Document 0g3VeQg96GNdvyqwbROpKjjkM

, G 1 ~-fr Po .~ ~ p. 1 71_3 921229CCN0543 I a .00tsnaAmWs a a orwcc COW j9 J0 0 3 8 31 a pASi O/ Y11 MO pwY L M7[ M YD MT ACCCOM 9 ' z 1 z 2 ' 7 "" 2' 9 9 1 2 11 1 2 low 1 c '~~ i993 ,~ ! EPIDEMIOLOGIC INVESTIGATION REPORT _ asr~~ WM=WffCMQ6MVWr This investigation was. conducted in response to a consumer's complaint that a 17 Y .O . female experienced severe -respiratory distress after being exposed to the fumes from an aerosol fabric protection product being used to treat a new leather jacket on 121 27/92 . The victim was hospitalized overnight and treated for the symptoms of chemical pneumonia . X IOCGtM p .o =a" V4 L ary a W- Rome M o Oconto Falls HI 1i I +aa pm. MOM= nuoamurowMtamawMwM Wilson's Suede and Leather, :. ._ Fabric protec o l 0 11915 ' 12 ADMIM ~a,_a Inc ., !!tnneapo3.is, Y-N . -treatment Wilsoa s Leather Protector(5 oz . ) < ~ om~o ~m ~ ,,a naaaMNO w~ ~eoa Mse19l wras~enwcn a ~oo~as t Same:as above- ,a. All or,Cr n rocp. ...s,r ..ir ,a-ai.areior ' - - - u. Puuwr uwmWas 1 0 1 7 ~t 2 treated and . : aw.o.w ,a ~ tranefered for .- 3 cb. . emical. 7 hn ospitalizatio 1 N. M QD1 PAW ,s. 1lVC NOWM N . lUM all pprts 8 5 -PitEim"`" '"- : A7UOroaa a+ . CAM faKE is. TM 91116f7m4T1018 1 aesi E i ano~ a 0 a 1lMtwea n s TEf-f N . :0 . 0 ro an multiple Sta Pt ,te p 2 / 3(7 6 ' '~ - n Peratiar 20 oranae r.M es NO MOy CAM dftlj VEC ~T OOC{ M MY NMi u CM /MY Mar OMCLGK W MIU ! ia waMme ~e.. ~wrr ar tw a. rj oowL arwca owrc MA sswW0 oate See attached narrative . . . -r.ti .w,:! r~~. . ._ . _ ~ - _-' -/-` _, /~ ~j'' ' ' ,v~ : :7s rf! C.ri=,od Gr M tsCroa A w. raA.r I WWI M6! ow1M MW AM aeaaowAc s.ria r aXSLw " APPROVED !Qt 15E lx2DOGw 3/'32194 J . 3011- Ml . p. 2 921229CCN054 3 SUMMARY : This investigation was conducted in response to a report that a 17 year old female experienced severe respiratory distress after being exposed to the fumes from an aerosol fabric protection product that she was using to treat a new leather jacket on 12/27/92 The victim was hospitalized overnight and treated for the symptoms of chemical pneumonia . PRE-INCI DBAT : On Sunday, 12/27/92 at approximately 12 :30 P .N . the complainant and her boyfriend each purchased a new waist-length brown suede leather jacket from the "Wilson's Suede and Leather Products," retail store located at A-1009 Port Plaza Nall in Green Bay, WI 54301 . As the complaint was purchasing her coat, the store clerk :suggested that it would be important to treat the new jackets with a fabric protection product to avoid damage from dirt or moisture . The clerk suggested that the complainant and her boyfriend purchase "Wilson's Leather Protector," an aerosol products sold at the store in 5 ounce cans . The aerosol protector is sold in a two can package, described as a "Leather Care Starter Kit . " The complainant and her boyfriend agreed to purchase four cans of the above described product . They were told by the clerk that they should spray 1/2 the contents of a 5 ounce can on each jacket, then wait 30 s inutes and spray another 112 can on each coat again . (Each coat then has been treated with an entire 5 ounce can . ) The clerk further suggested that each coat be treated again every 2 months by spraying an additional 1/2 can onto each coat, and, if the coats were subjected to rain or dirt, to spray then again immediately after such exposure . - The complainant paid $19 .96 for four 5 ounce containers of the Wilson's Leather Protector product . The store clerk, whose name is unknown, 1s described as having short brown hair, and being 20-25 years of age . This clerk provided no further instructions to the complainant and her boyfriend as to how the product should be'applied to the coats, and he did not suggest that the product's fumes might be hazardous . . ...~ . ~ . .~ ~_ ... . _ . p. 3 921229CCN0543 -2- I NCIBEaT : Later that same day, 12/27/92 at approximately 3 :00 P .M ., the 1 7 year old female complainant and 21 year old boyfriend hung each coat on a hanger and suspended the hanger from a clothesline in the attached and enclosed front porch of the family's farm house . The 17 year old complainant did the actual spraying of the fabric protector product, though her boyfriend was present in the porch for part of the time . The complainant sprayed 1/2 the contents of a 5 ounce can onto each jacket as she had been directed, and estimated that this activity took her less then 5 minutes . Both complainants then left the porch where the spraying had taken place until 30 minutes had elapsed at which time the 17 year old female then re-entered the porch and sprayed 1/2 the contents of a second can of the fabric protector onto each coat . She estimated this activity again took her approximately 5 minutes . The complainant's boyfriend was not present during this second application . Photographs depicting the complainant's reenactment of the manner in which she used the fabric protection product are attached to the end of this report as exhibit "A" . The complainant stated that before using the fabric protector product, she did read the instruction labels on the can, and noted the warning "Vapor's May Be Harmful ." She felt that the unheated, enclosed porch was large enough a space to allow the vapors to dissipate, and she left one of the porch's, crank-out style windows open approximately 6 inches to assist in further ventilating the fumes . The porch area is 26 feet long by 6 feet vide by 7 feet high . The porch has two pedestrian doors that provide excess to the main living areas of the house ; both doors were kept closed, except to enter and exit the porch during the spraying periods . Approximately 20 minutes after treating the coats for the second time, the 17 year old complainant noticed that she could not take deep breaths, and felt like she could not catch her breath . It hurt her to breath, and she experienced a burning sensation in her lungs . The complainant also began coughing uncontrollably, and felt slightly dizzy . The complainant's boyfriend suffered no ill symptoms . p. 4 921229CCN 0 543 -3- POST IHCIDaIIT : The complainant's condition continued to deteriorate, and she was later transported to nearby Community Memorial Hospital in Oconto Falls, Wisconsin for emergency treatment . She was diagnosed as suffering from chemical pneumonia, and was admitted to the hospital for treatment . Chest .x-rays showed clouding in her lungs, and she received chemical and oxygen therapy . The complainant was released from the hospital late the following day, 12/28/92 . . As the female complainant is a juvenile living apart from her parents, she was asked to obtain a parent's signature on the "Authorization for Release of Naee" and "Authorization for Medical Records Disclosure" forms, and then return the completed forms to the CPSC Milwaukee Resident Post . When these authorizations are received, the medical records will be obtained and forwarded as an addendum to this report . SAMPLES COLLECTED : The complainant still had two full 5 ounce cans of the "Wilson's Leather Protector" product remaining . These containers were purchased from the complainant as a CPCS sample, sample no . R 830-4408, and were later forwarded to HSHL for further analysis . A copy of the sample collection receipt issued to the consumer is attached to the and of this report as exhibit "H" . A copy of the sample collection report is attached as exhibit "Cu . APPLICABLE STANDARDS : The hazardous substances labeling requirements detailed in 16 CFR 1500 may apply to this pro'tluct ; the adequacy of the presentwarning labeling could-not be evaluated as the product's actual content ingredients are not known at this time . PRODUCT IDENTIFICATION : Product : "Wilson's Leather Protector" fabric protection treatment ; 5 ounce aerosol container, described as black in color with red and white lettering . SKU no . 