Observed Behaviors During Mass Chemical Exposures Are All of These Patients Poisoned

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Observed Behaviors During Mass Chemical
ExposuresAre All of These Patients Poisoned?
Presented by Alvin C. Bronstein MD,
FACMT American College of Medical Toxicology
Chemical Agents of Opportunity
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Developed by

• Mark Kirk, MD
• Contribution by
• Paul M. Wax, MD
• Scott Phillips, MD

American College of Medical Toxicology
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MONTANA POISON CENTER ROCKY MOUNTAIN POISON
CENTER 2003 Statistics Overview Alvin C.
Bronstein MD, FACEP Medical Director
POISON INFORMATION AND EMERGENCY 1-800-525-5042
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Montana Year 2003 Call Types
8,433
2,484
475
11,392 Total Cases Managed
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(No Transcript)
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Montana Year 2003 Call Types
8,433
2,484
475
11,392 Total Cases Managed
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8,433 Cases by Age Group Year 2003 Montana

• 5 Years Old Under All Age Groups
• Less than 1 Year 578 0 - 5 Years Old
  4,627
• 1 Years Old 1,409 6 - 12 Years Old 475
• 2 Years Old 1,511 13 - 19 Years Old 602
• 3 Years Old 668 20 Years Old 2,556
• 4 Years Old 276
• 5 Years Old 169 Unknown Child 17
• Unknown, 0 - 5 Years Old
  16 Unknown Age or Other 156
• 5 Years Old Under Total 4,627 Total
  8,433

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Montana 2003 Top Ten Most Common Poison Human
Exposure Categories

• Analgesics 996
• Cleaning Substances 833
• Cosmetics Personal Care Products 726
• Cold Cough Preparations 387
• Pesticides 361
• Plants 359
• Topical Preparations 356
• Antidepressants 348
• Foreign bodies / toys / miscellaneous 308
• Hydrocarbons 300
• Total Top Ten 4,974

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A Real Case 3/19/1994

• A 31 year old cancer patient with shortness of
  breath is rushed by EMS to the nearest ED in a LA
  suburb one Saturday night.
• In the ED, doctors, nurses and assorted
  technicians begin a feverish attempt to save
  her life.
• A nurse drawing her blood notices a peculiar
  acrid smell that seems to be coming from the
  patient and suddenly passes out.
• The senior ED resident picks by the syringe used
  to draw the blood and notices yellow crystals,
  smells it and also collapses.
• An oily sheen is noted on the patients chest
• Within minutes 4 other health care providers are
  also overcome and the ED is evacuated.
• During the evacuation the patient dies 36 minutes
  after arriving at the ED.

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Washington Post - September 13, 1994

• Was It a Case of Mass Hysteria or Poisoning by a
• Chemical

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Objectives

• Discuss important observations and lessons
  learned from mass chemical exposures
• Describe the expected behaviors and groups of
  patients that need care during a mass chemical
  exposure
• What is the evidence for mass hysteria?
• Could toxic effects from chemical exposure be
  mistaken for mass hysteria?
• Find ways to provide excellent care to patients
  without overwhelming health care resources

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Case Continued Leading Theories

• Patient drank pesticide in suicide attempt
• Patient used solvent (DMSO) as home cancer remedy
• Hospital plumbing emitted a toxic gas
• A secret methamphetamine lab operated in the
  hospital basement and the patient was
  inadvertently given a drug from an IV bag
• Mass hysteria
• And that the mysterious odor was just the smell
  of death

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Magnitude of Problem

• Operation Desert Storm
• 39 Scud missiles reached ground
• 1000 casualties/ 2 deaths
• 544 anxiety attacks/230 atropine overdoses
• Tokyo Sarin Incident
• 5,500 affected (sought medical care)
• 1,200 required medical care
• 12 died
• Bhopal Disaster
• 200,000 affected (sought medical care)
• 10,000 severe
• 5000 died

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Israeli responses to threat of CBW, 1991

• Scud Missile attack, during Gulf War
• Very real threat of CBW by Saddam Hussein
• No chemicals ever found in rubble of a scud
• 22 of E.D. visits in Tel Aviv were due to
  psychological trauma.
• Ref Steinberg, Armed Forces and Society, 1993.

