                     FAQ on 'the Toxic Lady'.

By Camilla Cracchiolo RN

copyrighted 1995, may be freely reproduced for non-profit purposes.

I.  Who Was The Toxic Lady?

The 'toxic lady' (as the Internet has perhaps unfairly dubbed her) 
was a 31 year old woman in Riverside, California named Gloria Ramirez.
Her body may or may not have emitted toxic fumes which made several
doctors and nurses in the emergency room of Riverside General Hospital
very ill. She was the mother of two children and had been diagnosed with
metastatic cervical cancer 6 weeks before the famous event leading
to her name.  

II.  What happened?

On the evening of Feb. 19, 1994, Ms. Ramirez was brought by paramedics to
the emergency room at Riverside General Hospital.  She was admitted in 
respiratory and cardiac distress, and went into full cardiac arrest about 15 
minutes after arrival.  A nurse named Susan Kane drew blood, probably 
for an arterial blood gas determination, as part of the routine 'code 
blue' procedure of the hospital.  Nurse Kane noted a 'foul odor' and 
immediately passed out cold.  A doctor (Julie Gorchynski, the senior 
medical resident) went to Nurse Kane's aid.  After seeing to her 
needs (probably by making sure she did not get a head injury from 
falling), Dr. Gorchynski noted a strange odor, 'took a deep whiff' of
the syringe and passed out.  4 other staff then passed out, all standing 
right next to each other.  The paramedics who rode in the ambulance to 
the hospital with Ms Ramirez and who remained in the room, as well as one 
nurse and Dr. Humberto Ochoa, the director of the ER (who came as soon as 
he heard staff were keeling over in the middle of a code) all were 
unaffected.

Since other cases have occured where ER staff became ill from fumes
emitted by a patient (usually from people who have ingested pesticides, 
although this can also be a risk to staff working in hyperbaric oxygen 
chambers with people with carbon monoxide poisioning) the hospital 
assumed that this was a case of toxic contamination, sealed the ER and 
evacuated all patients and affected staff (who by now numbered somewhere 
between 8 and 11, including clerks) and brought in the County 
decontamination unit.

III.  What happened to Gloria Ramirez during all this?

Ms. Ramirez died in the ER, after the staff tried to rescusitate her for
about 35 -45 minutes.  The official cause of death was kidney 
failure due to metasticized cancer.  Her body was placed in a sealed
body bag and sent to the county coroner for autopsy in a special
sealed unit.

IV.  Why is this case so unusual?

Because despite the apparently genuine and severe illnesses of the ER
staff, no satisfactory toxin that could have caused their illnesses has
been found.  This has led to speculation as to whether mass hysteria
could have caused the symptoms experienced by the ER staff.  Opinions
are still divided as to the cause of the incident.

V.  Well, if a toxin from Gloria Ramirez didn't cause these
problems, what else could have?

The main alternative explanation is that there was some toxin in the
ER and that possibly the hospital covered this up.  The hospital has
been cited before for improper waste disposal down drains.  However,
they were inspected by nine different city, state and federal agencies
after this incident.  While cited for some violations in other
parts of the hospital, no violations were found that affected the
ER.

The 'it's the hospital's fault' scenario is favored by Gloria Ramirez's
family, who have filed a lawsuit against Riverside General saying that
the fumes came from the hospital and also caused Ms. Ramirez's death.

The hospital, I'm afraid, did not handle matters well with the
Ramirez family.  First, the hospital suggested that Ms. Ramirez
tried to kill herself by ingesting pesticides. This was not an
unreasonable initial theory given the situation (which looked very
much like pesticide poisoning.)  However, it was ill thought out to
say this before preliminary lab results were back, since the Ramirez
family, like most people of Mexican descent in the area, are devout
Catholics.  To allege suicide is to allege a very serious sin to
these folks.

To top this off, the County then hung on to Ms. Ramirez's body for
several months and at one point improperly stored it, resulting in
gross decomposition.  The Ramirez family had to sue to get the body
back for burial, but by then it was unfit for showing.   They had
wanted an open casket ceremony so her children could see her face
and properly say goodbye.  I'd be mad too, if I were them.


VI.  What are the official conclusions ?

There has never been a satisfactory resolution to the case.  While
eventually 32 people reported what seem clearly to be hysteric symptoms, 
the people originally felled have lab and physical findings that
seem to exclude hysteria. (Hysteria can only be diagnosed in the
absence of observable lab or physical abnormalities)

The official opinion of Cal-OSHA is that, while some of the staff
may have been affected by hysteria, at least three people had a genuine
reaction to some kind of toxin or agent.

