Chemcials in Suicide

Chemical Assisted Suicide: Agent Review

Chemical assisted suicides continue to change and challenge emergency responders. Recent cases have demonstrated the ability to utilize various products and expand that challenge to health care facilities and providers. While we've focused much of our attention on Hydrogen Sulfide, cyanide and numerous other chemicals with high hazard potential have been used. For more, follow this link for background information on Chemical Assisted Suicide. In this series Mitigation Journal continues coverage of chemical suicide/blood agent suicide that began in 2008.

Recent Cases:

New York City - a man was found in a running car with an open bucket containing about 10 gallons of unknown chemicals. The car was parked near a "big box" home improvement store. We can only speculate based on media reports, that the open container of chemicals played a role in the death. This situation may have been one of many that mix various chemicals to form Hydrogen Sulfide.  

Boston - a woman ingested sodium azide and subsequently metabolized a form of Cyanide resulting in her death, causing the evacuation of the building and the quarantine of several responders.

Florida  - a man ingests a pesticide, malathion, and was transported to the hospital by EMS. The man vomits, exposing the ambulance crew and hospital providers to the effects of this organophosphate/cholinesterase inhibitor material. (see Are you ready for nerve agent exposure? Mitigation Journal)

The locations are different as are the chemicals used but, they're all part of a growing trend that poses extreme risks to civilians, responders and healthcare facilities.

Review of Chemicals

Various chemicals are used in suicide attempts and can include:

• Simple Asphyxiants - carbon dioxide, methane, and propane - displace oxygen in an enclosed space, promoting asphyxiation and suffocation by causing an oxygen deficient atmosphere.
• Systemic Asphxiants - carbon monoxide - exclude oxygen from the red blood cell by altering hemoglobin, decreasing the oxygen carrying capacity of the blood and resulting in hypoxia/hypoxemia .
• Blood Agents - Cyanide/Cyanide forming compounds, Nitrates, and Sulphides. Hydrogen sulphide, hydrogen cyanide, cyanogen chloride are major concerns. These materials interfere with cellular respiration and result in cellular hypoxia. Each of these products are toxic and can lead to rapid death. 
• Choking Agents - Chlorine and Phosgene - stress the respiratory system and the respiratory tissues. Exposure to choking agents results in mechanical compromise as well the potential for chemical damage that may result in pulmonary edema. 
• Consumer Level Hazardous Materials -  hydrogen peroxide, acetone, drain cleaners, and bleaches - can be combined to create toxic environments. Commercial pesticides may become contain hazards similar to chemical never agents.

Many drain cleaners contain sodium hypochlorite (bleach) and lye, an oxydizer/caustic. Chlorine (bleach) mixed with an acid creates chlorine gas and chlorine gas combined with ammonia results in chloramine gas. All of these materials are severe inhalation and contact hazard.

Many cases of chemical assisted suicide, sometimes described as detergent suicide, involve some form of bathroom cleaner (acid), pesticides (sulfur) , laundry detergent (chlorine), and in some cases bath salts (not the synthetic drug type). Hydrogen sulfide is created by combining acids and sulfides with other materials. There is usually some type of mixing container and empty chemical containers nearby.

In some instances, chemicals have been combined and created other materials that have resulted in differing signs and symptoms including those similar to nerve agent exposure with a similar toxidrome.

The details of the chemicals presented in this post are presented solely for the benefit of responders and health care providers. The intent is to increase the awareness to the growing threat of chemical suicide and Consumer Level Hazmat situations.

London: The Next Ground Zero

The 2012 Olympics in London are at risk of becoming the next pandemic ground zero according to research conducted by Maplecroft.

The bad news is that London is only part of the story.
Singapore, North and South Korea, Italy, Germany, Netherlands, Belgium, France, and Spain make the extreme risk of pandemic list, too. None of them are hosting an Olympics, yet are on the same list with the same extreme risk ranking. Confusing? No so much.

Many of the countries noted by Maplesoft are at risk of flu spread as a result of environmental and living conditions. South East Asia is noted in the report as being "a particular risk of emerging strains of influenza" and China is noted as a particular concern. This should not be a surprise. We've been following the development of widely publicized diseases like Avian Flu from these areas for several years. What's different is our level of awareness today. We recognize that global events that bring so many people together from diverse locations brings with it increased disease spread potential.