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Importance

• Actions are important
• EDs have little surge capacity
• Each patient needing Decon/PPE burdens health
  care system
• All or none philosophy is harmful
• Briefly mentioned or omitted from training
  courses
• No solutions discussed
• Labels worried well, Hysterical
• Expect 51 ratio of psychological casualties to
  poisoned in a mass chemical exposure SBCCOM
• Dangers of misdiagnosis

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A Cold January Morning

• 0600
• A pail caught fire at a plating company
  containing
• Sodium meta-nitrobenzene (85)
• Potassium CN (15)
• 15 workers of a downwind warehouse smelled smoke
  and noticed brief upper respiratory irritation
• Evacuated to nearby (5 miles) airport facility
  but not informed of potential CN exposure

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A Cold January Morning

• The original 15 evacuees and 85 contacts learned
  of CN exposure and several began complaining of
  chest tightness, nausea and dizziness
• Warehouse supervisor to dispatch the longer
  they are here, the more they complain.
• Several are feeling ill and weve got about 50
  people that were exposed over there, theyre
  awake and oriented, they just wanted to be
  checked out.

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A Cold January Morning

• 930 Incident Command decisions
• No decontamination at scene necessary
• Transport to area hospitals
• Hospital 1 36 patients
• Hospital 2 52 patients
• Hospital 3 12 patients
• 950 Hospital Treatments
• Hospital 1
• Gross decontamination in parking lot
• Lilly Cyanide Antidote Kit (N2)
• Press Release
• Hospitals 2 3 Check and release

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A Cold January Morning

• 1230p Media coverage prompted calls to Poison
  Center from
• Previously treated and released employees
  regarding appropriate treatment
• Hospitals 2 and 3 because several patients
  returned for appropriate treatment

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Medical Personnel Responses

• Cyanide is deadly
• Cyanide is bad stuff! If it were me, Id go get
  checked out.
• EMTs wearing surgical masks to drive upset
  patients were not decontaminated
• Medics c/o lightheadedness and smelled bitter
  almonds
• Two patients treated with CN antidote kit

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Lessons Learned

• Patients remote from exposure may exhibit
  symptoms
• Medical personnel can be affected
• Become victims (Fearful of becoming victim)
• React inappropriately by using therapies with
  potential for adverse reactions
• Treatment for presumed poisoning or
  misinformation can be harmful
• Decontamination in extremely cold weather
• Adverse effects of antidotes

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Lessons Learned

• Information management lack of communication
  between agencies are the greatest problems
• The Medias message must be part of the risk
  communication plan
• Hospitals were left to make decisions without
  little information or guidance
• Misinformation can overwhelm the health care
  system

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Expect Large Numbers of Patients after Mass
Chemical Exposure

• Types of Patients
• Obvious Medical Needs
• Poisoned
• Contaminated
• Exposed
• Nonspecific symptoms
• With no apparent exposure
• Just want to get checked out

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Hysteria???

• Does hysteria explain this groups nonspecific
  symptoms with no apparent exposure?

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How Can We Study This Question?

• Data obtained from
• Published reports and case series
• Observations from hazmat incidents
• Observations from other types of disasters
• Observations from training drills
• Militarys experiences
• No good epidemiologic studies only observations,
  reviews and opinions

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DefinitionsDiagnostic and Statistical Manual of
Mental Disorders-IV-TR

• Somatization Disorder (Hysteria)
• Poly-symptomatic disorder that begins before age
  30 years, extends over a period of years, and is
  characterized by a combination of pain,
  gastrointestinal, sexual, and pseudo-neurological
  symptoms
• Conversion Disorder
• In "epidemic hysteria," shared symptoms develop
  in a circumscribed group of people following
  "exposure" to a common precipitant. A diagnosis
  of Conversion Disorder should be made only if the
  individual experiences clinically significant
  distress or impairment.