The State Dept. of Health Services report said that most people (eventually
over 30) who reported feeling ill were suffering from mass hysteria, but
that the original six staff who were felled may have been affected by
either hysteria or a toxic agent.

The Riverside Dept. of Health says that they now believe that
Dr. Gorchynski, Ms. Welch and Ms. Balderas are not suffering from 
hysteria.

Lawrence Livermore Lab released a preliminary report suggesting that
dimethyl sulfate, metabolized from hypothesized consumption of DMSO, was
the cause of their symptoms  However, according to chemists here on the
Internet, it's highly improbable that dimethyl sulfate could cause this.
The final report was awaiting peer review and to my knowledge has not
been released.

VII.  What is the status of the case now?

The family's lawsuit has not come to court yet.

Julie Gorchynski filed a lawsuit against Riverside County saying
that they withheld key information she needed in doing her own
investigation of the case.  She is asking for six million dollars.
This may get settled out of court since Riverside Co. has stated
that they now believe Dr. Gorchynski's illness to be organic.

The Lawrence Livermore final report has not yet been released.

More Details:

VIII.  Who were the affected staff and what happened to them?

The affected staff were:

Susan Kane, the nurse who initially drew the blood and who fainted
first.

Dr. Julie Gorchynski, the senior medical resident in the ER and who
fainted seconds after sniffing the syringe used to draw Ms. Ramirez's
blood, and who was also the most seriously ill of all the staff.

Dr. Mark Thomas, the attending physician in the ER, and who was
affected third (unclear if he actually fainted, but had dizziness
and muscle spasms).

Maureen Welch, a respiratory therapist who was using a special
device (called an ambu bag) to deliver breaths to Ms. Ramirez and
who was affected fourth (fainted).

Bettina Berry, a nurse in the ER (I don't know when she felt ill,
and I'm not sure if she fainted or not).

Sally Balderas, the nurse who moved the affected staff and Ms.
Ramirez's body into a holding area, who was one of the last people
to report feeling ill, but also the second most severely affected
staff person.

Debbie Carrier, a medical clerk in the ER.

A recent Los Angeles Times article stated that the official tally of
affected staff is 32, but no information is available on the others.

Most affected staff suffered no permanent effects.  However, Dr.
Gorchynski, Maureen Welch and Sally Balderas continue disabled although
partially recovered.  Their symptoms included immediate change in heart
rhythm, followed by 'spasms'.  Two days after the incident, Dr. Gorchynski
had to be placed on a ventilator because these strange muscle spasms were
interfering with her ability to breathe to the point where her arterial
oxygen levels were 'markedly reduced'.  She also had elevated liver and
pancreatic enzymes and subsequent to all this developed a rare necrotising
bone disorder due to the cutoff of circulation to the bone.
                  
Dr. Gorchynski's case is particularly interesting.  She is a very
amazing lady.  Some people have suggested that the affected staff
must have had some kind of pre-existing medical condition, but all
evidence is to the contrary for Gorchynski.  According to the
spokesman for Loma Linda University Medical Center (where Dr.
Gorchynski wound up after evacuation), she is either a national or
world surfing champion, holding the #2 title in the women's
division.  She was, according to all accounts, in glowing health
prior to this.  Certainly hospital residents must be in good health
or they cannot withstand the grueling, often 100+ hour weeks
demanded of them during residency.  She had a masters in
microbiology and had been published prior to attending medical
school.  She graduated at the top of her class and according to the
most recent newspaper article I've seen on her, was preparing
from her bed at home (she was in a wheelchair at the time) to fly
to London to accept some kind of award for a paper she had written.


IX.  C'mon!  Give us ALL the details!  We're information junkies!

    
Ok, here is the official chronology from Riverside General Hospital:
(All capitalizations and spellings are in the original)


           Summary of Events on February 19 and 20, 1994
       Riverside General Hospital - University Medical Center
                       Riverside, California

                  Regarding Patient:  Gloria Ramirez

7:46 p.m.:      Ambulance and Riverside Fire Department dispatched
                to home of 31-year old Gloria Ramirez; difficulty
                breathing.

7:50 p.m.:      Fire Personnel on scene

8:07 p.m.:      Radio call received at Hospital from Ambulance.
                Pre-hospital personnel reported patient to be in
                severe cardiac distress.  Patient was placed on
                monitor, administered oxygen and an IV was started.

8:14 p.m.:      Patient arrived at Hospital semi-conscious in a
                life-threatening condition (placed in resuscitation
                room) with rapid heart beat.

During the 36 minutes (8:14 p.m. - 8:50 p.m.) the following events
took place:

*       Medical Team began care immediately.  Dr. Mark Thomas,
        Attending Physician, leading resuscitation - Dr. Julie
        Gorchynski, Senior Resident, Emergency Department, assisted
        with Nurses and Respiratory Therapy also at bedside.