What makes the 2012 Olympics in London different?
Nothing. In fact, the risk of disease transmission is not unique to  the London Olympic Games in any way. We would be having this same conversation if the Games were being held in Lake Placid, NY or Beijing, China. Mass gatherings have the potential to spread disease, influenza or otherwise. We discuss influenza most often because of the attention drawn to influenza A - H1N1/Swine Flu and H5N1/Highly Pathological Avian Influenza. Although they top the list of notable flu viruses, it's important to remember there are many other diseases of concern. These diseases hold threat potential regardless of the location of the event. The fact is simply highlighted because of the diverse population and environments the athletes and spectators will be coming from. Immune system status, comorbid conditions, and overall state of health of attendees will also be factors in the spread of disease. People will bring diseases as diverse as the culture and health environment they come from...and they'll take other diseases home with them, too. We should also consider the fact that the Olympic Games will be a high-profile event that may be an attractive target for a variety of threats including the biological bomber. Read more: YOU, the biological bomber

What may be different today is our awareness and sensitivity to the biological threat. 
Naturally occurring or intentionally released, a biological agent can be an extraordinarily deadly situation. Perhaps worse than a nuclear detonation, without the big bang, if you will. The good news is that, when compared to other threats, the biological event may be able to be contained and person-to-person transmission limited by simply washing your hands and wearing a mask. The non-pharmacological interventions go a long way to slow the spread of disease and support vaccination efforts. Read more on non-pharmacological interventions.

Technology is a new ally in disease tracking. As described in this video clip from Reuters, public health officials from all over the world are working to improve disease tracking before, during, and after the London Games.

How will the media respond to athletes and attendees at the London Games wearing masks?
This would not be the first time the issue has come up. The United States Cylcling team came under scrutiny for wearing face masks during the 2008 Olympic Games in Beijing. Pollution and air quality prompted the athletes to don the masks and subsequently sparked political issues between China and the U.S. Masks for pollution is one issue. Donning masks to prevent the spread of disease is quite another. Consider the global impact if we were to hear of a "flu-like" illness spreading through London and, at the same time, see athletes wearing N95 masks. It wouldn't take long for the speculation of an outbreak to be spun into the next pandemic.

Preparedness, of course.
There is another side to the threat...preparedness. The widely cited Maplecroft report clearly describes the 10 nations most at risk for pandemic influenza. What is less often noted is that this same report ranks an areas ability to contain a disease. This same research concluded that the U.K. is one of the countries most likely to be able to contain an outbreak:

"...the UK’s strong governance, highly developed infrastructure, well educated population and advanced health system also places it among the 10 countries with the highest capacity to contain a potentially lethal outbreak of a strain of flu." - quoted from Maplecroft.com

What's less clear is the preparedness in other countries. Attendees and athletes will return home with whatever (if anything at all) they've been exposed to. While strong infrastructure adds to resiliency, the lack of that infrastructure will add to disease complication and management. Read more on flu and biological preparedness.

EMS and Y2K: Planning like its 1999

Considering the Next Y2K
Coposted on Mitigation Journal

"No phone, no lights no motor cars,
Not a single luxury,
Like Robinson Crusoe,
As primitive as can be."
-the ballad of Gilligan's Island, G. Wyle/S. Schwartz. source: http://www.lyricsondemand.com/tvthemes/gilligansislandlyrics.html

Do you remember Y2K?
That "thing" commonly known as the Millennial Bug that was supposed to happen when the calendar changed from 1999 to the New Melania. What would happen when computer systems that were designed around a two digit date encountered the year 2000? Who knew? Computers were going to stop working, banks would loose all your money, and business systems throughout the globe would cease to function.

Amid the hype there was preparedness  
Information Technology exploded into a fury of activity that lasted for years and spent billions of dollars. The Y2K threat was taken seriously even though the impact could only be estimated. Governments and small businesses alike mobilized ahead of the threat to reinforce computer systems and upgrade technology. Fearing some form of cataclysmic event, civilians also took precautions and readied themselves for the December 31 deadline.

