Almost all the initial information about a Labor Day weekend hazardous materials emergency that spread from an Illinois packaging plant to four hospitals in and around St. Louis, MO, shutting down two major emergency rooms for nearly a day, proved to be wrong, said John Mueller, director of safety, security and emergency preparedness at one of the hospitals.
He was first told that two children were exposed to an unknown chemical while playing in a trash dumpster.
"I said, 'Okay, bag the kid's clothes, put them in a negative pressure room and I'll contact the hazmat team for St. Louis County,'" Mueller said. "Then I was told that they came by ambulance from East St. Louis."
That did not add up. An ambulance would not bring emergency pediatric patients to a hospital almost 30 miles away, crossing the Illinois-Missouri state line in the process, Mueller said.
By the time Mueller reached the SSM DePaul Medical Center in Bridgeton, a St. Louis suburb, the story had changed. Instead of two children, the patients were three adults who had arrived at the emergency room in a private vehicle. Two of those three patients were seriously ill after direct exposure to a chemical spill at an East St. Louis, IL, packaging plant.
Nearly three weeks after the incident, both Mueller and Dolph Jeck, a battalion chief for the Pattonville Fire Protection District who served as incident commander at DePaul, said they remain unclear about exactly what happened at that plant or how eight people sickened by a dangerous chemical ended up seeking treatment so far away.
Somehow, a barrel containing nitroaniline was dropped, exposing workers to the potentially toxic chemical that causes vomiting, convulsions and respiratory arrest. Ideally, the workers would have been transported by ambulance to nearby hospitals and the medical staff on duty would have been advised to prepare by donning personal protective equipment.
But that is not what happened.
Jeck took the first call to emergency responders about the contaminated patients while on duty at fire district headquarters station. The caller was worried it might be anthrax.
"Typically, a call like this would go through our alarm center," Jeck said. "It's not very often that we get calls from citizens coming right to the station. The DePaul ER reported that they had three people covered in an unknown chemical."
Simultaneously, the alarm center rang Jeck on another line based on a separate report and asked what kind of response he wanted.
"I told the caller from DePaul that we were on the way," Jeck said. "I told the alarm center to give me a first alarm response and that I would advise the responding companies en route as to the situation."
SSM Healthcare is a collaborative of seven hospitals in four states. Mueller serves as director of safety, security and emergency preparedness for SSM Healthcare's north operating group. The 454-bed DePaul facility was only added to Mueller's list of hospitals in mid-June.
"To keep our accreditation we are required to do at least two disaster drills a year," Mueller said. "Within our disaster plans some of the things we have to be prepared for are CBRNE activities - chemical, biological, radiological, nuclear and environmental. Chemical spills are included in CBRNE activities."
DePaul boasts a newly renovated emergency room complete with 50 patient care rooms. One addition off the vestibule between sliding doors at the ER's ambulance entrance is a 20-foot by 20-foot shower room specifically designated for patient decontamination. Negative pressure in the decontamination room means that air flows inward from adjacent areas, ensuring that contaminated air cannot escape.
Had the patients arrived by ambulance, the decontamination room would have been well situated. At about 3 p.m. Saturday, a white SUV arrived at the ER - the waiting room entrance, not the ambulance entrance. At least 15 people were in the waiting room at the time.
"The driver ran into the lobby of the waiting room and said, 'I've got two people really, really sick in my car,'" Mueller said. "Since he was contaminated, he in turn contaminated our waiting room. That was our first problem."
One person had vomited and was slouched in the passenger seat of the SUV, Mueller said. A second person was semi-conscious across the back seat. The driver said only that they had been exposed to an unknown chemical earlier in the afternoon.
"Two of my security officers reacted immediately," Mueller said. "Without any decon equipment, the officers and a medic grabbed those people and got them into the decon room as fast as possible. In doing that, they exposed themselves to the chemical involved."
Unfortunately, one of the two security guards was the leader of the hospital decontamination team.
"Both of them were contaminated, making them useless to me for the rest of the afternoon," Mueller said. "I barely know a lot of the staff members over there and here I am trying to run a disaster with my main decon guy already needing to be deconned."
The officers might have reacted differently if personal protective equipment had been readily available. But due to the recent renovation, the PPE had not yet been moved from its old location to the new storage cabinets outside the decon room.
"Maybe they could have put on the Tyvek suits a little quicker if they had been right there," Mueller said. "Hindsight is always 20/20."
Likewise, the medical staff rushing to treat the patients did little more for self protection than don surgical masks. Eventually, 15 members of the DePaul staff would require decontamination in addition to the patients.
"Nurses and clinical people immediately think, 'Okay, we've got to save the patients,'" Mueller said. "Actually, that should be the number three priority. That always freaks them out - 'My God, why is patient care number three?' Because care of the caregiver is number one. You've got to protect yourself first and then you've got to protect your building."
As an example, Mueller points to the outbreak of Severe Acute Respiratory Syndrome (SARS) in Toronto, Ontario, in 2003, blamed for the deaths of 44 people. Close contact with an infected person is needed for the infective agent to spread from one person to another.
