Code Orange at Children’s meant all hands on deck
‘Carbon monoxide poisoning — come to the ER,’ read the first text
Dominic Chalut had begun his shift at the Montreal Children’s Hospital on Monday at 7:30 a.m. — or 2:30 a.m. in Hawaii, where his mind, if not his body, still lingered.
As Murphy’s Law of medicine would have it, Chalut, a pediatric emergency doctor, knew his first day back from vacation would be a busy one. Mondays usually start out slowly in the ER, with cases of acute asthma or fever, but pick up around noon, with more severe bronchiolitis and cardiac problems.
This Monday, however, when the hospital called its first Code Orange since the 2006 Dawson College shooting, Chalut and his fellow doctors and nurses would once again shift into overdrive.
Margaret Ruddy, the associate director of nursing at the hospital, was in a meeting in the Intensive Care Unit when she got the first text just before noon: “Carbon monoxide poisoning — come to the ER.”
In the three minutes it took to get there, she mentally scanned the hospital. Although she is now the manager of the manager, so to speak, she is known to check in with the particularly sick kids herself, and she knows exactly where the pressure points are — who can be moved and who can’t — to make room for incoming patients.
She also thought back to the recent simulation exercise run by the McGill University Health Centre in October, in which a fictitious terrorist attack in Montreal sent 15 children to the ER.
Fifteen children were on their way now. It was a Code Orange, Level 2. But this time, it was real.
“When you know your resources could be overwhelmed by the number or the type of patients you could have, it’s a Code Orange,” Ruddy explained. “Level 2 is the highest level, when the whole organization is mobilized.”
Unlike at the Ottawa Hospital, which had to deal with multiple victims of a city bus crashing into a bus shelter Jan. 11, here it would not be a surgical issue.
But the number of young children who would need to be treated — each of them with one or two worried parents — coupled with the longer timeline for cases of poisoning, meant clearing the ER and calling for major backup.
Ruddy cancelled all non-urgent activities and called everyone on the “fanout” list to deal with the influx of children that would soon arrive.
An announcement went out across the MUHC.
The ER normally has about 13 nurses on duty. Within the hour there were 45. But they didn’t know what to expect.
Ruddy herself headed to the Control Centre, a kind of bunker set up during a Code Orange, where all the managers come together to oversee the situation: housekeeping to make beds available, transport to dispatch ambulances, psycho-social services to match children to their parents and calm the nerves of those who rushed to the hospital after being told their children were involved in an accident.
Equipped with multiple computers and phones, they prepared for the worst. The one thing missing was a surveillance camera to be able to see exactly what was happening in the ER.
Eight kilometres away, at the École des Découvreurs in LaSalle, something had gone very wrong. Children started complaining about stomach aches and headaches. Then they started vomiting. Then they started fainting.
By 11:35 a.m., firefighters had y arrived to evacuate the building and its 300 staff and students, suspecting a problem in the boiler room. A broken pipe in the heating system was believed to have been producing carbon monoxide inside the school, where extreme winter weather meant closed doors and windows.
The problem was that no one knew how long the children had been exposed. Several had complained the previous Friday of feeling ill, but the symptoms were chalked up to flu season.
Known as the “silent killer,” carbon monoxide gas can poison people in their own homes, while they are sleeping. Ontario passed the Hawkins- Gignac Act in 2013 to make carbon monoxide detectors mandatory in most homes after a couple and their two children died from carbon monoxide poisoning in 2008.
In Quebec, several people died from carbon monoxide poisoning during the Ice Storm of 1998, when they used propane generators or barbecues indoors to keep warm.
That’s what Dr. Chalut was thinking about, when the first of 15 ambulances arrived at the Children’s.
Patient No. 1 was an eight-yearold girl. “I felt tired, then I fell on the ground and went to sleep for a little bit,” she told Chalut.
She was one of nine children who had lost consciousness before being rushed to hospital.
Chalut put an oxygen mask on her face and explained he would have to do a blood test, with a little prick to her finger. Then came the second, then the third patient, all with similar reactions.
“We saw there was significant exposure (to carbon monoxide),” Chalut said.
Most of the children had fainted. One was dizzy, and the feeling wasn’t going away. Another had had a seizure. Even hours later, with the toxin removed, they showed the same levels of carbon monoxide in their blood as a smoker who’s taken a drag of a cigarette.
Luckily they were all calm. There was “no blood, no break, no cut,” Chalut said — only acute oxygen deficiency.
“We figured out pretty quickly that some would require hyperbaric oxygen treatment,” Chalut said.
But the Children’s wasn’t equipped for that.
And by now, some 35 children had been rushed to hospitals across Montreal — 25 of them to the Children’s.
Chalut called Sacré Coeur hospital, 25 minutes away. He was told they had two single hyperbaric chambers, and one that could treat six children at a time, all sitting under a glass or plastic bubble.
Together they decided 10 children would get the treatment, known as diving, in two shifts of two-and-a-half hours each.
It was time to tell the parents. Chalut held a group meeting to tell all the parents together. They too were calm, but they had questions.
What is a hyperbaric chamber? Is it dangerous? What are the longterm effects of carbon monoxide poisoning?
Carbon monoxide can have longterm effects on a patient’s concentration and memory, Chalut explained, though when symptoms appear years later, it’s difficult to conclude cause and effect.
“But one thing I’ve learned in pediatrics, is that the brain of a child is so much more plastic. I’ve seen children after a stroke.
“Where an adult would be wheelchair bound for the rest of his life, the child can walk and go to school and recover.”
Back in the Control Centre, Ruddy got to work dispatching nurses into ambulances to Sacré Coeur — each with two children and their parents — and co-ordinated the discharges of other children, while new patients with worrisome symptoms continued to trickle in.
Everything was under control — except for one thing. No one had thought about the food. No one but the children, that is.
Having missed lunch at school, they were hungry. In the ER, there was only crackers and water. But from the Control Centre, Ruddy organized the delivery of sandwiches.
Dr. Elene Khalil, the physician responsible for disaster preparedness at the Children’s, spent Monday going back and forth between the Control Centre and the ER. She was happy with what she saw: not one person carrying the whole incident on their shoulders, but a team prepared to confront anything.
“We were very lucky that the cause of the illness was recognized and the children were evacuated and are all well in the end,” Khalil said, adding she would be debriefing staff and parents in the coming days to see how things could improve ahead of the next simulation, and the next Code Orange.
Though at one point the Children’s redirected other patients and ambulances to Ste-Justine Hospital, the ER continued to receive walk-in patients throughout the day. On average the ER receives one patient every seven minutes.
It was a stroke of luck that Chalut, whose specialty is toxicology, was on duty that day, Khalil said — even if he was jet-lagged.
By 4:30 p.m., the hospital held its second news conference of the day to inform the public that the Code Orange was lifted.
By 5 p.m. the children sent to Sacré Coeur were sitting inside hyperbaric chambers, watching television.
By 6:30 p.m. Chalut was home, and looking forward to a few hours of sleep before the next ER shift in the morning. csolyom@postmedia.com Twitter.com/csolyom
We were very lucky that the cause of the illness was recognized and the children were evacuated and are all well in the end.