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What is it Called?

• Mass Hysteria
• Epidemic Hysteria
• Mass Psychogenic Illness
• Epidemic psychogenic illness
• Psychological sequelae
• Psychic possession
• Crowd poison
• Psychosocial casualties
• Epidemic transient situational disturbance
• Mass sociogenic illness (by proxy)
• Environmental somatization syndrome
• Traumatic stress response

76 terms found in literature to identify mass
hysteria Bartholomew 1990
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Be Careful What You Call It

• Condescending terms
• Negative connotations
• E.g., Hysteria
• Individual is to blame for illness
• Physicians cannot have mass hysteria
• 1955 hospital epidemic with 300 affected
• Once medical staff affected, condition labeled as
  epidemic benign myalgic encephalomyelitis

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Do People Panic (become hysterical) during a
Disaster?
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Define Panic

• Often a term used incorrectly to describe any
  type of fear, flight, evacuation or lack of
  coordination
• Flight is often appropriate
• Panic flight is
• Irrational, hysterical or groundless flight
• Disregard for others

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Panic is Rare During a Disaster

• Observed Groups of Patients in Period of Impact
• Cool and Collected
• Stunned and bewildered
• Confused, anxious, hysterical crying

Tyhurst 1951
Some authors suggest it may be more easily
provoked in crowded areas (e.g., subways) and
terrorist acts.
Burkle 1996
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Behavior During a Disaster

• Early phase following a disaster
• Strong emotions (disbelief, fear, confusion,
  numbness)
• Fear may lead to high levels of autonomic arousal
  in some
• Various rapidly evolving somatic complaints
• Manifest rapid heart rate, shivering, shortness
  of breath, muscle aches
• Normal emotional responses to an abnormal or
  traumatic event

Benedek Emerg Med Clin N Am 2002
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Events with relatively little panic

• Beverly Hills super club fire 1977
• Hurricane Hugo
• Sarin attack Tokyo 1995
• World Trade Center bombing 1993
• World Trade Center attack 2001

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How Many Reports of Mass Psychogenic Illness in
Literature Between 1966 And 2003?

• Approximately 70 reported cases
• A few reports earlier

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Features Suggestive of Mass Psychogenic Illness

• Sudden onset of symptoms after leaving alleged
  source of exposure
• Significant symptoms not c/w expected toxic
  effects
• Diversity of symptoms w/o physical signs or
  abnormal labs
• Symptoms develop after learning of the suspected
  exposure
• Recurrences in those congregated
• Benign morbidity with no sequelae

Boxer JOM 1985
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Additional Features Reported in the Literature

• Frequently in schools or factories
• Bad odors are triggers
• One or several are suddenly taken ill
• Numerous co-workers become ill
• Environmental investigation is negative
• Reoccurrences when returning to environment

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A Typical Case from the Literature

• Teacher noticed gasoline-like smell in
  classroom
• She developed HA, nausea, dizziness and dyspnea
• Several students developed similar symptoms
• Fire alarm sounded to evacuate school
• Emergency Response activated

Jones et al Mass Psychogenic Illness Attributed
to Toxic Exposure at a High School. NEJM 2000
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A Typical Case

• Symptomatic patients sent to hospital
• 100 evaluated in ED
• 38 admitted for observation
• No specific diagnosis for any patient
• Environmental Investigation over 2 days
• No source of potential toxins as cause

Jones NEJM 2000
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A Typical Case
Jones NEJM 2000

