Possible Exposure to Meth

[medicgirl05]

I am looking for information as I've never had a call like this before. I know that some of you who work for more urban systems have encountered similar situations so I'm looking for your advice.

Call came in for 2 patients with "possible meth contamination". The location was approximately 15 miles out of town.

Upon arrival SO is already on scene. We find our patients walking around. No obvious distress. We have them all get in the truck and assess. 2 refuse transport, which leaves me with one patient.

He states that the men were working and his boss sent him to an RV on the back of the property for some tools and when he opened the door he smelled ammonia, so he shut the door and went and told his boss. At this time the three men returned to the RV to figure out what the smell was , they opened the door and the one went in before deciding it might not be safe, and they called 911. At the time of our arrival SO had no idea if it was a meth lab or not. So we took the men at their word.

So....we load the patient up.

Vitals-BP180/80, P-140, R-24, O2-99% RA. Patient is complaining of Nausea, dizziness, feeling weird, and a racing heart. Transport time is 25 minutes. What treatment would you provide?

Thanks for your input.

[Just Plain Ruff]

ok,

let me ask you this

If these men were possible exposed to a hazardous materials situation which is what a meth lab is, did you decontaminate them or did you just let them in your ambulance?

Did you know it was a meth lab prior to putting them in your ambulance?

This I think is the first question that needs to be addressed if we are going to truly critique this call for you!!!

[uglyEMT]

Great question Ruff (as always).

medic if this is as you say it was, was a hazmat team called in? decon done?

you say you took them at their word. what was their word? just ammonia and not a meth lab or it was a meth lab?

even if it was just exposure to ammonia it is again a hazmat scene and all hazmat protocols should be follwed.

Ok I will assume this was done. All proper protocols and procedures followed. We now have a deconed patient in our rig.

Ammonia interacts immediately upon contact with available moisture in the skin, eyes, oral cavity, respiratory tract, and particularly mucous surfaces to form the very caustic ammonium hydroxide. Ammonium hydroxide causes the necrosis of tissues through disruption of cell membrane lipids (saponification) leading to cellular destruction. As cell proteins break down, water is extracted, resulting in an inflammatory response that causes further damage. Immediate decontamination of skin and eyes with copious amounts of water is very important. Treatment consists of supportive measures and can include administration of humidified oxygen, bronchodilators and airway management. Ingested ammonia is diluted with milk or water. Do not indice emisis.

If it really is meth again treat the symptoms. I would contact local area poision control plus med control to advise of the situation and ask for further guidance. (most of the care here is at the ALS level with IV meds and ECGs so above my SOP thus the reason for the short answer)

Edited January 6, 2011 by UGLyEMT

[medicgirl05]

ok,

let me ask you this

If these men were possible exposed to a hazardous materials situation which is what a meth lab is, did you decontaminate them or did you just let them in your ambulance?

Did you know it was a meth lab prior to putting them in your ambulance?

This I think is the first question that needs to be addressed if we are going to truly critique this call for you!!!

When we arrived on scene DEA and SO was already on scene. We were advised that decon was not necessary. Also when we arrived at the ER the staff was not concerned with decontamination. That's part of my question. I'm unaware of how to handle such a situation. At the moment when I was told by SO and DEA that decon was not necessary I figured they had more experience with such matters than I did. Maybe that was a mistake but since the ER staff was not concerned I figured I had done the right thing....???

[rat115]

Medicgirl, do you live in a rural area? If you do, one of the most important things for you to know is the treatment for those who've been exposed to Anhydrous ammonia. This is a commonly used fertilizer in rural areas which is often stolen and used for meth labs. The extent of use of anhydrous is one of the reasons that meth labs hide so very well in rural areas.

I speak as an EMT-B in a rural area. My husband works for the local Coop. I've seen times during periods where the farmers are fertilizing a lot of fields where just this one location (out of about 6 in the county) has gone through so much anhydrous ammonia that they had 2-3 semi tankers coming in with deliveries in a day and still couldn't keep up with the demand on what they need to send out. They also have to check over every tank that comes in to make sure it's not been compromised. They alert law enforcement (LEO) if there is damage that is indicative of someone trying to drill through the tanks or tamper with the valves so that LEO can start looking for active meth labs in the area.

Ugly did a very good job listing off the basic treatment for anhydrous ammonia exposure. Water, water, water!!! Get the patient out of the contaminated clothes OUTSIDE of your ambo and have Fire spray the person down. You do not want to have to wash out the ambo after the call. (I've seen a crew have to wash Roundup out of a rig and it took about 3 hours to totally decontaminate it and them. We ended up with our primary rig and crew out of service for 1/4 of their call time that day.) This is basic decontamination. Wash the eyes and skin. If you're not ALS and do not have ALS that can get to the scene, support and monitor respiratory and head to the ER quickly (not necessarily emergent) and let the ED know what to expect.

If you even think that a pt has been exposed to a meth lab, you'd do best to demand hazmat on scene and decontamination before you let the patient near your ambulance. You also don't want to go anywhere near the scene yourself unless you're in a "glow worm" suit. Remember, scene safety is number 1 because you can't provide care if you become a patient too.

Edited January 6, 2011 by rat115

[uglyEMT]

When we arrived on scene DEA and SO was already on scene. We were advised that decon was not necessary. Also when we arrived at the ER the staff was not concerned with decontamination. That's part of my question.

Here its a judgement call. If you feel the scene needs more then by all means get it done. Just because they are DEA or SO or LEO does not mean they know what is medically necessary. If you are unsure call med control and your supervisor. You should by no means feel wierd or what-have-you by making this request. Scene safety is of utmost importance and is taught from day one.

I'm unaware of how to handle such a situation. At the moment when I was told by SO and DEA that decon was not necessary I figured they had more experience with such matters than I did. Maybe that was a mistake but since the ER staff was not concerned I figured I had done the right thing....???