"In Toronto, you had sick people and a sick building," Mueller said. "You had to quarantine the hospital. That's kind of what happened here because we didn't have time to react and get to our PPE."
One passenger was listed in critical condition, while the other was listed as guarded. The driver was held for observation, Mueller said. Although the patient in critical condition was not thought to be doing well when he arrived, he was upgraded fairly quickly.
The Pattonville Fire Protection District encompasses roughly 30 square miles, at least 30 percent of which is highly industrial. Outside, Jeck directed responders to DePaul to stage about 250 yards from the emergency room.
"I met with the company officers," Jeck said. "I said, 'Here is the deal - we don't know what is going on here. We're going to step way back and go real slow.'"
Two mutual aid departments and the duty officer for the St. Louis County Hazmat Team joined the Pattonville responders.
"Our department as well as others utilize a unified command system based in part on the National Incident Management System (NIMS)," Jeck said. "We could have implemented a regional Incident Management System (IMS) structure with coordination at the county, state and federal level if the incident had grown larger in size."
Jeck was not a stranger to the DePaul ER, having worked part time there for 10 years. He ordered responders to proceed to the emergency room entrance door to make contact with anyone who could provide information about the patients or to what they had been exposed.
"Responders sent to the ER were instructed not to enter until we had more information," Jeck said. "We did not put people into that environment instantly. Their role was strictly recognition and identification."
Information was coming in from other sources as well. In addition to the three patients at DePaul, three more contaminated patients had arrived at a hospital almost 40 miles south. Hospitals in metropolitan St. Louis were also reporting two contaminated patients.
"This thing went from bad to crazy to worse in seconds," Jeck said.
Under the authority granted Jeck by the CFR 1910.120, SARA Title III superfund amendment governing the implementation of command responsibility in a hazardous materials release, the entire DePaul hospital complex was locked down during the first hour of the emergency.
"I didn't know what we were dealing with," he said. "We had no previous knowledge of any kind of hazardous materials incident in the region. We were way behind the eight ball here."
DePaul is part of the St. Louis Area Regional Response System that uses a modern wireless network to track emergency victims from the scene of an incident through their transportation to hospitals, while alerting emergency rooms about the conditions of incoming patients, Mueller said.
"All the hospitals are locked into this system through the Internet," Mueller said. "We went on 'black diversion' status. Ambulance crews and fire departments knew not to bring anyone critical to our hospital."
But even with the diversion order given, private citizens seeking medical aid for various reasons continued to arrive. For patients who could not be sent to other hospitals, an alternative emergency room was established away from the contaminated ER.
"We had heart monitors, oxygen and could actually take care of anybody critically ill," Mueller said. "Fortunately, we did not have any walk-ins that were that critical."
Still, the emergency tested the limits of the responders' preparedness, Jeck said.
"We drill continuously for hazardous materials response," he said. "We try to think of every possible scenario. But this was one that was not routinely planned for. My chief concern was to track this down as to where it occurred and what effect it might have going from point A to B,C,D and E."
Slowly, within that first hour, a better picture of what had happened in East St. Louis formed. The driver who brought the workers to DePaul remained alert and able to talk, finally identified the chemical involved.
"We were getting fragmented information," Jeck said. "Finally, we got the exact location and asked the East St. Louis Fire Department to determine what magnitude of spill was involved. They didn't even know about it until we called them."
As better information became available, responders scaled back the restricted area to just the emergency department, the entrance and the vehicle still parked at the entrance. Still, the potential issues seemed overwhelming. Initial reports from the DePaul ER indicated more than 50 people had been exposed.
The large number of people initially thought to be contaminated had Jeck concerned about the available facilities, particularly the small decon room. Responders began establishing a secondary means of decon in the parking lot outside the ER.
"The way hazardous materials response is structured in St. Louis County means we are bringing in resources from multiple different areas of the county," Jeck said. "It takes time to bring these resources together so we can begin our work."
Equipment summoned to the parking lot included hoses and special collection pools. Plans called for people determined to be contaminated to first go through a gross decontamination procedure in the ER's decon room. Then, the secondary gross decon would be conducted in the hospital parking lot, followed by a secondary decon procedure outdoors if necessary.
Thankfully, there is a difference between contamination and mere exposure, Jeck said.
"The decision was made that we would decon those we suspected to be actually physically contaminated," Jeck said. "Our research told us this product was a powder that required physical contact to cause contamination versus exposure."
As Mueller describes it, being decontaminated ranks close to a traumatic experience in itself.
"The decontamination team goes in wearing Level B suits complete with a respirator," Mueller said. "You are stripped completely naked and washed from head to toe, every nook, cranny and crevice. Your clothes are bagged up and considered contaminated. The bags are sealed in a 55-gallon barrel and taken to an incinerator to be burned."
Fortunately, temperatures outdoors were in the comfortable eighties. Jeck said avoiding embarrassment was far from the primary consideration.
