situation to them," Lutz notes. Meanwhile, noncritical patients were diverted to four nearby hospitals.

Rinnert notes that when there is a potential exposure, the ED and the hospital have a medical and ethical imperative to explain the situation to anyone asked to remain in the facility.

"This was the appropriate action; any time there is potential exposure, the hospital now has the responsibility to monitor them for signs and symptoms, but it is also required to tell and report to them what happened, that they may have been exposed, and symptoms to look for that should be reported," she adds.

Lessons lead to redesign

In the wake of this incident, a number of changes are being instituted at Greenville Memorial. Perhaps the most dramatic is the impact it has had on the planned design of a new ED.

"Because of this incident, we are redoing the whole front area," Lutz adds. "What we had originally developed was a very nice lobby, but we have now moved it back a bit and moved the triage rooms almost to the front door. That way, people won’t be walking through the waiting room."

This makes good sense to Rinnert. "The triage nurse needs to be close to the front door," she says. "Ours is four feet inside the doorway."

In addition, Lutz says, a series of two or three questions are being prepared for the triage nurses. Patients are asked their occupation, which can help narrow down possible sources of exposure.

There are other changes being made in the hospital ED. For example, all of the triage rooms now will be negative pressure rooms, as will the waiting room. And dosimeters (radiation detecting equipment) will be place at the entrance. "If someone comes in who is exposed to radiation, the dosimeters will beep and give us an alarm," he explains. The patient will be directed immediately outside, until appropriate containment and decontamination preparations are made. This addition is "a one-time fixed cost" to put the equipment in the front door, he notes. Dosimeters cost about $500.

The new ED will also be divided into four zones, so if one area is contaminated, the others will not be. "We have also developed a backup triage plan," Lutz notes. "If someone does come into triage, we have a family room by the ambulance entrance that we can convert into triage space."

A renewed emphasis is being placed on the awareness of the external decon facilities. "Besides educating the triage nurses, we have a small group of meeter-greeters, and there will be some education for them, as well," he adds.

Finally, GHS is going to lobby for a lab facility in the upstate area of South Carolina. "If we had our own lab, everything would have been much, much quicker," Lutz notes.

Sources

For more information dealing with exposures to unknown substances, contact:

  • Martin Lutz, MD, Medical Director, Emergency Services, Greenville Hospital System, Memorial Medical Campus, 701 Grove Road, Greenville, SC 29605. Phone: (864) 455-7157. E-mail: mlutz@ghs.org.
  • Kathy J. Rinnert, MD, MPH, Assistant Professor, Division of Emergency Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., MC 8890, Dallas, TX 75390-8890. Phone: (214) 648-3247. Fax: (214) 648-7580. E-mail: kathy.rinnert@utsouthwestern.edu.