And nothing happened. Did nothing happen because nothing was ever going to happen; or, did nothing happen because there was a unified preparedness effort?

Thinking of the Y2K situation made me think about how we would respond to a threat on our technology systems and internet today. We're in a far different world today than we were in 1999. The use of technology has increased exponentially in the last few years and certainly over the last decade. Today, automated systems control everything from finance to water treatment facilities. We're also in a far different world concerning preparedness. How would we do with a Y2K threat today?

It's not just business
We're used to swiping a card rather than paying in cash for everything from fast food to fuel. We've become accustomed to (if not demanding) instant access to our information and entertainment and we're accessing that content on the go via Smartphones, tablets, and other handheld devices. We rely on internet communication for telephone, email, and other communication.

Is there a threat on the horizon? 
Would we embrace preparedness efforts with the same level of enthusiasm today as we did in 1999? Would we endorse the expenditures in terms of time and money to make preemptive changes? If today's climate of complacency is any indication...we'd do nothing until the PlayStation stopped working or the iPhone wouldn't connect...we'd be too late. This Nike spoof of Y2K just might capture the level of awareness. Then what?

"When nothing happens, nothing happens...nobody wants to pay when nothing happens."

Today's Threats
Y2K came with substantial warning time. Time to analyze, harden, prepare. Information technology professionals had about two years foresight to begin working on the issues once the Y2K threat potential was identified.

Would we have any Y2K-style warning today? Would we take the warning seriously?

Magnify the Y2K threat beyond the inconvenience of losing your email and social media for a few days. Computer viruses, cyber attack, infrastructure failure, and the potential of electromagnetic pulse (EMP) top the list of threats. These critical threats will almost certainly come without warning; turning us back to analog for weeks if not months or years. We recently discussed the issue and potentials of a cyber attack and our lack of ability to detect it until long after it has happened. With all things considered, the biggest threat we may face will be our own indifference to the potential. Remember, it can't happen here. Can it?

How far have we come since 1999? View the video Y2K: Tensions in the Last Days of the 1900's and answer that yourself.

Commerce, Communication, Infrastructure
Damage to communications systems and commerce may be immediately felt by government and civilian populations.  Managing life without our cellular communications, chat, text messages, FaceTime, and social media may be difficult...extraordinarily difficult. The real punch of a Y2K/cyber attack will be rendering our critical infrastructure useless. Rather than crippling a water pump in a processing station, lets turn off the United States power grid. No access to your money, no use of credit/debit cards. Lack power for a prolonged period of time would begin a cascade of system failures that would include loss of domestic water and fuel supplies. Civil unrest and potential for violence should be considered. Suddenly, $4.00/gallon gas seems like a bargain. How about water for only $10.00/gallon...cash only.

No Panic, Please
The intent of this post is raise awareness and assess threats. Cyber threat is not a Cassandra Paradox, it is a reality. What to do? Simple. Acknowledge the threat potentials and employ your standard preparedness strategy...and don't, repeat don't, take anything you see on Doomsday Preppers seriously...that's a topic of another post.

EMS a Key to Crisis Standards of Care

Standard to Sufficiency: IOM Framework Paves the Way 
Coposted on Mitigation Journal

Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response has been released by the Institute of Medicine and should be required reading for anyone who participates in emergency preparedness.

When disaster strikes changes have to be made. Planning has to turn into action. Public health, emergency medical service, and hospitals will be faced with tremendous pressure to do the best for the most with what they've got. I call this situation switching from a Standard of Care to a Sufficiency of Care - the latest publication from the Institute of Medicine (IOM) calls it Crisis Standard of Care. The Tenent Health/Katrina decision reinforced the health care planing message...IOM tells us how to do it -

IOM defines three levels of care:

1. Conventional Care
2. Contingency Care
3. Crisis Care

Overview

Crisis Standards of Care document totals over 500 pages divided into easy to digest volumes that target key pillars of Hospital Care, Public Health, Out of Hospital Care, EMS, and Emergency Management/Public Safety. The standards are built on a platform of ethical considerations and legal authority that segue into other critical, but often ignored, components such as community engagement and creation of incidents and triggers for action.