18996003 . Date coding ink printing on the bottom of the container is apparently smudged and incomplete states "Cl 2" . p. 5 921229CCNO543 -4- Manufacturer : Wilson's Suede and Leather, Inc . Minneapolis, Minnesota . ATTACHl U TS : Exhibit "A" "H" "C" "D" Photographs depicting the complainant's reenactment of her use of the product in question . Copy of the sample collection receipt issued to the complainant on 12/29/92 . Copy of sample collection report number a-83o-4408 . Copy of the original consumer complaint . p. 6 t.MEA~ G~iLB .'f 6 lr ~z.~j9~9 L U .S . CONSUMER PRODUCT SAFETY COMMISSION 9a j i2 9ce'Pv osy3 ~ Z. NAME Qf -'- __ T1TLf .OE q=tl10UAL . . . . - . _ . - . . : . . . . _ 1. QAT IT i. : t. : Y.^ ^t_ .? _ . :ti . : .r . _ ,~;~..~!..-" ~--~ -jf .~prs~yr : .. . : i l l4~pFA Ct1Y ;~M0 STATE ry! eW!r ZlI. Gad.0 ro'~ t.~3'JY'J : A LS S 4i! ~ :r :~ IS Yv !. 3hfNLes ooLLECP6o.la.6rWWaa Mc;ir.ic ;.WW wr,iM., -arI -.Mr I.,pl!r Y..,i/k.rlsi 1. ; )3 ~ ~ta1i: ^ ra 7~atti .e5iax3~ .s r. :~afriK4 Xlflai t r "' f ~' ~ ;lA~ MbNq uwpht +tin .aWe4d by do crww~ :P.LrtK:MlOlye Qwnvairi pnwat w Sedlw tJIA w 1k, a a ~. .mKt WOO Act ( 13 i uac fto w ~!!t>>!0~ K!+~ /~~ m".s.A,e..on Art (a U4 .4~ws(e)jkdri r~irali M~ AN~~ ..w' r Tf'Pl1I! U3,C..~9!Il .~WJI: ~+~~M~:NM 6 ~etierY~d. s~~ uws~ cif~'l ~ie ~otei s 4~e te+~nc aiae d '_ - Mif_~~_r~ - :~ :~ ..~~:9JOR~ . - :i-.~. - . c ;~,,~ ..s+r^''r)t`.`~~.'~:~-':~i'M.:F'tC"-__'~ :_' .. '. . ' , . ._, ^Tr:_~. -y + -" .. : .Tj_~' .. . .fi~f'.'--l~i. . . .. Ll : .aia ~ 1i " . sY _ _~i_: ..L::_ ~ - . akcu~e~i 9 4; .=~' ":I~a `~ -~~~ '9ti : Li . _ . . . , - Y-7iY:~:J9 .. . ~q .- .~ .'-.~ .a.~ ,9 . .:.. r..'....1-s.a:.~~y.;.y,Y ~. F' e, ~J r,y` ~~ . .^~~T:..~ ~". i+~'~`~%~:~;~;,.~' .`~-' ' -. 4ji A t s ti ~ ._s. .V~ _y.~!ir~aa_. ~ . a . . . . .~: .':' .~ ' ~.. .?r.' : .. -- . *.:'fF . d `.) ~ .L :s'W-_k-~sn.l . . ~%~'' ::.%r.- . i i_ t .'11. . '~f~a:~ r !' "Srt . .~:..y . .. ry . ^jia~ :[!% ' ::~~ : :''f., " :y~ . .'- _ " . ' _ . . ~'.' L' _ - - ~;T_ ^i . ._r .SM"~ ~-R~i`-_''.~..:.. k .tit'-i .'-'. :~7..'_.`i fr 7_ 41 ;--- r : :I-'^ __ ~~ . _ . ' ~'iSLtt`'-:ti~.'.jryr-R~.yb t~i . ~~ .b:`".s~ - :~. '~ * c'.::~ . :~~~'~ .~r~ .;'i'7 ~`:.=~...tF ::'s ::%.Y ~''~ :;~:.9{~':'::~0~. .' - . . . l .r^~ ~~s.i~ r'n~M eoti~+i~-alf;.i~ i'at- ' ~ ' ~. ;::GZ!i!'~-).":`'i;! ;3!!'~7~~s~t:~:_~'+ :~-+ ;FiT3 ;Y c. ~:S~iT ... :t=?r~4-,.r.~~-w:M '' :r`! .. :ifi`l~itE'?~::, ':.~as'~ :.;_ " . ~.-z~ :M~r ;J.. : . ' , /r~'-'s. ./L7~~'d~~i . . . . . . . . ~s . . .. - b If. EAMPIFS WERE n,eoHwSm ti. rw.e fl.. COLLECT" ~ w.wu.p 1. Cl wwowo rr. tr nw.ktl . :. . :. t1ECEPT FON S AMPLES ~ _ p. 7 [1 . U. S . CoNSOlOrt+ PA00[1L-t S 6/t,dV " C`~ iI z 9/92 saXP l E cou Ecr=c ~ _-,Z_4L y-L/= a 9 c c aosY3 Flag (2 . Dstc Col_~ . ~~t ., ..,r , . yJr. .. .,.....,a . 12/29/92 ( i zl ~~n~~830-] 4408 ] [4a- Product mame 14b . Nodal [4c . 2ffiISS [S . Assignment taf . J ' [ r . -fabric- treatment product [ Wilson's 5 0 z- [ 0952 (6 . Coaplata for Import aapirs (7 . !QS 1 [ 921229CClf0543 A . Hours : a- Port of Entry [ 32672 (a-detiTiLY 2 . [b .2ra'el ~II0[b-Entryo&dae[ =O- J [ C . Country OrS.aia : 1 9s. Home 9O 1 9b_ Collecting 7i3 . [ da. t7astoos Cam~et : - ' [[ . F[ OC FOCiI t i ) [[_1_0 .$,~ 1~lat~L . . . [11 . Ia~ro f e.s Valae .of,],ot 112 . 51zo of lot . {' retail luc approz.$10-~ -[ !vo available from consumer i ~ (lE . Shipi~~lir .et ."Yort YYz .Dr XeathrIilon~sud a A-1009 Poit Plaza Ma. l l [~W o . o56154 [ m t [ID 6 reen Bay, W1 . 54301 [nw ] 1 16 . Sapport1,ag doem.mrs elsed: [ a- Iaaoies OL S date: 'N/A b . Pate Shipped: ) ( -- 8hIpp1=E record *'& date : . . , [ 4 . A MA--!t: sdamar: name title a date : 117 . ?roae2et c~i~~./~' "SaUap~lky-edonas:ciostlos'r_ o.~frii{_ t~ht-ored5_ ~o-auaadcr re.v' ahei.tr_eo_sl-oe-l_tCt. .ea.ar-~~ of. ::._;.S"KWiDia/o1a8'9s96.0L0e3atiiDeartePeroodtiencgt-osr_t"aCm an 1ps ) ) ... ..v;~a--7r ~ ...~ . .~ . .__ , _ ~ ISa .[ .CDIIt> .ipLr. ;~6 Fiono7`4,labe~ing'desc'ribes-pudoct .ae kin--suede '?[ ~da 1ea~e he inrfaceoieasy-viperoff ;,,] -- ' -~ 18 ~iaer~nrt ~1'+Js'~'s a~rri`nua'`viidL~san~ iaasEe 3~atrii~tions ) [ Naaaan for co)l setioa i aaal7sis :aiaaded :fBSa Z CPSd FF, PYYA nSA ] F/D'to IDI~ l21229CCN0543 il ~ear :pld~fe ~4 le surffered dL r s afterJ ~ i -- ua1aR trie product) content an~fa f~ ar.s) ( 19 - -0110axy of Field Screening : . ] [ Hone . 1 I2O- S+miple Size, Met. hod of Collection : i Sample consists of irio ' unused cin as described in 0 17 above . ) . ) [~O ~~ packaged . together in a .black cardboard display cootainer . Sampie wa ; it remained in my possesaioasiobtanedfrmcsuatheridnco12/9 and ) [ in the locked CPSC off ice until ebipmeat to the Sample Custodian on 12/31/92 . SampleJ {21 . 1dentiiieation on sample (22 . Identification on seal ( "x-830-4408 DRe. 1 2/29/92' {^Y-830-4408 Deanis Z . Blasius 12/3 11 92 " (23a : Sapl e dullrafed to i 23b Date [24 . Orig . raport-ftacords sent to] (MSample Cuatodiin via p p rim ( 12/31/92 ( FOC R - Laboratarr/OffLao ESEI . [ li5ffi. t 7c 1 CERH [ 1 CrvCl ( 1' OMEM j 1 ] (26- ,..mir. was shipped #a & .cardboard box which was sealed and identified as coder ] ("122 above ; sample itself was tagged and identified as described 'in 021 above . Sample] [ was mailed via Y .P .I3g to the Sample Custodian on 12/31/92 . to be forvarded to ] ~fficLaj .further analysts'. Sample collection receipt, copy of original assignmen 1 Z7 N+lstad Saylea R-830-440 7 t i [28a . Ca]ZKtars name, ticlg aemplolee # ( 2 8b Collector's sianause b date Dennis P . Blasius . Iavesrigaior . 0 9003 ~ 12 1 31/92 1 29a . Se.3avar 's aae, citle a employee s (29b tavievar's signature S data ] i ( S t Osscribaa=ion: [ ozig t-b t I i Fiscal ( J Data [ J Hd4a [ JOther [ cZ sC rasa 164 J (Rs. . !/91) .. p. 8 ~ ~Oz~ 9a~~~qcc~roSS/ 3 CONSUMER PRODUCT INCIDEW REPOR T ~ . Ta~a~ Ma ~+..w pnrq a A. MY . Ocoato Falls, WI . 5415 4 A ON iMM N N MweW /4 ' Raspoadant'a girltriead was . applytcs'an .aRrosol leather protector treitaeat to her newly purchased leather jackot ; rittla began experieacin= severe raspiratori distress attsx s.evetal aixlntw sxEosur .e to Ch* pioductra fumes . Vic4i' vas'isscdiataly transported to a naarby hospital for traatmnnr,'aad remains bosad to date , . . 46 now or - ~ 12/27/92 T. YNOM . a , Aam"'T`' on r,"a ` AtAOt lc~ Ku m ~I,~Y - r. .~~rrtnra d~~rr .y ~ !~ ! - Ysrosol._apiay leather proteetor 16 Wilson's Leather Protoctdr Wilson IL.sathir Company So x'- CaCL Y.inaaapolis . klT . x NAMES MMK low a Wilson's Luther Product s Port Plaza Shopping Ceatar Gresabay, WI . K T V<Ifi00Y~iOMNAOM MMV~ @If4lR00= tN11L1N!!D trts NO 1R YEN, BOOM OR A sflR THE CAM 12/M AM UQMa' day Dun" SL OOK! MOD{JGTNAKwNINfla WO.fT IF SO. NoTTc 11. 111.YR YM CpffJlCtlo T!# 1MIatAClVM f 1s. N 1m MIOOIxr sRL AVAM/w 1a. HAY Wt use YWI! IiN/ YYI}N 1lMi m carrArrhN+ o -eXa- rnNOT T. cao Yoxu n.mnto o ir" wT r=rs orNoo Paarran arttio~ i+o . AnMDWMr4N UM xa1 . ao wsm my omm a os.+ , a aocU retr Ha 22 C. I2/28/92 6enals P . sl,sia ., r.Ks-xp - 1 x rasaw.v acrsoM C'~-~~~~~ ~r- 013 6 W. stoawz Comm 4a~~~4ec~ro5y3 ~ 9sz ~a arewntma. aa. st.a%.Ra Win amts ' t s~vS te C[f~.=~ Ju~1e-. ;~~ ;~ F OW lCRM t7f p AOy p. 9 , -~ a..r..a Exhibit "A " IDU 921229CtU0543 ..r . ._ . . Photos of the enclosed porch area where this j_ incident occurred . ~ : - ~~= . I ~ i I .~ . ~~ ::t P . 10 Exhibit "A" IDIt 921229CCH0543 .. . . . Photos of victim re-enacting the manner in which she used the product . ~ .. .. i ~.. p . 11 Exhibit "A" IDLi 921229CCN0543 'V- s- ~ front view photos of the open window providing some outside ventilation (left) . and a of the suspect product as purchased by the consumer . T i. 7t . .t ~r~ --- - .' p . 12 Exhibit "A" IDII 921229CCN0543 s- i'. Date coding marking on bottom of containers (C1292 . ) NE6.1 Y.ZvES p . 13 Exhibit "A" IDI/ 921229CCN4DS4 3 . . .. . . . _.Y+;L_! . _ ;~ Photos of the labeling on the back panel of the aerosol container . ~, . 1 , ~ / p . 14 ~ ~. co ( 7 Z- an-'a 3 COM -40 IVA 611 4. Q00W OF V , Wo ar 9 : 2 1! 2 Mum OM IM ,o i .2 1 1 2 2 1 9 INVESTIGATION REPORT. This investigation was initiated in response to a repor t that two sisters, ages 10 sad 19, experienced severe respirator y distress after being exposed to the fumes from an aerosol fabric protection product the y were treating a new . leather jacket with In theirbaaement . Both victims were treated and released at a local hospital em ergency room . X Marmp.. .r~.aw a Mr a IOU home 1 01 Gillett Wl 11 I ,eL to= P"Co,,cT 1 u~auaowswwwrronswAre~. wMr.cs+~aa .oaws ililsoa's Suede ,tad Mather . Inc . ; I".inaeapol~a, rn Eati seaanEDC" 0 9 5 Wilson's Leather Proteccor(S oz .) wa s~oo~ ~OI~ f't ~~ 3 "R.