• School reopened Monday morning and several
  students complained of symptoms
• Symptomatic patients sent to hospital
• 71 evaluated in ED
• No specific diagnosis for any patient
• Environmental Investigation
• Epidemic Intelligence Service, EPA, ATSDR, NIOSH,
  OSHA
• No source of potential toxins as cause

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Common Observations Noted During Cases of Mass
Psychogenic Illness

• Schools or factories
• Bad odors are triggers
• One or several are taken ill
• Numerous co-workers become ill
• Vague complaints without positive objective
  diagnostic tests
• Environmental investigation is negative
• Reoccurrences when returning to environment

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Evidence in favor

• No source
• Exposures are below occupational exposure
  standards
• No correlation between attack rate and level of
  exposure to toxic agent

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Problems with Data

• Case Reports /Observational studies
• Inadequate environmental data
• Delayed environmental sampling
• Patient evaluations
• Was everything ruled out?
• Often cannot rule out low level exposure
• Excuse for an incomplete investigation of
  low-level environmental contamination Faust JOM
  1981

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Problems with DataLetters to the editor about
Jones NEJM 2000

• Can you ever have a comprehensive environmental
  investigation?
• Dry floor-drain traps/ 1000 gal grease trap
• Odor reported in 31 locations
• Odor reported by several not ill
• Delayed environmental sampling (passing plume)
• Suggested substances
• Hydrogen sulfide
• Volatile organic compounds
• Laboratory solvents

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Most Common Symptoms of Mass Psychogenic Illness

• Headache
• Dizziness/lightheadedness
• Nausea
• Dry mouth
• Eye/nose/throat irritation
• Drowsiness
• Numbness and tingling
• Chest tightness
• Weakness

Boxer JOM 1985
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Theory Fear and Perception of Poisoning

• Perceived high risk of uncontrolled release of a
  dreaded, catastrophic illness
• Input
• Mucous membrane irritation
• Lightheadedness from solvents
• Noticing a bad odor
• Observing friends become ill
• A natural response would be fear
• Fear leads to autonomic arousal
• Misinterpreted as poisoning more fear

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Caution

• Beware of toxicity mimicking psychogenic illness

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Neuro-psychiatric Symptoms associated with
Chemical Exposures

• Hypoxia
• Phosgene
• Irritant gas exposure
• Reactive airways disease
• PPE
• Hypoxia
• Claustrophobia
• Heat illness

• Decontamination
• Hypothermia
• Low dose toxic effects
• Nerve agents
• Hydrogen sulfide
• Cyanide
• Hydrocarbons
• Carbon monoxide
• Delayed effects
• VX
• Phosgene

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Is it Psychologic or Poisoning?
Nerve Agent Poisoning Chest Tightness Dyspnea Tach
ycardia Nausea/Vomiting Abdominal
Cramps Involuntary Urination Fasciculations Headac
he Coma Diaphoresis
Psychological Chest Tightness Dyspnea Tachycardia
Nausea/Vomiting Abdominal Cramps Involuntary
Urination Tremor Headache Syncope Diaphoresis
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Is it Psychologic or Poisoning?
Psychological Dyspnea Tachycardia Nausea/Vomiting
Headache Dizziness Syncope Diaphoresis/ Chest
Tightness Abdominal Cramps Involuntary
Urination Tremor
Cyanide Dyspnea Tachycardia Nausea/Vomiting Headac
he Dizziness Coma Diaphoresis
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Reported Neuropsych Effect from Nerve Agents

• Sleep disturbances insomnia, nightmares,
  excessive dreaming
• Memory problems
• Depression, fatigue
• Anxiety, irritability, giddiness, restlessness
• Problems with information processing, poor
  communication

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Toxic vs Non-toxic related behavior?

• Making this Dx more difficult is the rare
  incidence of Psychochemical Agents.
• Ex stimulants, depressants, psychedelics,
• deliriants, BZ

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Is it Contagious?

