A female wild land firefighter was involved in fighting the STATION wild fire in California on September 1, 2009. During the cleanup phase of the fire she was over an area of a hidden defunct mining operation. While extinguishing the residual flames of a tree trunk, the roots collapsed into a hole and a strange blue flame emanated. She backed away and retreated from the site. Minutes later she suffered symptoms of tremors, nausea, and dyspnea. She had what was described as a respiratory arrest and was resuscitated. She was taken to a local emergency department where she was hospitalized for two weeks. A Sherriff’s hazardous materials team investigated the incident three days after exposure that documented an airborne cyanide concentration of 45 ppm near the area in which she was working. An airborne level of 50 ppm of cyanide is immediately dangerous to life and health. I evaluated her on October 19, 2009 in my Toxic Exposures Clinic. I performed an MRI and MRS of her brain as well as a neurological workup. At that time she was confined to a wheelchair because of difficulty walking and neurocognitive deficits (abnormal thinking). I reviewed her brain MRI/MRS with a neuroradiologist. She had non-specific encephalomalacia (brain swelling) within the parietal and occipital lobes, she also had an abnormal choline peak on MRS. The medical literature reports cases of elevated choline with encephalomalacia (brain swelling) involving carbon monoxide and cyanide exposure. She has been in physical therapy with some improvement, however cognitive (the process of thought) skills are worsening. My diagnosis is exposure to cyanide which caused brain injury.

There are no known pre-existing conditions that are related to this injury. The conditions I have described were reached after careful examination and standard testing, and are not mentally imagined or induced by the patient. Wild land firefighters face a number of hazards in the course of their duties. The affects of cyanide inhalation are just beginning to be understood at the wild land level. Suspected cyanide exposure can more effectively be dealt with if proper diagnosis and treatment is given in a timely manner. Proper treatment is available, especially at Level 1 trauma centers. Regional poison control centers can provide medical toxicology consultation and antidote recommendations for the patient. Proper treatment for suspected cyanide inhalation needs to become standard protocol for wild land firefighters.

By John B. Sullivan, Jr., M.D. February 16, 2010