- KOME m WJMWM Same as above . +s ~OSOMMCOr CL sim lur .d/.wi/ . *~ ~aOiv~HON : . . . . . -. . . u. rJl~lr`arowote 2 t reatcd a t .R . . 1 ehmieal 7 1 " DandE -released-- - D paeamonia - It MM WAY +f. OWPOWS sn rr. K iw.a ~a TIM raanmtnn w. aM arar Tr <8 . all parts 1 8 5 victim o CKSM .2 a D Z 0 a a<r*AMerts M . CAN SOW= SL SMIM040 ev ,,e w GAY u State Healt 0 2 multiple 9 Dept . ~ 3 O , ,a ` 7 d fi HwnioM TO ora M sees . FAMMOU CAM oMn oaa MAY oeana an w+[ ~ - oP= may sot oaawt UT r" x MMVY2W[ on s.wo . of a.. s+w a 1016 wKCawc9 wsCtoA MCmQ+ 0M See attached narrative . . . .-__-~._~._- -.-_.-.: - .: . ::.- _-~.~:.: . C' Z~t3 7 eM e ~~ ra +a w.~.. raa AM an W so[ ,wa .imnXW.a sw= rwNCRIM" J1YA7Cia9 !m DS~ VOUPW 3/J11" tna W . "u-M" ~: p . 15 921229CCN054 4 SUMMARY : This investigation was conducted in response to a report that-two sister, ages ten and nineteen, experienced severe respiratory distress after treating a new leather coat with an aerosol fabric protection product . Both victims were treated at a local hospital emergency room and released . PRE-INCIDENT : On Sunday 12/27/92, at approximately 3 :30 p .m . the nineteen year old female complainant purchased a new black leather waist length jacket from the "iiilson' s Suede and Leather Products" retail store located at A-10 0 9 Port Plaza Hall, located in Green Hay, Wis . 54301, phone # 414-432-3121 . The complainant was assisted in making this purchase by a female clerk named Darla, last name unknown, who is believed to be a store manager . The store manager suggested to the complainant that it would be important to treat the new jacket with a fabric protection product to avoid damage to the coat from dirt or moisture' The clerk suggested that the complainant_ purchase "Wilson's Leather Protector", which is-an aerosol product sold at the store in 5 oz . aerosol cans . This aerosol fabric protector is sold in a two can cardboard display packaged, described as a"Leather Care Starter Set" . The two container set retails for approximately $10 .00 . The complainant agreed to purchased the fabric protector product . She was told by the manager that the entire contents of a five ounce can of the product should be sprayed on the coat before it was worn, and that the coat should be retreated every six months afterwards by spraying an additional one-half container of the five ounce size can onto the coat . The clerk provided no further direction as to how the fabric protector should be applied, and provided no cautionary warning that the product's fumes might be hazardous . INCIDENT- Later that same day, 12/27/92, at approximately 6 :30 p .m ., the nineteen year old complainant sprayed the entire content of a five ounce aerosol can of Wilson's Leather Protector onto her new jacket . This jacket was treated in the basement area of the family's twostory single family residence . The basement is unfinished, though a portion of the basement area is used by the complainant's ten year old sister as a playroom . The area where the coat was treated x 14ft . wide x eft is described as being approximately 16ft . long . high, and is adjacent to the home's gas forced air furnace . There are several windows in the basement of the home, however none of the windows were opened during the time period that this incident occurred . p . 16 921229CCN0544 2 The spraying of the jacket took approximately five to ten minutes . The complainant stated that she read the instruction and warning labeling on the aerosol can before starting to use the product . She noted that the labeling stated that "Vapors may be harmful" and '"Please do not smoke while using this product" . The complainant felt that the open basement area was large enough to preclude her from having any problems with the product's fumes, so she sprayed the can's entire five ounce contents on the coat in one application . She did not find the fumes particularly offensive or overpowering, and noticed no adverse physical effects while using the product . Photographs attached to the and of this report as exhibit "A" depict the complainant reenacting the manner in which she sprayed the coat . The complainant's ten year old sister was playing approximately twelve feet from where the coat was being treated . At one point the ten year old was asked by the complainant to assist in holding the jacket open during the spraying procedure ; the ten year old did so for approximately one minute . A photograph of this procedure, reenacted by the sisters, is also contained in Exhibit "A" . Approximately fifteen to twenty minutes after finishing the leather protector treatment of the jacket, the ten year old daughter complained to her mother that she was having difficulty breathing . The ten year old complained that she had a burning sensation in her lungs if she took a deep breath, and that "it feels like somebody is sitting on my chest" . The ten year old laid down on the living room couch to rest, at which time the nineteen year old complainant came downstairs from her bedroom also complaining to her mother that she felt like she could not breath . The nineteen year old could only take short, shallow breathes, and she began coughing uncontrollably, feeling like she needed to vomited . The nineteen year old also complained of the same burning sensation in her lungs . POST-INCIDENT : The girl's mother suspected that the victims were having some reaction to the fabric protector ; she immediately called the local poison control center but was told that the "Wilson's Leather Protector" product was not listed in their files, and that she should immediately take both girls to a local hospital for emergency treatment of their symptoms . The victims' mother drove the girls to the near by Oconto Falls Community Memorial Hospital, 855 S . Main Street, Oconto Falls, Wi . 54154, where they both received emergency treatment from Dr . Wallace_ Both girls were giving oxygen tests, chest x-rays, and were found to be suffering from symptoms usually associated with chemical pneumonia . The symptoms begin to subside, and the two victims were released from the hospital approximately two hours after admittance . As of the p . 17 921229CCN0544 3 date of this investigator's interviews with the victims, 12 /29/92, both victims complained only of a lingering cough and no further symptoms . Attached the and to this report as Exhibits "B-E", are "Authorization for Release of Name" and "Authorization for Medical Records Disclosure" form sign by the victims . The victims did not wish - their identities revealed, except as necessary to interact with other investigative government agencies . S ~r.FS COLLECTED : Of the two five ounce cans of "Wilson's LeatherProtector" fabric protection product purchased by the consumer, they had one full unused container remaining . The other used container had been given to a local Television Station . The remaining container was collected by this investigator as a CPSC sample, sample number R8304407, and forwarded to HSHL for further analysis . A copy of the sample collection receipt issued to the consumer is attached as Exhibit "F " . A copy of the sample collection receipt is attached as Exhibit "G" . APPLrC&ALF STMMUDS : The hazardous substances labeling requirements detailed in 16CFR1500 may apply to this product ; the adequacy of the present warn ing labeling could not be evaluated, as the product's actual content ingredients are not known at this time . PRODUCT IDENTIFICATION : Product : "Wilson's Leather Protector" fabric protection treatment ; five ounce aerosol container, container -described as being black with red and white lettering . S1(U number 18996003 . ' Date coding ink print on bottom of container is apparently incomplete, stater. "C1--2" . KU OFACTURER : Wilson's Suede and Leather, Inc ., Minneapolis, Mn . &TrAQUIC'rs _ Exhibit A - Photographs of the prQduct use reenactment as well as photographs of the product container itself . Exhibit 5 - Authorization for release of name forms signed by p . 