ANY, ANY, ANY time you feel unaware or unsure contact medical control. Advise them of patient status and any pertanant findings. Ask the questions, thats what they are there for. ER staff may have been unaware decon was not performed, remeber the old addage all assuming does is make an ass out of you and me.

Now back to what was stated by the patient. He smelt ammonia and now has symptoms of ammonia (or other chemical) exposure. Right there the red flags should have gone up. Yes ammonia is a simple decon- remove close and lots of water. But say it was another chemical or substance, you could possibly put you, your crew and rig down for quite a while.

If I show up to a scene, even if expsoure isn't stated, and ask questions and it begins to sound like some sort of exposure I go immediatly to worst case protocols and contact med control. If CO then fire is called and house inspected. Hazardous material my protocol says notify poision control, FD, and PD response team. They usually will send out FD in SCBA with a hand held tester and check air quality and possibly the clothing, if its safe then the amount of response is limited.

When it doubt medical control it out!

hers a real world example:

Called to a residence for a patient with altered mental state. PD arrived before us. We go in and a friend found his buddy acting lithargic and not talking right. PD was there a few minutes before us and the buddy even longer. Just as we get in the residence my little CO meter starts chirping (one of those few dollar home depot kind, not FD or anything) I tell my crew to grab the patients, yes now I feel we have 4, and exit to the rig. Call FD and they come and do a sweep and low an behold the guys pilot light went out and the home was full of CO. Now here PD was figuring drunk or drugs (there words not mine) even the buddy thought so. If it wasnt for my little alarm who knows what would have happened. Moral of the story, just because PD is there doesn't mean they know whats going on.

edited to add real world story no other changes made

Edited January 6, 2011 by UGLyEMT

[mobey]

When we arrived on scene DEA and SO was already on scene. We were advised that decon was not necessary. Also when we arrived at the ER the staff was not concerned with decontamination. That's part of my question. I'm unaware of how to handle such a situation. At the moment when I was told by SO and DEA that decon was not necessary I figured they had more experience with such matters than I did. Maybe that was a mistake but since the ER staff was not concerned I figured I had done the right thing....???

Sorry: What is SO & DEA?

What are thier HazMat qualifications?

[HERBIE1]

Good advice so far. To clarify, the concern would be about exposure to the CHEMICALS used to manufacture the meth, not the drug itself. If the person ingested the drug, that's a different story.

Many questions-

If the person went into an enclosed area with those chemicals present in the air, then it could be an exposure. Look at the patient. Use your senses. I would be VERY cautious about such calls. Ask questions. I would not simply take their word that the scene is safe unless I knew they were trained responders. WHY was it that the LEO folks were not concerned about a Haz Mat situation? Are they trained in proper detection and handing of such things?

Example: About a year ago, there was an ammonia leak in a local factory. Haz Mat crews on scene working on controlling the leak, and FSR finds one victim who self evacuated from the area. As is the case in many of these situations, there are TONS of people on scene- lots of chiefs and folks in positions of authority, and everyone talking at once on the radios.

At some point, EMS is notified via radio that an exposure victim has been found and is being brought to crew in the cold zone. Their first question- has the victim been decontaminated. Yes, they are told. The crew suddenly finds the victim thrown into their rig, reeking of ammonia, and in some respiratory distress. The crew does a quick decon on the patient, but the smell is still overpowering. They treat and transport, notifying the ER that they need a decon station set up when they arrive. Bottom line- one of the crew spent some time in the ER with respiratory distress but nothing permanent. The chief who claimed the person was deconned ended up getting disciplined for endangering the crew. Apparently there was a communication problem- the person in charge of decon claimed he did not see the patient, nor did he even know there was a victim. The fire crew that found the patient notified their superior officer, who mistakenly thought the firemen had put the victim through decon. Nobody notified the incident commander. In other words, a total breakdown in communications and protocol.

Moral of the story- do not assume what you are told is correct- especially if you have reason to question the source of the information.

[Chief1C]

Rural Assumptions: SO - Sheriff's Office?; DEA - Drug Enforcement Administration?

Are there any skin burns? (AA)

Since I live near METH Valley, USA.. We've trained extensively in this. Whatever they have on them, you don't want on you. If it's just exposure to anhydrous ammonia, that's one thing. But if contents of the lab have made contact with him.. You need an actual Haz-Mat trained crew to be notified. But the NFPA required Haz-Mat Ops course that, likely, most firefighters have, is good enough for now. Oxygen and ALS. First, consider your cuff and possibly stretcher straps a write off and bill him for it.. Second, yanno those PPE kits that they make ambulances carry? Use them. Third, take the patient out of the ambulance, strip him to his birthday suit; have the firemen wash him off with a lot of water. Like 200gal, not per minute, ha ha, but in like a gentle fog pattern. Then put a tarp on the stretcher w/ blankets. Lay patient on blanket, and wrap the whole mess around him. Probably going to want to take the victim to a something a little bigger than the common fork in the road band aid station.

[medicgirl05]

Ok. Next time medical control will be contacted.

Things that I didn't post- The patient denies skin contact of anything in the RV. So we are only dealing with inhalation. (not saying decon wasn't necessary, just clarifying)

The ER staff was aware that decon had not been performed. After we were assigned to a Trauma bay there was some discussion about moving him to a private room so an exhaust fan could be used. They didn't move hime though...

So...I'm wondering what treatment would be provided after decon. EKG shows sinus tach at 140. IV established and infiltrated. I stuck the patient 2 more times and didn't ever get a succesful line. He was a previous IV drug user so his veins were shot. No airway burns. 25 minute transport time.

GO!

Thanks all for the input. I did CE on this last night after the incident and didn't get much out of it......