J R Soc Med 2005;98:141-145
doi:10.1258/jrsm.98.4.141
© 2005 Royal Society of Medicine
Management of chemically contaminated bodies
Adrienne Edkins MSc
Virginia Murray FFOM FRCPath
Chemical Hazards and Poisons Division (London), Health Protection Agency,
Guy's and St Thomas' Hospital NHS Trust, Avonley Road, London SE14 5ER,
UK
Correspondence to: Professor Virginia Murray E-mail:
Virginia.Murray{at}gstt.nhs.uk
 |
INTRODUCTION
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In the world today over 23 million chemical compounds are known
to
man.
1 Of these
chemicals, about 70 000 are in regular use
and some 500 new ones are
introduced every month into the
market.
2 The
extensive use of chemicals in industrial processes and their
storage, disposal
and transport present hazards of chemical
accidents (incidents) with the
potential to harm humans and
the environment. The mass disaster at
Bhopal,
3 the sarin
subway
attacks in
Tokyo
4 and the Lake
Nyos incident
5 have
increased
public awareness of the dangers of large acute chemical incidents
in
modern society.
The majority of chemical incidents can do harm if incorrectly managed. The
role of public health agencies, emergency response agencies, health providers
and related organizations is to prevent, anticipate and respond to chemical
incidents so as to reduce the impact on man and his
environment.6 All
these agencies have a duty to ensure the health and safety of their personnel
in such incidents.7
There are well-defined procedures in place for the management of chemical
incidents, including advice on incident scene management, decontamination of
casualties and use of personal protective equipment for emergency
responders.6,8–10
These guidelines are designed to contain the hazards of a chemical incident
and minimize the environmental and human impact. However, in certain cases,
chemical incidents have resulted in a spread of contamination from the scene
to other
locations.11,12
This contamination arising from activities subsequent to the actual chemical
incident is known as secondary contamination. A hospital emergency room may be
contaminated by chemicals from a patient who has primary contamination with
material from the scene of the incident. Secondary contamination can occur
from a patient even after death and may pose a serious health risk to persons
in contact with the body.
Recent incidents of secondary chemical contamination from human fatalities
have revealed a need for a plan to manage chemically contaminated bodies
effectively. Incidents involving chemically contaminated victims have resulted
in confusion and adverse health effects in
responders.13–15
The absence of guidance on the efficient management of chemically contaminated
victims has increased the negative impact of these incidents. This paper aims
to promote awareness of the potential impact of secondary contamination from
chemically contaminated victims and offers preliminary guidance to those
involved.
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CASE EXAMPLES OF SECONDARY CONTAMINATION INCIDENTS
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The following accounts describe the main events surrounding
incidents in
which a chemically contaminated body was encountered
and serve to highlight
the risks and difficulties associated
with safe management.
Incident 1: suicide by ingestion of aluminium phosphide in Australia13
The patient was found collapsed at the roadside after ingestion of
aluminium phosphide—a rodenticide that produces a toxic gas, phosphine,
on contact with moisture. He was transferred to the accident and emergency
department (A&E) of the local hospital by ambulance, where he died.
The A&E staff noticed a 'garlic like' smell and suffered
headaches and nausea. Once they realized the body was emitting phosphine they
placed it in a gas-tight chemical-resistant body bag. The bag began to inflate
from continuing production of gas from the body. The body was therefore
enclosed in a second body bag and a hazardous materials drum and buried with
the aid of earth-moving equipment.
Incident 2: suicide by exposure to aluminium phosphide in the UK14
The patient was found alive by emergency personnel in the cellar of his
home. He had been exposed to a lethal dose of solid aluminium phosphide. The
patient, together with an open metal canister bearing a toxic hazard warning,
was transferred to A&E where he died. The attending staff noticed a smell
of garlic and experienced symptoms including nausea, headaches and dizziness.
However, the assumption was that one of the team had had garlic for lunch.
None of the A&E team immediately commented on the smell. It was only when
a neighbouring emergency treatment area became contaminated with the smell
that staff realized the body was releasing phosphine. The air conditioning was
stopped and the department was evacuated and decontaminated. Access to the
department was blocked for 15 hours, during which time seven patients were
diverted to other hospitals. In addition the ambulance used to transport the
patient required decontamination and was out of use for 11 hours. The body was
moved to a well-ventilated area where it was placed in two normal
polyvinylchloride body bags inside a plastic lined coffin by fire personnel
wearing personal protective equipment and cremated. The management of the
whole incident took four days.
Incident 3: industrial accident involving trichloroethylene16
A factory worker collapsed while cleaning an 'empty' tank that
had contained the industrial solvent trichloroethylene. The patient was
transferred to the local A&E department by ambulance. Biological samples
were taken for toxicological analysis and he was decontaminated. The patient
was transferred to the intensive care unit and died three days later. In total
9 people involved in the incident, at the site, in transit and at the
hospital, were contaminated as was shown by positive toxicological results for
trichloroethylene.
Incident 4: industrial accident involving chlorinated hydrocarbons (the Crymlyn Burrows incident)17,18
Two local authority workers collapsed during routine work in a sewer in
Crymlyn Burrows. The men were found dead, submerged in a sludge that was later
found to contain fluorinated hydrocarbon compounds. The bodies were
transferred to A&E without previous decontamination. Despite a strong
chemical smell associated with the bodies, emergency responders, who were not
wearing personal protective equipment, did not initially suspect a chemical
incident. Adverse health effects, such as burning throat and headache, were
experienced by hospital staff. The bodies were moved to a mortuary with a
dedicated air supply. Fire personnel decontaminated the bodies and the
mortuary. Pathologists wearing personal protective equipment performed
postmortem examination of the bodies in stages over a series of days. The
suits had to be ordered and delivered since none were available on site.