18 921229CCN0544 4 Michelle Rodefer . Exhibit C - Authorization for release of name form signed by the parent of Lindsey Rodefer, a Juvenile . Exhibit D- Authorization for medical Records disclosure form signed by Michelle Rodefer . Exhibit 8- Authorization for Medical Records disclosure form signed by the mother of Lindsey Rodefer . Exhibit F - Copy of the Sample Collection Receipt issued to Linda Rodefer for the sample-of sAilson"s Leather Protector" obtained as a sample . Exhibit G- Copy of the Sample Report, sample number R-830-4407 . Exhibit N- Copy of the orignal Consumer Product Incident Report, dated 12/28/92 . Medical Records pertaining to both victim's hospital treatment were requested on 1/4/93, and that information will be forwarded as a addendum to this report when it is received by the Milwaukee Resident Post . P . 19 . . T4x$qa~.i~9CC~;aS`/y U .S . CONStNHEA PRODUCT S"VY COMMISSIO N AUTHORIZATION FOR MEDICAL RECORDS DISCLOSURE TO WHOM IT MAY CONCERN : You are hereby authorized to futnish the United States Consumer Product Safety Commission all infacmacioo and copies of any mad all records you may have pertaining to ( my case ) ( the case of WANOW Iielatiatuhip to you including, bu t not limited to, medical history, physical reports . laboratory reports and pathological sfidcs, and. X-ray reports and films . ~ l~-a(~Dec-o 9R w ftt i eas) 40C foa11 NO . 170 p . 20 U .S. cOHSUAldI MOOUC 7a I a .l. } Z c n/ ~ S -VS( aurHORIzAnaN FOR MICAL RECORDS DISCLOSURE TO WHOM IT MAY CONCEM : You are hereby anrhorized io furnish the Uaited states Canaomec Roducc Safety Caemisaion all iaformadon and copies of an y and all recoods on ma hav e peminiag co ( ay case ) . - -'-~+- . . : _ . _ :( the --~-----_ .- .. _--~ el .. . .. . - - ----- - z ---_ . .. .' _ : - ~,%k.Gd.%Cj _ .i b-- ~--. . . s - - - ~-=- RrlarinasLrp W yo u . . ._ . - iodudiaj, but not limited to, medial hiscorY, physiCal rcpoccs, labotatircy Capons Mod pathological slides, and X-ray repoms and films . 91"; goo toa. rsw..~.~ - . - - ~r. . ..~ ~~~~ ~ , VEC f01~/ NO. f~0 p . 21 'rF' ,zhql9 t MA U.S. CONSUMER PRODUCT- c, A'?oj c - - .,- - -- 9..21x. _ 9 c'cN oSyV SAFETY COMMISSION oft le 47,f :0 3 : wwt: ds -_ . . . . 1 m6 oFuaMwu. . - s.. . .~ _ . a DAM . . . . . ~~~~ -ate~ ..'A:Q ;u_ . . ._- - s' . . . . . ., .f. . . ._ . . . . . . . .. .. - . . . : _ MJ6AlEA .. .. . 7. 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COliSOM PItOUQC'I 58ffiLE COZI ECTI ra-r+lk 9a/22 5 tc.,Av 0 S 5"l Flag 1 2 . Date Co2lected(3 . Sample type & ausiber ( ( 12129/92 . .11-11 Physical R-830-4407 ] t [ t W DOCUMMatarv 1 44 . Proa,aet -Pam ( 4b. lsodea. ( 4a . 21ErsS ( 5 . Assignment ref.) ['fabric tieatment prodikt uuso n'a Soz- 0952 1 921229CCN0 544 ( (_ ( [. f ] (6 . Gosplets, for Import samples 17 . MIS ( 8 . Hou rs : a. Port of ~ ( 32G72 (a-Activity 2 ..00 ~1 b . Entry data ( - fb .Sr:vsl ~ ] c- Countr?' of Oiiain (9a . Hose 10 1 9b_ Collecting No. a . ~a~a .~ ' E t ] [ ~ : ~sto~ ~t [- [ ) ,.Ssap14 Cost . [11 . :3asv3Fa value . of lot'- (12 .:8tzg of lot; approz : - =$5 :00 ' ` one iviilable froo eoasuier t13 . . .Ba~~tm:asartes : [ u. abip,p~arlForatm. ~ir_ . [ls } t i . .i_,l l.a_o.a-tu s:t - ue ede~ d ad .. e eathS er It E .e . N. #~a son :t a :Sher } : Yo ;t Plaia :I~'a11,' af ) [ [ A-10b9 port Plaza - !'.all { G ett, HI . 54124 ( Zp 9 M){'oreeo Bay, 54301 . . [ MO 126 . ttaAcbadT- b In ootera & date: ~ : 2(/~ . pate shipped: { e . S4ippiiy~ record #'& daze : ' . . ' ) { a . Affidarrit atimers asua title & date : [1~. .~r T... . ., . .~ _ ~ . ...,- . . . . - .~. .-,w .- . :_ . . . . . . ' : : ) [ SasiplecQusiiCS'oone'S -. .. ..,s ..'ounce ie. roiolcau-pfi1. 13son's Leather P=otector ." Caa is , - j 1_ck ;~n : . .teoi --~*-~~, r :vith?.z =ind vbite ..~--l~a.s tt-extiir.-i-g.,g:,J .-r~. .`~lm'=l1~996Q~3 . = Dat e ..- codiag ~Eaa/ ~"-da ) ~~'~ ~' `~ss 4 iJ Y y i . . . r~~ aBY~~Q ~~rities-,proilinet =ass ..'lnakla6' suede .. J . . - .[:.aadr3eatt~e~.:#taY!~ ~~~ts er~ssisCant~~~paydirt,o ttiessurface .--t -ecnthiaer furthi:r" rioita-vaYaioirt~aiad~eaRa`iditzoctions . . : :_..f_o.- .r_:e,-as 7,,,.w.tpe.-of]f '. (1! . Reason for :colleetioa A - aaa13^s3s-peeded: 43SA z CFSA FFA pPYA_ NSA .} ~ E{- F/I- I'to- IDI- i 9222n 29CCs K054f 4 (1h 0~Z :e O ii~lriodgttydEQ`seoin~tefnet raehrea~f?~ d anies~~ i safter (19 . Puma=J of Field Screening : - ) { Hone . - - ) (Sa. m Sipzlee(20 , Net hod of Collection : E Sample eoasiats of_one unused csa as described in 0 17_above . This can. was one *of a [ two can set,packagcd .tog F ther in a black-cardboard. display container, Saap2e was E obtained from consumer at her rsideace on 12/29/92 ; it remained in my possession and] E in the locked CPSC office until- shipment to the Sample-Custodian on 12/31/92 . Sample) [2X . Identification on s>srla .1 22 . Identification on sea l ( "g-830-4407 DRB 12/29/92 1"9 -830-4 4 07 Dennis g . Blasius 12/-31/92 " [23a . Sample delivered to I 23b . Date (24 . Prig . report/records sent to) [ Sample Custodian via F .P . ~ [ 12/31/92 ( FOCR ] ( 2 5 _ . IaboraeorY/af#lce P m f i an [I 1 CE li J I CECA [ t 01M [ 1 J (26- IIsaw<rks" vas'shipped i n a eardboard~bo: which was scaled and ide.atified as under ] [i22 above ;sample itse} i Was~tagged aad.identified'as described`ia #21 above . Sample , [ was mwfledvia P .P .k= to thq'Sauple Custodian oa-12/31/92, to be forvarded 'to ~~cfio~r .further analysts . Sample collection receipt, copy of original asaigoment 127 . Related Saamies R-830-440 8 [28a- Collactnr's Lame, title 6 eaploles * [ 2Eb Collector's signature & date Dennis R . Blasius, IavesZigator, / 9003 ~12/31/92 [ 29a . Y,eviever's n , title a employee [29b . Reviewer's signature S data ( [ [ ' [ ] Distribution: or16 [ 1 Lab ( I Fiscal ( I Data [ I lU tr-r ( CPSC rem 164 (Now _ 9/91) J other (- ) p . 23 CONSUMER-PRODUCT INC ~_+k ya l a s ./y 11w+[ OF NNOlloiafr titM ++oNS Uo. I~y ~tqro ~~~~ ~~ . : - sr 4. lai r a , Gillett, NI . 542 pW s ~sapo a daat' s _tvo daughcers, ag4a,19 and 10 . were In the b 4ssieat of their hoee treating a new leather" coa ; vitf~ aa aerosol leather protector produEct, `Altar isveral Alautaa ~ exposure ~o the prod~cet's Eats both individ~sals Degia expert wing severe respitator7 distrsssRAnrludiag difficulty b=sathiog ; caighSpg,'apb ti.s6tn~ss In their cha'sts . aath Telessa_-d vict~: .._i_. '_rV. .e. r. .a_.tr, anspo_ rted t.o a . ~lo_ca.l.-. .h- .o. s. p. ita._l_;.',t.i_h.e.r_e. thsP-veie_t=sated ._ . . _ __ . and s~esaooM ' . .. . .. . , .. . W. Pam 12/27/ 0 2 _ _ as_soiol sprar -lcathar :protector .~ .4 iiioa'.4~aL1s:r ~Frotaccor , . ae- . 14-~.s~~+: ~s!'.~~;7'_= -. .4~.` r~~.il7:ti ~~.`?,-a~ :ntt-q.~ se-- _ ~_ F__~1sQQ~a'a.piW=smiw ,,_Lr.~T`. .~', ~~~ ___ ~C_~v~.~~_r._ ,~______ . ~ ~~n4dijlOl~a j ~$ . . . _ .. . . ~"o-::3 :: ~- : ...:.r . ~ __ :_ . ^ s:r' s ~ ~ _ rJQA~ .tOd~O= ."CiQa . W _- ^ - _ .~.w~~ : ;~ : +-_~ ._ .. . wilapoes T.iatber Products Por~ Plaza 8tiopph s Center 'cr.labey, Wt . K WAS M oouar n,uMUSq asrawp oa 11111100111We I& rnooucr ruacwAw salr u~a w NO = r YiR, wrCw a J1nsR lhi pan MsOpyys9 12 2 2 AM ~ oa IL ooes reoouar MW xaiuawe waM IF So. l+o?L aR~ 1 7 1NVE CQRAG7fD "t 1(Al.PAGftNE R 14, M i?110110 MWCZ 9T.01.IpIAaJlatt7 tu. MOWN lML1P" IMM[ 1MiM 1 M -1 .. IIO ___ IR llQr. CC V OIT R/IN w Vu T _ 110 - 1 ~a M ?4" caKra~cr rawt m r+o f Mar. as a 000srtnn to0 st. ossa s ~ 1 2/28/92 J& FvttqMlaACft s~ . Deaai s sRr. Blasius, 98-8P a. ~~ x FWMW cam" ~ ~"~fON - . t ., aaoasora wYa a~m .a 0137 : CssC I~D111s 17!-AIM _ _ , . p . 