• Crowd Poison
• Groups without nerve agent exposure complained
  of symptoms experienced by those who had been
  exposed.
• Fullerton Mil Med 1990
• Symptoms spread
• proximity of affected/unaffected persons
• Reassembly of the group
• line of sight transmission
• Jones NEJM 2000

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Is it Real?

• Emergency Response
• Dont get caught up on figuring out if it exists
  or not
• Psychogenic illness is a diagnosis of exclusion
• Research
• Need for good epidemiological data that clarifies
  characteristics of each group (defines needs)

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Helena Meth Lab Seizure
Housing Complex Evacuated. A lot of what we did
today was precautionary
20 Oct 2004 Helena Independent Record
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Proposed Solutions

• Emergency Response
• Dont get caught up on figuring out if it exists
  or not
• Psychogenic illness is a diagnosis of exclusion
  
• Dont ignore these patients -Plan for them
• Teach emergency responders toxicology principles
• basic toxicology principles - e.g., Dose-Response
• Look for objective signs of toxicity
• Create a holding environment
• Location away from high-tempo triage activities
• Symptoms monitored and re-evaluation

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Proposed Solutions

• Include behavioral care experts in community
  emergency planning
• Strive for Single-Voice communications with
  media and public
• Teach Risk Communication skills to community
  emergency response personnel
• Continue to study and better define the social
  behavior of mass chemical exposures

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Terrorism ResponseRole of the Poison Center

• Information is ANTIDOTE for fear
• Poison Information Centers recognized as the
  central information resource for hospitals
• Police, fire dept, Self Defense Forces, the
  poison information center and hospitals need to
  form a information network - Okumura AEM 1998
• Poison centers can provide
• Early Recognition of Disease (toxico-surveillance)
  
• Early Notification to Hospitals
• Information Resource regarding human health
• Access to Specialized Resources and Databases

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Role of Poison Centers

• Base disaster plans on what people are likely to
  do rather than what they should do - Auf der
  Heide
• People will seek advice from sources that are
• Familiar, Trusted, Available
• Survey says?
• Already part of public health system and
  emergency response
• Improve public health infrastructure by enhancing
  existing information network

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Summary Minimize CHAOS with organized approach

• Expect Large Numbers of Patients after Mass
  Chemical Exposure
• Use Basic Principles of Toxicology
• Realize the Dangers of Misdiagnosis
• Information and Resources
• Communication is Key
• Dont forget hospitals Interagency coordination

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Was It a Case of Mass Hysteria or Poisoning by a
Toxic Chemical

• The Injured 5 health care staff hospitalized
• ED nurse hospitalized for 9 days and stopped
  breathing on occasion, developed chronic severe
  headaches, fatigue, SOB and needed to see a
  psychiatrist who insisted it was organic cause
• ED physician hospitalized in ICU for 2 weeks
  requiring mechanical ventilation
• 3 months in a wheelchair
• Avascular necrosis of knees requiring 20
  operations

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The Exposed?? (n37)

• 11 of 37 present in ED noticed unusual smell
• garlicky, ammonia like, gas-like, or
  chemical-like
• 26 of 37 including head ED doc did not notice
  odor
• Paramedics who transported patients and drew
  blood in the ambulance noticed no odor and
  developed no symptoms
• 23 developed at least one symptom

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Three Investigations

• Coroner
• Patient died from cervical cancer
• Fumes that sickened the hospital workers was just
  the smell of death
• Cal-OSHA
• No safety violations
• Three employees had involuntary psychological
  reaction to some agents while the rest suffered
  from mass hysteria
• California Dept of Health Services (CDC)
• 1. an outbreak of mass sociogenic illness
  perhaps triggered by an odor
• 2. Also possible that a few staff members were
  exposed to unknown toxic chemical

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The Smoking Gun Hypothesis??
Dimethyl Sulfoxide Garlic odor
oxygen
Dimethyl Sulfone
cold
Dimethyl Sulfate Onion odor
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Thank you
American College of Medical Toxicology
Questions