Twenty days after the incident started, the two bodies were placed in coffins
for burial and the storage fridges were decontaminated. In the days after the
incident, about 300 people attended A&E with symptoms resulting from
contact with the incident scene or the victims' bodies. Included among these
patients were emergency responders, police and fire personnel. The A&E set
up a clinic to respond to these casualties. Routine medical emergency
admissions to the A&E department, with the exception of
emergency19 calls,
were diverted to nearby hospitals. The clinic was run for eight days. In
total, the management of the bodies and casualties from the incident took
twenty days and was a multi-agency process.
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LESSONS AND ISSUES HIGHLIGHTED BY THESE INCIDENTS
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These incidents highlight several issues associated with the
management of
chemically contaminated bodies. An incident need
not produce mass chemical
fatalities to have an adverse impact
on human health and resources: chemical
contamination of even
a single victim can lead to serious contamination
consequences.
14
These
will be much greater in the event of a mass fatality chemical
incident,
particularly if the chemical is persistent and highly
toxic. Events such as
the closure of A&E departments and
mortuaries may have serious knock-on
effects on other facilities,
and health professionals and emergency responders
may find themselves
having to work for extended periods under difficult
conditions.
Chemical incidents do not have to involve exotic substances or chemical
warfare agents to pose a threat of secondary contamination. The chemicals in
the incidents reviewed here were common and accessible to the public. If the
nature of the incident is not initially recognized, the personnel in
attendance are at serious risk—health professionals, emergency
responders as well as other people on the scene. The Health and Safety at Work
Act (1983) states that the employer has a legal duty to ensure the safety of
employees at work. Health professionals and emergency responders, therefore,
have the right to be protected from the hazards associated with a chemically
contaminated body. The fact that the toxic effects of many chemicals have not
been fully characterized makes a realistic risk assessment for every situation
difficult (Box 1).
The poor management of certain aspects of the above cases was due to a lack
of defined roles and responsibilities during incident management. Personnel
accepted tasks that were neither their responsibility nor defined by their
'job description'. Absence of advance guidance and lack of
preparedness is a recipe for confusion. For example, if staff do not know
where to get chemical-resistant body bags this will increase the time taken to
manage an incident and may place added economic burdens on those who run local
services in the area.
A defined and practised plan for dealing with these situations would ensure
more efficient management. Staff would be less anxious about the potential
hazards if the plans had been rehearsed and all personnel were informed of the
emergency procedure.
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EXISTING PUBLICATIONS AND LEGISLATION
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Reports and guidelines issued by agencies identified by the
Chemical
Hazards and Poisons Division (London) as responsible
for emergency response
and public health protection were reviewed
for details relating to the
management of chemically contaminated
victims. Verbal interviews were
conducted with key personnel
from the Home Office Chemical, Biological,
Radiological and
Nuclear (CBRN) Team, members of the London ambulance
services,
members of emergency response groups, coroners, burial and cremation
authorities
and other relevant agencies. The review indicated a lack of
policy
and guidance on the management of incidents that include
dealing with
chemically contaminated victims/bodies.
Although there is no defined guidance or policy for incidents involving
chemically contaminated bodies, detailed guidelines dealing with the
management of CBRN incidents do
exist.6,9
The reports that mention the issue of chemically contaminated bodies are
largely case histories and do not provide consolidated guidance on how best to
cope.14,17,20
Guidelines and legislation to regulate the disposal of human bodies do not
consider the potential risks associated with chemical contamination of a body,
although there are some reports on the risks associated with contamination by
infectious
agents.10,21
Additionally, there is no definition of which agency or authority would be
responsible for management of the chemically contaminated body, although
currently the responsibility for the management of human bodies is that of the
coroner in charge as defined by the Coroners Act 1988. The lack of guidance
for the management of these situations results in lack of preparedness and
communication problems.
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DEFINING THE PROCESS
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A proposal has been developed to minimize the risk of secondary
contamination
from the chemically contaminated victim. This can be considered
as
a series of steps leading to safe and respectful disposal of
the body
(
Figure 1). Each stage of the
process will have its
associated risks and will require efficient management
to minimize
the potential for harm to those managing the incident. The general
advice
given is not tuned to the management of specific incidents involving
chemically
contaminated bodies and may not be feasible in certain cases.
The
guidelines (
Figure 1) highlight
what are thought to be the
major factors that need to be considered, to act as
a base from
which individual organizations can define a contingency plan
that
suits their individual needs.
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CONCLUSION
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Although chemical incidents associated with chemically contaminated
bodies
are fortunately rare, these events can have serious implications
for health
and management. A proposal has been developed for
management of a chemically
contaminated body. The general advice
arising from this may be useful to
organizations in defining
a tailor-made, individual contingency plan to suit
the needs
and roles of their agency. The coroner remains at the heart
of the
process, with medical toxicology available 24 hours a
day to provide advice
and support.
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Acknowledgments
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Adrienne Edkins, a Beit Fellow for Zimbabwe 2002/2003, was supported
by the
Beit Trust.
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INTRODUCTION
CASE EXAMPLES OF SECONDARY...