24 _ Fx~,4. ~ e- . ~~c~ g~ ia : 9~cN s yS/ II_s . ama*R F9=XT sAE"E17C OCtlu-S lGN . N1T8GRY~lTZCN FM RECFASE CP NAM 7hank you for assisting us in collecting infarsoaticn on a Potential product safety problem. She Gbns~mer Rod~xt Safety ~aaissicn depends am n con cern ed people to sharea pco3ict _ safety isi ifonoatias n with as . We -tain a record of this infc rmati,oci, and use it to assist us in i3eatifyiurg aria resolving product safety poobl+ems - W ro utinely forward this inf ouaation to MWAlfact: and private labelers to inform thou of the inwlaemat of their pLx)duct in an accident, situation.' We also give the inf omatian to others requestia9 inf,otMti-C n about specific. prodacts . r eed the individual's ne m so that they can obtain additional iaformtion on the pro&jct or accident situation . Would you please indicate on the bottom of this page v hether you win allow us to disclose your iame . L you request that yair name remain confidential, w e will of course, honor that reauest . After you have indi- eated your preference, please sign your name and date the doasaent on the 13nes ptwi,ded . I~1 You am hereby authorized to disclose my came ard aci& ess . I 1 with the isfotaation collected on this case- My identity is to remain confidential . 1 VVV i _ .. (Sxgnature) ( ~s ~o ~ o 05 (ffite) { auars.AW VMWr~x r. p . 25 7 A7 L qaiaz 9cc A:rsvY II-5 . C CNSO iFR p-RCCUC .3 9SFnY a"acSICN AU =TICti FUR RELEASE Cr t &ME 'Ibank yvu for assi sti ng us in Collectun infacna tian an a potential . Pmduct safety p ro4l,eu. be J(]3jnskjjver Pr433cIct Safety ~~ K~~+~+ depes~ds ~ concerned people to share psod w t - safety irifo~atian with Us . We maintain a ,record of this in5osmat3,~, and use it to assist us in identifying a W resalving p mduct safety paoblems- We rroutinely forward- this irdomation to nomifacbxers and private labelers to -infom tt elL aC the Inaalvemeat of their pro&ict in an accident situation .' We also give the irk)~Ewt i,OR t0 .-othetS Tl'Qt125ti11g ftm j.[i atli0[1 abfllt S p i Lc fic- ptpdLxts . I 6~rw+fiM-+TM+or.z lBed tfie Is new so that they ca n obtain additian al information on the prcduct Or accident situation . Would you please indicate an the bottaa of this page ,Fyether yaa will a]1cw us to disclose pms rsmne . If you request that your c a me iemeUn Confidential, we win of ooutse, ha= that reauest. Aftes you have indicated Your pref~,- e ~, please sign ~s name x rd date the doeae1 on t*ae lines Provided. 1-1 You are hereby authorized to disclose my isame and a8clress I_! with the infutsoati m collected at this case . ~~ ~ -L1~ MY' identity is to rein m~i,daslial . a-((~paSte2,),9,- 9a urwr~~wm r- - y p . 26 Exhibit "A" IDIt 921229CCH0544 Additional photos of the instruction and warning labeling on the product container . a- .,--'--- ..._ _ . . . y~ .~,L 'I .4. ... ,~V. ~. _ T~. J. ~_ . , . .y,, .. .~ +Y+ I .. . . . . ~ ] .j 11 ~ a` p . 27 ON 5 Exhibit "A " IUIO 921229CCN0544 Photos of the suspect product . '0 A ww-w I 0 JA' N ~ If 1M I! $ ~! .i ._. p . 28 .~ ~~_ F ~ ~~ Exhibit "A" IDIt 921229CC10544 ) . . ~---_ ----. . -.--. - ~3~ f i ~ =~ r ~f :f) 1 .l ~. . . , w photos of coaplainant re-enacting her use of the suspect product . .`--- . -- ' ~ .-M ~ ~. - - ` p . 29 Exhibit "A " IDIO 921229CCN0544 . - .. - - ~ ~,~i:Y :~.- . . .. .:e :i _ ;-: ::.r.:- .. ~-~':'. . 'Q ~.. ; ~'A, F A:iM,~ - Date coding information on the bottom of the contaioer ; states "C1 . .2" N~GATZVfs p . 30 Exhibit ^A " IDIf 921229CCE10544 .~ `. ~- j - -.: ~yi~=__ :~ Above : Complaiaaat and her sister re-enacting their use of the fabric protector product . Below : Photo of the product in questioa, as purchased by the consumer . ~~ ~ , p . 31 , _ - . - - 3 (C~81 MAR 41993 t . CdiElq. 1 MVtl7UNTOlf s a 3. ofVC4 cone EPIDEMIOLOGIC 930111aQ10667 18 1' IdJ, H-401 , aM .QF M , o "If x DAN M, GAY INVESTIGATION I I I ] I ACCWS 9 1 2 1 1 2 2~5 '~~ 9~3 0~1 1 2~8 REPOR T 4. aYNO rs,s of .ccooj r on cofi&mAwr - Con 12-25-92 at ammmxWt4y 0830 hours a 43 year old male and his 17 year old son suffered chemical ptM abnia after entering a znau in whic h a leather protector had been applied to a mat . Both were treated and released at a local emergery-y room. f. lOCA1fON I tr~ ra we~l .e.~ - CTiY 1 tTATE Home (Niece's bedroom) 1 1 I 0 Raleigh Tennessee FT T-N-1 -al MW /POpK.T I.eathex protector IM 1RA0lANM017MYL IIOOEI.Nq01. tu.usacn>wa a .ooF eW Wilson's . FAb3kher ciVtbqr,- 5 p 0 9 5 2 Wilson's, Minneapolis, Kn. 5542 6 "L xBoO mOM100U0Y n/a ~ III. 1CA 11M . MOM MONK rwMOk:nr M a MoFAM n/a t : AM Of VC7Yt rl !Of A1M wwrbf orM m 0w09i10M ,i tNRMY CNONOLR - 0 4 3 ~ :~ a T E R a Chemical 6 8 - , . . OOOY,t,Rr lf: I1f7NOMOOfip~p~sfl~ : R1 .. / ) IL rim offtZrKLA"M Tom spe w All 18 5 victim a "taaat~ 1 2 0- o>~ ~ IM wTYApetorts Hulti _ a U. CAM lwwcf ~ r 0 IIEVwww BY . Y11 5 ND GY~ . a repwasoN man== ru4ES /daNpii CAM em" C!C MAY tltlCLAS! w NMrd a ' CIlC WY ow 0 naII7[ Y11 MUM u 7a NMrYIflV! ISw Mreim at aw FWI - U . ~BO~OR~L Of/ICf OMtC1q1 lNIlW OAT I . _ . Narrative begins on page 2 . . .- _., (~/d~~~ - : -- .~ -- . -' '~ - . .T .3 : ~=~ prs[ O/MFA 3109 1tN0 .WOr nONK L1e7S i IR ESS"y avwnvED FYIR a5E 1~^S/32/94 CIEL?AT~ 3 04 1-OQ]9 p . 32 930111CCN066 7 attachment 03 U .S . CZhVSUF7Ei ?RapUC7. SAFrTI COMMISSION AUTHORIZATION FOR MEDICAL RECORDS DISCLOSURE TO WHOM IT WAY CONCEM : You ace 6e:e l)v auonorizea co iu =iso :~e Uaices Scaces Consume= I -l oauc : safe: Culsnission all ioiormacsoe and copies of any and ali _ecords you may Save percaioinS to ( =p case ) ( h: c cue oi r1 & e lL~d Vam Zacioash:Q to YOU iineluaia3, x:c noc limicc-i co, ae-licai i :scor7, aaysic M l :e3ofcs . Iaooeacorr Z 2occs an d pacboiog :cai slides, and X-ray K ?or:s and Fiims . acH . r (Sip :ar~e1 _ - OSC M11Y NO. I )O p . 33 -Z- 930111 CCN0667 Pre-Accident The victim, a 43 year old male. lives with his wife and 17 year old son in a onestory single family dwelling located in a blue-collar working class suburban convnunity near Memphis. Tennessee. The victim, a(etter carrier with the U.S . Postal Service, said prior to this incident he had not missed a day from work due to sickness in over 10 yea rs . He said he has been in excellent heallh, an&was not on any medica tion prior to this incident He said he smokes cigaretfes, ave ra ging close to two packs per day, and has done so for some time. He explained that the day of the incident was Christmas Day. He, his wife, and son went to his sisters home for (xuistmas breakfast, as their custom had been tor several years. He said they arrived there at app roidmately 0730 hours . After greeting family and friends who w ere there, he said he went into one of the bedrooms, which had been designated as the "smoking area" to smoke a cigarette. Time was approximately 0745 hours. He then returned to the living room and kitchen area and ate breakfast Th e family then began opening gifts. The victim said his niece received a new waist length leather coat for Christmas from her boyfiiend, who was there. Th e coat was in a garm ent bag . VVhen she opened the garment bag, the first thing that fell out was a can of leather protector spray which came with the coat He said she showed the coat to e veryene, then took it to her bedroom (which was the room designated as the smoking area). Unknown to the others, the niece's boyfriend proceeded to spray the leather coat with the 5 oz. leather protector spray in the niece's bedroom, as it hung on the outside of the closet door. The victim said he went back to the designated smoking area and smoked another cigarette a round 0830 hours . 6qgdqnt - The victim said he noticed a peculiar smell In the room when he went to smoke a second ciguette, but assumed it was caused by stale cigarette smoke. After leaving the roo m, he said he felt a pain in his chest, and began coughing violen tly. Post-Acciden t rRte victim said he and his faunily left his siste r' s house around 0900 hours. His wife said by the time they arrived home, both her husband and her son felt so fU, they immediately went to bed . She said they were complaining of shortness of breath. p . 