By Dr. Ken Lavelle, MD, NREMT-P
The Albert Einstein Medical Center
This column looks back on a case that occurred in my home state of New Jersey about 14 years ago. I remember reading about it at the time and it has stuck with me throughout my career.
I refreshed my memory regarding the details by reviewing the report, the Fatality Assessment and Control Evaluation Project report published by the New Jersey Department of Health and Senior Services, Occupational Disease and Injury Services.
The case involves the line-of-duty death of a deputy chief with 36 years of experience. He was described as an individual who was physically fit, and was the safety officer of his department.
In August 1996, his department responded to a fire in a fast food restaurant. All involved reported during the subsequent investigation that it was “just a routine fire.”
Per the report, the fire started in the flame broiler and spread to the fat fryer. It spread through the exhaust fan and ductwork to the roof, and upon the first engine’s arrival, that it did have visible fire on the roof.
The deputy chief responded from home to the scene. He was seen outside of the building, near the back door when a large cloud of smoke from the fire banked down toward him.
He was not wearing an SCBA. He later reported he inhaled some of the smoke, held his breath and walked out of the cloud. He was immediately attended to by a BLS crew on scene and rapidly transported to the hospital.
At the hospital he was in severe distress, and almost needed to be placed on a ventilator. However, he improved and was discharged after two days.
Ten days after the incident, he was at home when he collapsed. EMS found him to be in cardiac arrest, and efforts to resuscitate him were not successful.
The medical examiner reported that the cause of death was “marked tracheobronchial inflammation, alveolar hemorrhage and pulmonary edema due to smoke inhalation containing phosgene.” Phosgene? Where did that come from? Isn’t phosgene some old chemical weapon?
Immediately after the incident, the department initiated an investigation into this “routine fire.” What was found was that the fire on the roof had involved an air conditioning unit, and a hose containing Freon 22 (chlorodifluromethane) had ruptured.
When this substance is exposed to heat and decomposes, several substances including hydrofluoric and hydrochloric acid, chlorine gas and phosgene are produced.
Phosgene is a toxic gas, considered a pulmonary irritant. Its structure includes a carbon, oxygen and two chlorine molecules. It was used in World War I as a chemical weapon.
Today, exposure can occur in the manufacture of dyes, resins, pesticides and pharmaceuticals. It is also created in the heating and combustion of chlorinated organic compounds. This is how this chemical was found on our “routine” fireground.
What are the health effects of this substance?
Phosgene is slowly dissolvable in water. This means that when it is inhaled, it does not dissolve in the mucus membranes of the airway quickly, so it can travel into the lower airways. If it was rapidly dissolvable, it would do so in the upper airways and its effects would occur there.
Once it dissolves, it turns into carbon dioxide and hydrochloride acid in a process called hydrolysis. The hydrochloric acid causes inflammation and death of cells in the lower airways and the lung itself.
There is often a 24-72 hour delay in the onset of symptoms, which include coughing, shortness of breath and rales (fluid in and around the airways.)
Victims may have a rapid respiratory rate and heart rate, and their blood pressure may be low. The more concentrated amount of phosgene that is inhaled, the faster the symptoms can develop.
Sometimes, as in this case, there may be a period where there is improvement, but the damage to the lungs is still present and the symptoms can return.
So what does this mean to us on the fireground?
First, we should encourage firefighters to wear SCBA even on the outside of a fire building. It is very possible for smoke to be blown into the area of those working on the outside.
If we are in an EMS or rehab role, we need to make sure we establish our area far enough away from the building so this does not occur to us or those we are caring for.
Next, we need to keep this case in mind while assessing firefighters with exposure to smoke. Few firefighters will admit what level of distress they are in. This is normal for the fire service.
But we need to see past the bravado and accurately assess our patients. Any firefighter with shortness of breath, abnormal vital signs or an abnormal physical exam needs to be evaluated at the hospital.
We won’t make a big deal of it, but will check and X-ray and observe them for a bit. If the abnormalities continue, then we can admit them and initiate appropriate treatment. If they improve they can often go home.
In a perfect world we will know what is in the smoke at every fire, but this is not reasonable. The reality is that every fire can cause smoke that has a variety of chemicals, even in a residence.
In retrospect we can see how this fire in a fast food restaurant had phosgene present. Think about how many fires involve an air conditioning unit and thus, the same chemical (Freon) that broke down under exposure to fire.
I bet the EMS on scene at this fire did not think they would be treating a victim from a life-threatening exposure to a chemical weapon from World War I, but that is exactly what happened. Stay vigilant and stay sharp.
Stay safe.
The Albert Einstein Medical Center is a teaching hospital offering a full range of advanced health services to the Philadelphia community and beyond. The center has more than 600 primary care doctors and specialists on staff, with an additional 1,200 affiliated physicians. The Department of Emergency Medicine at the center has staff trained in emergency medical services, special operations medicine, and disaster management. Ken Lavelle is an attending physician at Albert Einstein, and previously spent 14 years working as a firefighter and EMS provider. He serves as medical director for several agencies in Pennsylvania and New Jersey.