A key to this document being noteworthy is the detailed incorporation of emergency medical service, out of hospital care and public health.While most preparedness documents clump these disciplines under the health care umbrella, IOM takes a refreshing stance by giving each of these disciplines receives appropriate attention and legitimate planning guidance. The quality doesn't stop there; IOM goes even further, including at-risk populations, palliative care, home care, and walk in/urgent care centers as contingencies for planning.

Planning

Template from IOM document

Hospitals have a "duty to plan" and the framework for planning and plan development is exceptionally easy to follow. Step-by-step guidance is given in terms that are easy to understand with a process that has a natural flow and will be a nice addition to your 96-hour planning. Based on my experience, this process with integrate well into existing planning workflow. Following the IOM planning template may also help you avoid my 7 Surefire Tips for Emergency Plan Failure. I also recommend a review of the 6 items that good plans have that bad ones don't.

Training

Recommendations are made for the inclusion of tabletop exercises (TTX) as a means to testing plans created under this framework. TTXs are my favorite training exercise; they are fantastic activities that can be accomplished with a reasonable amount of preparation and very little funding. Follow these links for more on  tabletop exercises and exercise design. See also my five tips that will enhance your exercise design program.

Review
The IOM Crisis Standards of Care -

• includes template guides for palnning
• includes EMS, public health as major players 
• accounts for mental health, palliative care and at-risk populations
• call for tabletop exercises

Includes recomendations for -

• establishing trigger points for switching between conventional, contingency, and crisis care
• modifications for protocols/authorized use of CSC in planning
• guidance for liability protection and reimbursement

Recommended areas of focus -

• Volume 3: EMS
• Volume 4: Hosptial
• Volume 5: Alternate Care

Chemical Suicide Sickens Paramedics

Latest Chemical Suicide Attempt Prompts HazMat Response
Coposted on Mitigation Journal

Consumer Level Hazardous Materials (CLHS) continue to prove their devastating potential. Chemical suicides and chemically contaminated persons may cause evacuation and closure of your emergency department. Unfortunately, these situations and their potential continue to go largely ignored.

FOX News is reporting on a situation in Florida involving a person who attempted to take his life by drinking a chemical pesticide. The man later vomited, releasing the chemical and causing paramedics to become ill and the emergency department to be closed for hours.

What would happen in your health care system if just one emergency department was closed from chemical contamination? 

Suicide by blood agent, often called chemical or detergent suicide, has been growing in popularity for years. These situations continue to be a threat and have evolved with the use of various chemical products. Hydrogen Sulfide is one of the main chemicals of concern as are cyanide and phosgene.  These events are often carried out by mixing the requisite chemicals in a vehicle parked in a public place. Follow these links for more on chemical suicide in cars and chemical suicide in general. Cyanide was used in a Kansas suicide in 2010.

 

The chemical used in the Florida event was the pesticide Malathion, an organophosphate/cholinesterase inhibitor that can cause a toxidrome similar to that of chemical nerve agents.  Organophosphate nerve agent exposure can result in a variety of symptoms including the "Killer B's" of bradycardia, bronchospasm, and bronchorrhea. Nerve agents in this class block the effects of acetycholinesterase (AChE) and result in hyper-stimulation of effected body systems. 

In contrast, blood agents (Hydrogen cyanide, cyanogen chloride, and hydrogen sulphide) interfere with cellular respiration and result in hypoxia. They are highly toxic materials and result in rapid death. Chlorine and phosgene are known as choking agents and stress the respiratory system and cause edema in the lungs. 

You don't have to wait for a terrorist attack to think about these chemicals. 

I discuss all of these materials in Maintaining a Culture of Preparedness - a talk designed to draw parallels between terrorist attacks and everyday Consumer Level Hazardous Materials events. 

I encourage everyone to:

1. Review their agency policy on decontamination and chemical protection  and inventory
2. Review your hospital emergency evacuation plan - is it realistic? 
3. Review your plans for mass fatalities and management of chemical casualties
4. Have your plans reviewed by an independent evaluator and test your plans with preparedness  exercises. If you'd like help with plan review and exercise design, contact me 

Follow this link for a summary of Mitigation Journal podcasts about chemical suicide.
Special thanks to Mike for sending the original article