34 -J- 930111 CC1V066 7 coughing, chest pain, fever, and chills . She said she telephoned her sister-in-law and found out her niece and nephew were also experiencing similar symptoms. After talking about what was oxurring, they both realized the only unusual occurance was that the niece's boyfriend had sprayed her new leather coat in the same room that had been designated as the "smoking area ." The wife said she decided to telephone the poiso n control center for advice . She was told to take bar husband and son to a local hospital emergency room for treatt men She said they arrived at the hospital around 1245 hours Their temperatures was at 102 degrees F . Both her husband and son were examined by physicians and diagnosed as experiencing chemical pneumonia. They we re treeted. prescribed medicatlon, and released . . . . The victim said he continued feeling very ill with he began taking the medication. He remained at home recovering for three (3) days . He said his son was home recovering for 4 days, although he continued to cough for the next 10- 14 days . The victim said while he was being treated by the hospital emergency rem staff, at least two physicians and one nurse questioned him on whether he had Intentionally inhaled a chemical for drug abuse purposes . He said such questions were Insulting and contributed to the discomfort he was experiencing . The victim's wife said several of the family membe rs became ill after being in the designated smokinQ room on Chrism= Day. however. not all of them sought medical treatment She said she subsequently contacted the local newspaper and reported her family's reaction to the leather protector spray, and found out that individuals nati onwide had sustained similar ftesses . Th e victi m's niece who owned th e leather coat was visited and she stated she also became 91 and was bested at the local hospital emergency room. She said her boylriend, however did not become ill . She said he purchased the leather coat and spray leather protector from a store in the Oakcourt Mail in Memphis, Tn . She said since the inciderd, he has subsequently purchased a second container of leather protector for her coat, however, it was a different size (7 oz.) and contained different label statements. She provided the original container for my examination and permitted me to photograph it however, r efused to permit CPSC to collect it as a sample due to possible litigation _ The room designated as the smoking area in which the spray protector was used was examined and noted to consist of approximately an 11'x17 area containing furnishings such as a waterbed, two dressers, and a storage bin (a diagram, wos drawn and is attached) . The victim's nieoe stated the leather coat was hanging on the outer frame of the closet at the time the leather protector spray was applied. and left at the same location to d ry. She said the room temperature was set at 73 degrees F. The window for the room was closed . There was no ventilation. p . 35 -4930111CQV0667 Product Infoxmation : Product Leather protect.,or, product in black metal spray can, 5 oz_ size , labeled in part : "**WIISOIiS LEATHER PRDIMCIOR** C XTrIQd- VAPOR MAY BE BAti W IL_ oQM>a1TS [P>CER Pl1 MSEIRE . ItIIlD CAMMULLY OTHER CAUTION ON BMX PANEL . NET iTP . 5 OZ .**FRIrSONS MII*a APDi.IS, MN S5426**" . Martufacturer/Distributaar Fiilsons Minneapolis, Ms . 55426 Product ppde "292" stamped an bottom- of can Standards Information : Product is subject to 16 CFR Part 1500 -vkr the Federal Hazardous Substanc9s Act . Attac}mmts : 1- Photographs 2 . Authorization to Release Name 3 . Medical Risoords Disclosure 4 . Medical P45cords 5 . Poison Control Records 6- Diagram of ro an 7 Assigrnnent p. 36 MFITi WZ,C :sZ :c.=L .. .w.. .. :r Wr .w ~ "ca'~r NAME AM- ' "' "'a "LAMES ADAMS DONALD NONE 7 " ;~v~~~~: L 3 M I62O533-00 NO ua s Moftm r ; 930911Q~667 "a'~.a c"1n ,3Y 4 ~ER2$79834 w"'""" 000000 ~'''!9 z REFER . DR . E-~~` ~ ~+'"~a;a wwr n~ ~ .rZ=O 'E 7V[ c h . Eva OR n DR M . CARif LOwM + 4POUOE NOIS~ ' ,N0'~'~ -- ''Yl 1 r HOME saff Pann e P s+cZ w wML usn d~~ j HKJA "` . , ;'- s7., . ~~ t !'~~~ r ,, ~.r-r" .y .~ ;r~. i" ~;=;:~: . _,!'a =,,,:,~. `.~.t PHONE wstomr aDIFF Hw REATHIN6/INr HALEDr CHEMs ICAL S rx ~ = r SS J ~~ ; l~/S ~ /v1 Il ""~`- . . .~^ +. ~ i ~ . ~ :._ ~ . !T~ .:`J.. t :i ~ . .~ : ~-`~ . . ,. .s ~'t= . '-;~ -~ ~ .:i .._. .~ . ~ ~ . . ,, ~ .~ ~ = .~+~,, % . .. 1ldW10E KI/lil~llpn _. OFF K CO. Olt1 . ~ -~ OAlOP {Yf M +q 7 . ~ IL ~1~. e` D.' OIL ~ ) coil" HOME M ...CAf,o,. &---Y /1-110!10n Al. hl p~CE pipy/RiK /1~0 Q ti GLLFD ) Oi CF11I~ AND To pArmp . . -3 ,Z A . . ~ Lc ~` 4 i . - :~'Ltirv~A~. """ N ISOMMIS ' P foam a om cm / 5;;-7- lAN OA $f~ pz y~y ~ NOw7E4. On f MO nThq N UtslS ~_ ~ 1100A1 ~ A 1 r rwao~rt rwavitl us ~~ ,... ... ~~ 5~1tStitc)Onr O SEwOUS O Cqn~x I p . 37 93(1111CA4 M attadma' t 9 IR 23198234 oi6 ea53 3-ooi ADA?15, DONALD L 2 0 4 3 OR . 0 NONE 001723 :~. .~,~ . . V&KmOfO 5%WAAffpwdQ Jb" A/e 1780 WARNER AYE EMERGENCY DEPARIMENT ROOM NUMBER 7 . N -3 NFDI~~EAN ~pEN ~ TLb[E ~ T P R EQU[PMEtiT, & LAHORA)PURY OHSERVAT[OM 1 0 /.?1V +`r ~ J6 !l~~2 J ~~ . SIGIIATUItE munN.s SIGNwTURE aatleis INTA OU7PUT "AL 1,1010/67 114 1Jf111CK olKlAd Plrl n f oco . p . 38 93011102U667 ~ ~1(3 ~Q i~(~ ~ attOd"I 4 N~wH" i~"n;~,0.. : , :: : .: 3 LABORATORY REPORT (got) 11i-ms' - . l4 wr,~w~x wum ~ o~,e 162053'1 ' ;+E/!)K ~% : ;'+( ] 'l :' , ~i2 wa1RJn+MYr R0j1BR,n. Aoar Na Aft tac `eoc~ollslWe ,inAMSI'sllNAf.3) L, iK2A5 :I'l d'tY H NIIAF; OR - .aFSw wAww.ac PAM O 4 I2/.~5~`9~ O!_r :, . : :7~~"~ ._ .. ._ . . '~~ . "b;' ,y., J. .: . : : . ;, :t ..: . ;` ;.: : : -'' . . Y . '?j _1f2; .~"~~'~T`~ ..' . .. . .~ ; AR TKkr~ A1.--Hi ddlf, .r.AS . . - _ : . _ - `'c : ::c.,-. ;~' . .:4_z:~_' -_ *= ,'-,~-a''~.~.': aesr~i~i . i~4/" , 7 .3}-7 .45 :: dk+'aR(AJ..:PcYI~ . . :. . 35-4 _~ f - s ~ r~~-%N: ---,, . -ic.- :.=. . 1.Y4Ply ,+I. ~Pn? . _ . 95 11- 5 1AP :,-,~~z~~,zv qRnASanr1,A~'Yi~H . . ART HA S :Ci L1~FIGIr . . ~~ ~ - ~.:~.ct+~, . .r. : : . ~.L":: A4'iRR (Ar, !'1J- 3 T3 , -2aAIP. PIfHC r1f1:R - _; tY4 `-r ::5`: .:llhfi1. A.: . - - a~ .TlMli _ F,tKti~ltR, : ItK41l .. ~ . _ K. .. ~ .~''' ~.- -" ~:Hixr,n~r~^.~F: . A,).F:tJ .TT+ST YItItFpRMKI) _ . -.~.~'-`.~. ..1 . - .:a- ?`` -'` ' ~ S9 13 - to . .i- .. 1.0 . . : . . Ats :F8t5.99 ~ -- . .: .. :: :. _'~, ' .-! . - '3 . CLIPIL'L1~L ,PT.[I[li1 t'Cx. .R 1IxF . . ' . , .;,_y~:.. . : .Y :. .,;,, .~ '. . .~ " - {:. =?iK4.~; ., . . . r v . .~ ~ . _c,- .r , ~ : : ; ~" ~ :,~;_~: 5 : .~ ,;,_t{.:~: .F':;-?. . J`~`~ ~y 5 :~i` < !T- .'r_~-_.Vte;w }i~3..`~ i ~~-~c _ . - ~=?~,f~C- . .` . . -;L, = ~ `~ . : 14_ . . . 5_U"~~ib: Q~ ~~ . , T .~ ~ a~ ir i 1Z}~ ' . .:- :.,. : l-. :~ -. ... l~fi0-.fi':7e11<,~; " '~ 3 . ~ - '~_~r i:, it1{~f1=1~11<+7 .ii . ~:: . -. - . . . ~ . 3 . - 4 .. C : ++..{1 aa . A&4 . - H[~11AYC)CR Ct . .. , _. ~ . ~ ~2 : C=57_`:A: r. ,,~f.y~:'- A:- _kl( 4 H71fi11 _" : , _pA_0-1.fIQ 0 .'s~.~. _ ~;: ~:' _th:H Htf_M11) !` c . Ml :$f. A)ttf111 3T .R-76 .fF' . : :.~' :`: ' ~- fi.A[ra.kf , ;f]1lHC L50-d40 . ..} . . ''QAIl1%HH3 plow 7 .4-10 .4 ~MF : .ID[TIA}, - ~ 'Y i ti~ pt~^LD1FE-Y . ; . 5 1.ID 1 ..~~.,~~:s......,: .~ SK,; HRlI'fl211PH[l. . 50=1A _ u,.S ` LYMPHOCYTE 14 20r- 4 0 M : Ny,~ ttpiJ) N!?1iTd1IPH[L~ t ; 4-5 `!s~ _ _ ~,.... ] A ~-.~~ .-R IJM -{{ .1 fJ{r~~ ~~~.i. - _ -.i -_ . - .. . -'~ C_-f:i.J. M[1RPHf,J.17GY ' ~ ~ w., _ - - r: . ..~ .~l..- . ..-!~'1_~:. , y3'1`- :C'J,JrS?..'.1ML-iii.y.ItA'w i _ :~- .' ~-.`~s~~~:-s`'~'~f -~'`1~~~` - -. :;. . . . . : t- . -s. .-..~'. _ =} . z now p . 39 930111CTD667 afta3aat 4 X-RAY PROFESSIONAL SERVICES BY : ~ MEMPHIS AA010LOGICAI PROFESSIONAL C ORP. u- c $ C7 uN . OF ~~ 23798234 01620533 16-72-75 North Radiology ER J ADAMS . DONALD L . Age 43 NM I ER PHYSICIA N 12-25-92 CHEST PA AND LATERAL : Heart size is normal . Minimal chronic appearing densities are noted in the right upper lobe . No active infiltrate is seen _ Roy KulR M .D ./cv~/ Printed : 12/26/92\ -Tp : 38 AffirH ~ ... .. . . v1JL7L .., ...~. . . .. IfF X,nro vevrw~L v.. ..~ p . 40 930111C11W667 attlAduwt 4 s .,~ N _ . ~ ;. - v ~ T_ ;~ -- >~o - - ~o ~T~ A t o 4 r> . , ~ . O , 3 ~- ~ " . . ~s ~ ~ ~ -- `- r 7' v-. ~ +;~ _ O ; ,Y,~,; _ J .~ p6 .~;_,,.,~._.~.:. _. . . - -~~~t~: ~ ; - 3'i i S7 = ~ - ~ p . 41 930111CII~A667 '~a.owr.~ Ea 2 3-19-8 234 01 \ 2,63 :3 j~A71ENT AFMCJWE SHEET atbxtvat 4 AOANS aONA[ .0 L 00 DR . 0 NONE '001~23 MMUMM 1780 WA R N E R - AY E .n..r. .