"We are going to do what we need to do," he said. "If we have to put people in uncomfortable positions to protect them, so be it."
The single concession to modesty was that both gross and secondary decontamination of women was handled indoors in the DePaul decon room. After decon was completed, responders issued the subjects surgical scrubs and put them aboard a rehabilitation bus for further medical screenings.
In the course of decontamination, responders discarded the personal possessions of the patients along with their clothing. This included the keys to the SUV. After the vehicle was decontaminated to the degree that the seats were removed and cleaned, it had to be loaded on a flatbed trailer to clear the emergency room entrance, Mueller said.
Doctors moved the three patients from the decon room into the emergency room patient treatment area, Mueller said. Keeping track of which treatment rooms were used would become important later when efforts to detect possible further contamination began.
"Eventually, they were taken into the hospital proper, but that was several hours later after having lab tests done," Mueller said. "It was okay to move them to a patient room so the rest of the hospital was not affected."
Hospital officials brought in St. Louis-based Bellon Environmental Company to confer with the St. Louis County Hazmat Team and handle the actual cleanup of the emergency room, Mueller said. It was determined that those people in the waiting room when the driver rushed in would not require decontamination.
"They felt that he was in and out of there so quickly that if anything came off of him it would be very little," Mueller said.
The rumor mill continued to grind. East St. Louis City Manager Robert Betts told media outlets Saturday night that two contaminated packing plant workers had died. Federal agents called in to investigate whether the chemical release was linked to terrorism later confirmed that the spill caused no deaths.
"That was one of our biggest issues to deal with because it really threw panic into everybody to hear there were two people dead," Mueller said.
Further aggravating the situation is that DePaul is only 10 minutes away from Lambert-St. Louis International Airport and is located on Interstate 70. Republican presidential candidate John McCain was scheduled to land there Sunday and travel past the hospital en route to his scheduled event, Mueller said.
"The FBI took an almost immediate interest in the emergency, trying to figure out if it could possibly be some kind of terrorist statement," he said.
AID FROM LITTLE ROCK
Bellon proceeded with eight to 10 hours of clean up in the emergency room, wiping walls and mopping floors. However, while they could handle any physical work necessary, special expertise would be required to determine the extent of the possible contamination. Mueller was referred to the Center for Toxicology and Environmental Health in Little Rock, AR.
Dr. Richard Kind, senior toxicologist for the center, said his five-member team could respond as soon as possible. Travel by commercial plane or private vehicle meant the team would not arrive in Bridgeton for eight to 10 hours. Using the center's private plane would put the team at DePaul in four hours.
"Our emergency room was shut down," Mueller said. "We can't see patients, generate revenue or serve the community. The decision was made about 8:30 p.m. to fly the team in by private plane. They were at the hospital by 1:15 a.m. Sunday, which was pretty impressive."
Once on scene, the toxicology team began air sampling, an eight-to-12-hour procedure to complete.
"They were monitoring for the particulate counts, trying to determine the threshold limits for how much nitroaniline might be in the air," Mueller said. "They also used an ultraviolet light source called a Woods lamp to detect any contamination on surfaces in the treatment rooms and patient areas."
One of Kind's team also visited the homes of several of the workers to track down further contamination.
"Some of them went to their homes first before going to the hospital," Mueller said. "So they took the Woods lamp to see how much chemical might have fallen off their clothes or become airborne in their houses so no one else would be exposed."
Research indicated that symptoms stemming from contamination should appear within 12 hours. With a hazmat remediation company in place and no further illness reported, Jeck struck out the alarm for DePaul at 2 a.m. Sunday.
Air monitoring continued until 10:30 a.m., at which time it was determined that any nitroaniline present was negligible.
"They sent off samples to the appropriate laboratories for analysis," Mueller said. "As expected, the air inside the building was actually cleaner than outside."
Not all the hospitals involved were that lucky, Mueller said. Although the ER at the hospital south of DePaul also reopened Sunday, actual contamination was found in a treatment room.
A public information officer for that hospital declined to comment to Industrial Fire World about the hazardous materials incident there, citing concerns about possible litigation.
Of the two hospitals in St. Louis proper that each handled one worker, neither closed its ER. In the case of one of the hospitals, the decontamination area is detached from the emergency room.
With the green light from the toxicologists, the DePaul ER reopened at 2 p.m. Sunday. All three patients who arrived Saturday were released within two days.
Changes are already underway at DePaul in the wake of the August emergency. First and foremost, decontamination equipment has been moved to the emergency room ambulance entrance for immediate access, Mueller said.
Almost as important is improving communications to deal with the rampant gossip and rumors, particularly after the entire hospital complex was locked down, he said.
"People up on the patient care floors heard there were people dead all over the place," Mueller said. "It was panic. People were very concerned about what was going on and how sick those people were."
Jeck said his fire district conducted debriefings with all the other responding fire departments, police and remediation companies with an eye toward assembling an extensive post incident analysis.
"Everybody is going over the lessons learned here," Jeck said. "We want to know what we can do differently to improve the situation next time."