*       A full code 'resuscitation' was in progress.  Emergency
        procedures: defibrillation, administered IV fluids and blood was
        drawn.

*       As Susan Kane, the Nurse, drew the blood, she noted an
        ammonia-like smell.  Several other health care workers noted the
        same odor.

*       With seconds, Susan Kane fainted.  She was placed on a
        guerney.

*       Dr. Julie Gorchynski assumed Kane's role in caring the the
        patient and subsequently passed out.  Another physician attended
        to the fallen staff.

*       Dr. Mark Thomas continued care of the patient.

*       Susan Kane and Dr. Julie Gorchynski were moved into the
        holding area.

*       Susan Kane's condition worsened.  She experienced difficulty
        breathing.

*       Evacuation of the Emergency Room was ordered by Dr. Humberto
        Ochoa, Chairman of the Emergency Medicine Department.

*       Maureen Welch, the Respiratory Therapist, while ventilating
        the patient, became ill.

*       Dr. Mark Thomas, the attending physician then became ill.

*       Medical Care of Gloria Ramirez continued uninterrupted by Dr.
        Ochoa who was assisted by a Respiratory Therapist, Resident
        Physician, a Paramedic and two Nurses.

*       Gloria Ramirez was intubated, adminstered addtional
        emergency medications and defibrillated multiple times.

8:41 p.m.:      911 was called by Hospital.
                Fire Department Dispatched.

8:47 p.m.:      Fire Department arrived.

*       Nurse Bettina Berry, who was caring for Gloria Ramirez,
        became ill.

*       Gloria Ramirez failed to respond to resuscitation measures
        and at 8:50 p.m., Dr. Ochoa pronounced the patient dead.

8:52 p.m.:      City of Riverside HAZ MAT notified by the Fire
                Department

9:10 p.m.:      City of Riverside HAZ MAT arrived on scene.

9:15 p.m.:      Hospital Administrator On-Call and Hospital Safety
                Officer arrived on scene.

9:29 p.m.:      City of Riverside Environmental Health Resource Team
                notified.

*       Evacuation of all patients and staff from the Emrgency Room
        was completed.  Kaiser Hospital, Riverside, was notified
        that RGH was on Emergency Diversion - redirecting all
        ambulance services to other community hospitals.  Kaiser
        communicated this information to other base stations.

9:30 p.m.:      Hospital Administrator arrived.

9:30 p.m.:      Coroner notified and arrived shortly after.

9:30 p.m.:      The Fire Department cordoned off the area outside
                the Emergency Room.

*       Emergency Room patients were transferred, admitted, treated
        and discharged.

        No patients demonstrated any signs of exposure.

        In the parking lot, Sally Balderas, RN, exhibited symptoms.

        Six staff were transferred to local hospitals.

11:00 p.m.:     HAZ MAT entered the Emergency Room and performed
                air-test sampling for common hazardous gases.
                Results proved negative.  (No contaminants
                detected).

APPROXIMATELY MIDNIGHT:

*       Planning Meeting was held with: HAZ MAT, Environmental
        Health, Hospital Administration and Coroner to determine
        course of decontamination.

APPROXIMATELY 12:30 A.M.:

*       Decontamination of Remaining staff took place.

2/20/94

2:15 a.m.:      HAZ MAT, after consultation with the Coroner,
                reentered the Emergency Room, placed Gloria Ramirez
                in a double-sealed bag, which was placed in an
                airtight container and moved to the Hospital Morgue.
                HAZ MAT decontaminated the Emergency Room area.

3:07 a.m.:      HAZ MAT released the area to the Hospital staff.

3:10 a.m.:      Hospital Environmental Services Unit conducted
                extensive cleaning of all equipment and furnishings.

7:00 a.m.:      The Emergency Room was reopened.

9:55 a.m.:      Body was released to Coroner.


HERE IS WHERE EVERYONE WAS STANDING:


                          Maureen Welch, RT
                          (affected fourth)
                   ____________________________
 paramedic intern  |                           |
 (not mentioned as |           head            |
   affected, gender|                           |
   unknown)        |                           |   unnamed nurse,
                   |                           | unknown if and
                   |                           | how affected
                   |                           |
    unnamed nurse  |        EXAM TABLE         |
                   |                           |
                   |                           | Dr. Mark Thomas                
                                               Thomas
                   |                           | (affected third)
                   |                           |
                   |                           |
                   |           foot            |
 Susan Kane RN     |___________________________|   Dr. Gorchynski
 (drew blood, passed out first)           (took over drawing
                                           blood, passed out
                                           second)


                     Dr. Humberto Ochoa (came in later)