~~:.ru . . . Al1YlENT AFTERCARE SHEET i. M E M P H I S T H w ` IV/25/112 ; 7}~ IrembWpt ya, -oeived the Emeqertcy Dept is an H-3 - E-3`s44 22-8 ~enieryenr,y treat cny It a ~r raaaon~lit~r m see yaw ".. for it*o~w-up and oandrwM~p care_ you muet make any GENERAL ~JCfIOTlS: - No wBg11I baa,lnp . ~ ~ ~~l Nod necessary arcaigementa yontsetl and take 6mm v4lh You Oo your doctor. Ela+ASb atlscY9d axtretnRy as n1ud1 as passable for__' - tdays ice pack to afbc0ed area kNe+midmntly for days. u lA&frh.la,ao oossiMr eyaweMr n?. aubae3a. or Wutsh o010~o~Qf fA gera o to6 t lkw ftars bean retinad m Or. ~ Wbw-tp cam. Malcom * poittii ent. to We -ywr ptysician -_- in : d~ . ~ ~ s ~ , . M x-ray was performed and a prolin9rtary intarpratapon l~os nwde . The t'net report rvd be a~arle by the Rarltobg st If anY 'ipnNcent chances are merit You wiY be aotqfed at the jllephane aumber you Il+ted. F !Wap ace bandaoe if Ino NOW or bwe. Rawrap at leas[otica daily. 11~Thp vresaiation you nx eiued 0onm4as a a,bstanoe that may make you aivway. Do not dare or dmk .Icohot wNre takt . L.'_ dicstan. . t - - -. Th a OnOM21PbOn you received conmhs a sibaWnoe that ter ds to upset yaur abtaarh Do not take meclicatlon on an empty ahort,ad~ A Mbaratory tent nequUinp several days for caroollon was p p(orrned . The "sst/ts wi0 be tawattled to your docior. 1Rixr may be exwsed Mom work or school (ior . (tqt to oroeed 24 ham). For this beyond tltis parloct approval manit be obtained Gam your Pdvab PrNaCan a 00,r;W 1/ ptr,"cm You may return to work or achoat today. . INSiAUGiIONS FOR GWE FOR SURIRES: ~~.- . . M i- ~ ~~~ i ~ ~~ n~. t` 0~~ . - ~e ~ ' . .-. . . ,' . .~ . . y -. .~ .u _ (3) Watch for idaQlorf . dryam . m dOCtOf k fOdM6l ~ Cf QfaflwQb~BVBO ~ .i-~r, r . - (4) If you return to ER for *Am terlwvat. YOU must brinp form and come between the hours of 6.fl0 am and ~ ~ ~~ .~jaa 11 :00 am MaTA(JCiIOuS FOR CARE FOCL47WING HEAD PLRJRY. 1) FM GpM1y for twenty-faur AOtns. No aedetNes or dtir~ks (2) Awake patient away two (2) hours for the next Iw~etve 2) hacxs (3) K any of the blowrg symptoms ooar, contact yaw Nmediatsiy. if you are unable to Mach your phyaiciarn, raAm to the Eu+eiyetx,y Department lar assistanes. A. Itubitly to aiotae or awoken pstbr+t ~ .! FL GfadTdy to mOVe Outs and too aquaily. ~+~ j C Wnitlnp, catvtlleior4s. mental oodueton, trsllasen0sts ; double vlsiorl, hklnmd vaiom d,*,,Ue ot bbod ar clear AqM Um-nose or eara . - _ +=' - " R S- headache unroYe vsd by medfcation- a2 PftocrW*m received an"M*MrAucratvS: - ~~ ~l r :~ z_~ ,~ ~~ d~t~a?`- .,r Z~' G r s . ~_ G~--..- ~ ~~4~i--s ~c-~e. 0~'- 1/r1~~ 1~~2er,o~--/ lt you are not much inprvved in hoira or, M you beca "'wurae at any time, contact yauc ptysklan Apht aw ay. it unable te ~eacli Yvu physder+, return to the amarpea,y departrnant: I understand Rw se irNtr .; tlons p nd socapt ttiertit M15TRl1CTED C r l.it .v Drj ~ . ~ ~tc f'sv 14xse Oate -- 1~ f~ / L- p . 42 _ 93o111030667 +~~ wc at~ tadnat 4 o MUM 1y EdC.:L CORDS r PARr I GENERAL OONLlfiIONS OF BAEfifik7lCY MBOIf.'AL iFiElt?IrFM - OON5ERT 70 TAEJIlL6Ut took OMWt b A MNpitl i diM WOW s cost d IiRr dl Wdq dM " r r WNL A! m"ho OW Oo iD r w wmd ME w wM wool"" draw beewst A ~t~[x ~tn L~ c1f~/1 : 71~r~aon w~Yb Otarmir rn lXwYrMtltOi~l/1~f YdrYtw~!/~w~wl~AeraatArvE ~ M~o~wws~~e r~rr~wsww A.~w~rtw~rwlt~/wMrr~rtlvaA oW .Oi~ . rwnt~1~y ~~M~r~errrrr+sswwr.~fr srwMsrw r w rri~M AQlIIYfwwr+y Mb~R ~drYR ~dr~Ml~wloYward~f ti iMe/w~e1l~NriAnr M .7r Wwy l aYwawmr r dr1wrw~ d A~ynA~M~ Ar swr Iwwta.rMwrlo/ P.~w~r tome r or .tr rr~wiM~w~ r.~MM Mfr Mrsr dMM~taf Aa~Ywetrl~w~Yr Nr~v ~wwrwo~fi.Y R =MLMNffMlj;ltiitlwdolr+l~~wMfwwo wid so rorsaMrrQm MM.kMAYLMrr~kMqwYMwYrrsi~wdlarbM~es~i .~itrrw~~v~iwrM~ rr~w.rrt~ w~r.r~iarrN~ rrwr~++sriw W~r.~trwwi ~s~ eriorr+.~ rw ..+r .rwa a ~ttDS~ tr rd.e a w . . ..ww r w~. I. .r r wi. w. r+tia.e w~.www . r w . rr .ww r.~ Waft r.. a. ww so"""t tr A. .~~-r ~-r'~R r tr g rrK oft" t~ ~ oft OW ti m Md OWOMOM~ ~ % ad t~Mj t t~N 00 an ~~ Iostl1I r ow W Ono ~oRa~/~Nw~b~awMArwbwwretrw~AMd ./frYY~ L PV FZ! L fE1FJ.RE OF WOfrillalON, ASS10NdFW CF ftSIJRAN(:E BETIE~7iS AND fNAMGM. AGREE7AE?1T !Mw ~ ft~,,~j1~ UUrhrK~r 0y~Yw~rMitakrl~oerl~rMrakwry~o rr~rrrt d ri Awr r w~rrr M w pw~ r r r .~ ..~ ~ r~w .+~ rrDM~K M r r M r M M~ily/Y r~a 1~~ t.t K*~Y fAtrrrr aw~riA %own ftfti eme " !r ZrdtrRMrr4~ AR Mr~4~IMrrr~r ~o r/lri r dIw~Y6~rw /r }ry~ YwYri iwOr ~r MY r ~ wYd~tafs~ r IWrl~rria 1 w~wM rr W'wm d .w oo a badw M wtlt w f~r tts ~i[ ~iM oft aM~dia,wNYOra w11rW~ am ro r lr~*r --- - r ~w~rrww wrM 810011144" w &*" 0 m o u A o Mow" " Is a ~ ~dnd~rd Y~wvr Vr M[rA .ywR rswY id IN Ye .drr MC dNam ft W n a" ft= of 11111 MR" mew to " a " W v F~ r' siw M w 1Ak+w tiit I r1 Is Irllrw,ll~MMA 1M~ r~' irw~.~ ~r r wYNr M T~IYrNIrICYrf 1rlwaw~rr M/AN~Y~~rM/wrlfrrM~fO~Mtll~y~rl~r~rMti~~N~N NwQY/Nb/4rM~w/rr~tM~b1~L rd ww tawrrw wM M~ t/ tr ti~ ~d f 41 " b ts MrM1 ~t rf 1r~ r~~rr~ wd w~YAI irwwr wwwir~rA~ ~nl ~rd~ r ew d MtA M~Mr~K a/ r M rts~t MMw /I~tr M Mwr U t L11tarI~IM AfMrM' r owsi4 al rtnww ru rw" r W, INY own" wii lot w/trtw AN am " dw ~I~a %Ma "onMAN~ wtaf~iitr/rwdqswrrw~Otw~Uwyr~wl/qMr~ _warAjMw~w lii Ut~ CO qlB lIQ UL/!R I.t lilla ON MA! ttN1 1111 AD ll! 1001110001M WO (W 711 1 RIME NW D/ IORn 00 9 001411 131111. Or A4L IUM M! MW= N, ON A C OM WNW. s DM lq6C OR NAY NANOIY'ND tOrI11~Y\~rpsr~Pb~~rlMMor~~e~~MY .aaw\~iYawre: fW caPs-Nr Y~r6N or Y0~ rk11M'NrspOtlm w/Orkrola emir as bF*j dw1 wtir rW o+rarrsft P+a++m~e~wr asearvo .rt MIN11, SW Mw Ir Aa IN omw.r a 1 .06e .+ Ar ~.ifr Allq~oYrtn Okr~+w 4r fw~we A ft KIM, w..r ..+r .rws ft I row ue pow ovision, r W "araft :8 enA is s commono ra, m Gr. ua we .o~~ ....oa ra .12t U, weiaaiw wwt AID MR EW1w O4 S3i3-N Oo S 2N / 51 /n 1re 7 ? NONg rc/aerl . 4007114 A0LtO'J+ML2-E t 7 2379822 1 OF t~lnc pat M S DONALD L H 10- - 2 96 cau~a 5 " 1949 43 W M 0 OTHER 0000 AaolNst - w I HO PREF ,wewr ~ - uE : 901-~Sa-3S32 1780 WARNER AVE MEMPHIS TN 381271335 trrtaa - ._ 1110tn.ars Ana m s tw .x 13S POSTAL SERVICE UNK MEMPHIS - TN 00 000 0 0 aoollvloW aMr61 11 MOW . ~aA QUE MOW= Jabs+soM .wi ! 'r_ooE m T 10 T NCn.E v NRB.oC ~oawAY.KR w1ER A AISJE Y1YR ff 99-999-9999 1A0n0~w/0o~0sA/r00 2A3aa7n9o s8234 ADAMS DORAC =1E :357-4i 6 9 ATHER 0000 0 Gdtrallx IYtBa N AM WWPL LW P GAR! (~~~t) IE7f'pOMM lIYRY ~t'Ji7p A Ita 1//~ *imam "400a WtfM ~oioaFa - am I _ 1 V Ma sooni7s - tf! a "se'' now "^e * plAt 1780 WARNER AVE MEMPHIS TN -418127 E-3544---8 999-999-95 00"'0" LETTER CA rLWIP"""` UN K US POSTAI. SERVICE f NM MEMPHIS TH 0000 0 N~AaTiw L Arf"iSO OCQ:B~FQL$EiT,T82t CArRvia{r .wHwATL_ :ASSQC,.-~E _~ .]_F ~ ._ ' _~A~~ i13D 0$6O =1~ H 96A - ~L -''I QIO . ~~" 00/00/00 . ~410-86- L396 P .O . BOX 9668 SCOTTSDALE AZ 852 a _ _ _ _ ~ :. .-~N : . : . .~,:,-.-.,~-' ~s~--. _ ; -..~~s,a ::::~~" . -a~o:.' . .?4 _ . .. . . 1wswm tCNw m :: :.. -~X_ ' rwCINM o " sro 1. w.[11 .a.w Wra ~~:~~ an ONE s ~JC!A4lnQ r..`. .~.~. __ . . ._._- p . 43 .v.cvE=C :.e-o" wn K 00 NE OT A SENDS TO F PATIENT9 . r . 3 . . ~:`0 r w Mri e51 e e 1Q~667 STAPLE PLEASE FORWARD THIS CLAIM TO att3chnOrt: 4 AREA YOUR INOIVIOUAL INSURANCE a CARRIER""rTHANK YOU ACTP! ee4e781 ARC 6 34*Mot P CO e VEALTH INSURANCE CLAIM FORM Y601GA11E YldCAlO CNMIPUS OYWPYA Gp~ FEGI~ OTI~~I ta r41MEA31D. rluIrE1l Itpt FNDOIIAMw am 11 } Awer.+ e mraovw ~so.wass~o 7 rA NA4E ~.aONawE. Nrla OMM ~vAr+. a ~s+>sv ~` 7t'01 41~86139 6 3 1~ w% SEX a . NSUNEOS wAYE 16aM Alwa Ff NaM- lidft WAM ADAMS DONALD x-o 12 e5 49w ( X F ADAMS I)OIJALQ !tATiENTi Ap011E3i A a . SwaO 0. FATIfFIT IIEtAtqwyM TO wWREO 7 . lVSINW p'S AOOIIE851N0.. SrMC I 1780 WARNER OR CRY lTATi MEMPHIS ~oX-0,0-Q O. ATFNT iTAT116 T C .wls Y.~.aQX ow~ 178 0 WARNER O R COW STATE z MEMPHIS N ~ DrCOOE f~EF110lIrAKaAY+C~I 71 COCIE I 30127 ( 9ix 563-3332 E'a'r'~ t"S>,mr.n ~ r.~n.n sr. . 1 38127 ~t~~~~00E ( 9e 1 3 6 3-3332 c 0. Yra . NMr ' 10. 4 A f0: I. 06Uqi0-f /pl,If,Y G10yF on FCCAYIrODE11 a07MENwllNEd7FCtlCVplGilpwNtrYlER aME EvY 'qUF SI W aWSY tA ~O 'SOE ATM fiOFtrIwC W~WU11NENf~ OR 322 L u ~s Cx 12. 06 49 [}X 0~ w~RM~S0AIEOFMiN SEX D 00 M . A1AOACCbfNfT hAC,ESSWII n lIYK NAY E PC] Y~ F I- + u '~ C7 x . v a E, .ld/E, NA.rE OR Sp10p~ ,AYE OfNE11 ~ ~~ SENO TO PATIENTrrwrrw`7 i MSU~MIGE OR PROGINIAM NAYE ACGOEi1TT i .4~ a r~ FIM NAYEOII MqOfM1.NIE ? MElEIIVEO FOR LOCAL USE a 6 T14M AOiOflE1111EA1.1M #9fE/If N d L C/~ ` wr .7wr ~~ HAN+ ~ YES ~ XIO ~rawOw~ISr~Oae .~aaw00a F7 ram rAU F+ww a 1a0Et'SOaAUMOaREOrEwsoYsEfahA7{R~t.wri0. 11.rAT1E1R'ZORAUTiqMj~PE~O1fS=CN111U1E 1~1rpMwAlOAa11n1.aM/C/O~MIMon~~ .ww{Orf F~'wiMAdwJtalM~bYMv .~r0F/1laiirrtf~ylRtY 1 p0~0~10~/DO~~w.lYrwwAY/~awAa/pw~MYWLLNrwba~r~NFrkWam~wrpw+~ Y+rosarrAaOMw.. w!' 9I8NATURE ON FILE 12/28/92 SIBNATURE ON FIL E s1014o oAli >W E :F'il~pM~OI tiiFATElffIWlNpfAYEOtIirRMUIEiL , DATES PO1aTEftlS ATIWTUNAKATOTIOIKNqMIr<IROCC{IFAYIO n OO ~~ MIORY NaC1Yq d1 f3NE FMSf OArE him 00 YY mm 00 vv 100 Y y df l MIfONAMer{w+ t+loM TO 1ir/ or_ 17. MrYtICMN OTIE11701#PE 1 fa 1 O . WIrER OF NEFfNIN6 PMKIdON 10. Y06IRAtILlT10N pATEi REUTW TO d/q1~pT~11WCES r 1" m tromYY 00 1/Y YY oo rr c To tt.rffEAVWFdllqi'XllSE 70.OUTSOE LAS* EGWG65 - Clip 11 . cuanosot wArnE OF a .-E-w10Tr . NE 23U OR . TO f 17EAE . NE srr v+Et 1 -E --- qS f u YEO~ ILAD AFSLrIrSSVe COOE OAKGOaL 11ff. NO. ~ 16 6 0 J. L-.. . _ Z3. PRIOR AUi1W11QAfIptrN1WE.0 ' Z a. it . A O E F ' ~M1EIA10t Sp1VICE.1 PYr,A Tpe SI1F/tfFS um 00 TV mm 00 w ed at IE~qYi1tWWIG~owwiwo 12 28 9 3 9924 ~ M 1 1 OIAONOSIS ~ 1bYwQES ~ ~ EYO tCr 1 92 Y M OWSOkU PWt C Yrg 2 3 C 12 28 9 I 12 28 92 3 3 71e2+ 3641 t 1 58 so 1 5! I - Wr 12 28 92 A 8es 19 1 32 Y 12 '28 - 9 3 854 2 1 25 Go ~ v. > 71 rEOEMi TAM l0. NU~rEA SSII EN m. IATFXT-a AGCOIAIT NO. 3T. f li fOTA CNAIIGE n -0. AMOUR PAD 3Q rNMICi CUE 62146826 9 X Y1843129C 212 e ys 71 f~iYAnslE OFrY1l51YF1O11maw r .~E11 a,AeApoAaoweESattAUmwYEnE swE11E 32. 0WRIMS ON COEMAI nALS ~MOHIBOpK..awA...arwl a~~ ananY +llE s+eaYwSS~YE"31"!'~~'211e~ss'aFCOOe 1~w. r e+ .a '~h"'"""1""r'+".rA ..nra.1 i'cc~y,t ~J BARTLETT-RALEIGH INTERNAL MEO SAMUEL 7 . VERZOSA .M .D 513 4 STAGE RD SUITE eeese NENPHIS,TN 38134 30 0 1111/93 'lATe ir.,, ~s^. :a^?i~.n .ir-.. . . .w . . :o. .rc--. ...~ .^~__ . ._ .__. . ._ ~ ^ . __ __ . . p . 44 mom :nw . r~r .rr ~ . PATIENT/ADMISSION ~ na vat 91O11102i667 "'c '0'0 c-&t3dhmarkt 4 ER2:3798234 000000 rRAT37p!$'23,1 i!Ali, stsonAL wirsiaiw DONALD L :3 M iG2('!433-001 HO REFER . DR . M FU GMa s s tuwas:s nasn.w ~ onEa owoES E-3 :5I422-= MACK= rw GH E .aoc~ee~a rouC~ Nov~ 4~a , ~a aa wuse sow AmaT.a nnar,ww mm wn % s [_[( s we 0vr R M CARif ,topet 1-MAq PIVATE ~~avsrw* snouoNr aY N,a ea . as. ~ .: Es : - ,~aa,: -- t~ = :+s s VEHICLE ''Pe~`w' ""i'E"r ^''e -.. '._~,,ti.., .~'~t5~'`~'s'=,:. ~ DIFF BREATH IHG/INHAL .ED CHEMICALS ' ~.. . .: . . rYi..<F+e.,~. ? . ,~~.~=~~~U:'~t;%'%'" =~' 2a.S~" 3 - ~~s, +:ti~ St-a~ .: ~b.i~. ' - i : r. . ' .. . ~ 'Wfr`Lt ,, m4K.~'-'. ~_ -~.~.-'r ::.'~~ ~ '~ ~ , .'!t ._. .' a ~ ~ .~ . Q ii{ .''t'~ , . . . ~ ~r. r, - . . .-~Y,*'r'FT _ ~=~~'~. ~~i'1~!~ _~ ~``?[iS?r; Kp : . :~ - s' ~6 . . ~ w1y_.. - .~' `r _~. . :.r~:_ . . ' .{(,' R h.y f ~ - f`i 'nya!{ :K`1P.' . aT .'! _ ]~~y} si : ' - 1~ '~{~ 1 '.T~~6. - ~" -F ~~ -L- . % ` ~ - ~~~. 'J W Qt r -~~ ~: ~'N`s. ;~2~ ~9~"~~ ago -i/~y.h -0111 3CHAM E /ARNMO M 7t (, ji. ' .~ Q :'.,~":}~..- '~~, 2 . .'l~~' K W. '~.';. : ,t :r : _ .M'. . . 4 .:a .r _ ~>~._:a .~' . ~A . ~ :~ ~~ ' Y '; ': fI. i~ _y.~ ~~~I_ . .. ~iS': . . ~ . . :_~.q.~a .. f ~ : .C'.. . .~ . f I~ S~ ;Y:' i'~ ~ - !l~ :~~ - ~~~~ /~y~. -ti ~:-. ~ '~i . .rA :`T}. . .~ii stfr. _ _ .'y ~ ? ~~ ~}~j !.},'.i~^ '~'~ i'':L _ . ' !i.- . .a -~-%S3.,.ir,:_ .~ _ _:~,~r~i`S~:c =de ~.:s: ~ .:i~:. :nl~: ~,. :s .< ' ) t .r- .y~r h,- ~Mr ~ ~'+tt~. :: . - : ~lTl) ~!} '.~ ~> r+~'.i~_-~ :iS''''i=s 3~:"`, 1: ~~ t.~ t? '~xY'' _:):"'T -`~~'-+ -i%~.~ ~'-' - i . `_.. .. . ' ~ _ ; .~_ - = j,` t~r - _~:~'w. ~ :~i~T~_: :", _: f~..~ : t~K_ r~!'.: . . . _ . ~'~,: . '~F :. ~ 7.T i.~._.'' . : :!c ;~: . arosna. w o snueInN *o wex iaF.o o0rr as 0wR wm wmorr ! loom etu on We OR vsti sa~rr ui~fi caarqN an seo+NlsEinWa/EA tow o.coKCtr r waaau. on r w sa~ s+ Nana O oom O s .*swc~or+r O xwaa r3 M. am" MtsON17 awa ...wo~w~ row.uwG ~u~ffoa wn~cMws soww/El p . 45 _ . 51 820 42 , . .2~~f ~'~ 4 . ,,N.. SMI= ouc !nm. _ . . .. . . . .. ' 0 Ada n , ' -.t~ ~T1 8 .Ke F~ .w a~ w. S 1 F SO1 q cu 1 ~ nC/~l,~ 28 .5d :d - ~i ~ F n . fLC t f i f-t L h h A L NPna fn / RALEIGH nED1CiME PC : S ""ro7)o~' '?$ x.rr' : - ~ . .--- TOTA MW SALES SUP ~ ; (J M CUSTOMS .wwr . l wxwMe m ww a .+ tr.wr p wrr.~. COPY Mll~rr.r ar Niw w N caArYwr ~/rwrt~~r Mw~c lMPORTANi REfAW TM CO" FM YOWtlIECOR06 e1 Rec ~~ ~ N0$7~8880 DaCLAR5 CA FOR RENT 1 V (,,f~,6 ? e 4 a ~ FO R ~ ,,ffom CCOUK . pNMBJ~ coo `~ dwOL 'x IflOi~-ii.:S :/,'~ . ..~. G~^ _i::~ .s~',. .~'` ~ ~ tM-`s~t'~, d1l/MiGEOIE ' t :.. : . ~~~:.:: ~ 4. . !'~lal~ :i" . [- o try C.c p {~fi~~'~" S~ F ~~- l ~9 ~ .,U,Z.ol.0 y M -~ - - a ol aoa k Ctti u .5 . `' ~ V/`nMC~`"Iwli~~ s, 76q as ~ ~hL ;,- f~~1~J, a..a;-wc rct ... G lOC't ~- , '^c.^} 4-, U s i . i", ~ I- .vQ~ ' p . 46 930111024667 attadinExt 4 E UU FORK FOR UNAMIGN BILLS NALC Health Benefit Plan _ . "(B~eN~,~l be paia to merilbel) =W WaY~fl~ Court . A.~+, vlr~aa " I . . . ~ :~~ ~ :.?: : : ~:.:.]Y' ~i)r .\:-la'C:L3. ' :l . a: (A03) 72~4is7 r : ~: :. . : STATEMEMT OF I4ENIBER ;*':$ :"'#."' -~ "A ' ur Lb~npkfabAiydea~slpryMAawtoirehprtlnfedNACdN1dvJM 'i7 : = . 0 diti'KaORFfAMM OiIOQEi .7 . .~ . . . .. . . . . . . . :'~ ` .. ~. _ .~ .. . 1~Ih: e-ir_ .n ~ . . . ~ MEMBER INFORMATION''_ 2.- .PATIENT INFORMATION - -- I. _eanr- r cooE SOClAL SECURIII NtN+IBER : :~ a ~ " _"` _ ~ i : . ` : ._:~J Y~.-_ .~I~~M1~ N .Y .. _ .--_. eirLoMarrsrAnati A=M It '~iwr a s aueA%VM s Wjrrvrt R a' : -_ _ . . . . _.. . IVAN . L , CO,,a. ewr JUNK - - (4 9 saw i ar a FeRtww inrar.en T1MXft,d,F Wwrusuna M ~v 'sons o lo t kadntqaa related lo YES No ' ryaa qiw: _ ~__ . ._- :--- . . . .---- . __ . .------ . oraovand by : ~z . ., : . _ . . . - ~- -- . 3. Wafura'CompsnsatJon O . 111 ` OatsefaaJdarM,dlaprrniaand a.om. pMSatioeci~im! . . .. ~ ma btr~ reen+ e oiw IM a . .. . _ .e w1y N ~ . ~Ge ~e.(~t, wn.~ 4. Aecidontat Injury . . __ _if p . Ow.phos aed dbpnosis -12, -0 S-i~._ ~~fo D!r. r~. ~~-a ~ 9 r ~Sa~ ~ S~S~ a~ fr \l !~ ~~050 . . . `~~S 1 w y 1)yr lQi~ e~. .~ .-.4-1y1 5_y(rG { ~\ I Lr' C '7i b d~n oa..a t~r r~o6de a+lo ilrranw7 YES O No~ll Thrd wAr ~r t~~fZ ~~ O ? . r yes. ~ compaiB ny~ 's Iname alld add~ w -, 1 eA 1~1! _ ~ d . ~ M~r -w4 ' I .-- . S. Medicare Number 6. Other group medical / do" coverage BlacWs drto: .0 '~ k yes. b Insurance Issued tlrvuph adiw employment? YES D NO 1 3 . _ . Is Ws an tpq pofry9 - .YES u . No u . --_. . _ S41 - 3Si Nams of person to whom Issuod P,0141110n0hiP to P mdwd Name d oryanizatloo or employer qwarph which abhimd ' HOSPITAL OR lICAt tllINIANCf: . Ham and address olotherinsurancecor"pan -' _ . . : . . _ _ . '- . . ._ . ._ . . . .. . __ . _ .. . . __ . . . - - ??~ Ef(sctfw .data _J-~ Cancellation dri_ J 1(.,'~ - Forw r i Self or~N o F.maty o p~QL ~ _ Ham and a~ ddress o- f cow-kaurmo- s mmpa- i y 131sctivs daft _J~~ Canca6dbn daN " /_~/ Po~r r' __ . s.r o~y o r-.mry o I authorize any holder at madlod or after nls>.d Information to release ta NAtC Heath Bondk Plan any kdoesladon in regard to mysd or my famYll n~o~suy bt proop~lnp Ws or any related dsim . `1~.~:~ AMnsalr+b lem" Ar Pair+tY w~ -J A- 9 3 r or~ w,, in t* that lfwabovaHonnafon6oornct.tlutthe aicbsaCsyprosvsweniecwrad WARNINIiMyietwAonW hbastdonordarwih:l lor the named patient and I am a mamber in good stand4q of NALC . iniump essi yym M10M Dolhis 11a 1 mh 2 v401atlon of 1he law p:nhhabN by a ina krWrisart W or ''17 A ..la~t ecu,- (ta U.S .C. Section 13a1 and nu. s u.S C.) 04W& -Mai .a- p . 47 430i11Q2rX7667 : . : . .'' CLA1M FORM FOR UNASSIGNED:.;BILLS :..a -attalnat 4 NOM wn.n &v dah= aw aoeoG WborAq.:~a:a.yeanra~d .vl~l~a~ .apun;am.a+wny ll alrsa Wa. e. o s.n.a.pakdu. a'ta d I Ior~ or Mho.. p .r.nrs u.m. al,a a.r,a. a .ad, ..vks a 3<,a ca .e o n al hi , . EM .! baa ac eaea~ rl .r~l~ ~ 0 a~~ a~~ ,raP ~! ! ii,~ :~,.i_ ~arl~ ~=:~r: : :;~_,t'~'s ,t .i: r?~r;~^ . a arodl. rr,,r>r+o. oo ip ly r. pmwy oe t& cWm r,.tl .~urra! a p .ynwn ~!n n .a~ e. r,ld~d.a fa .ad! IA wb il d. . . . . ~. . . . . . . - - 3 '>> . .+:. .i11 J- . PAE9C M ION DRUGS AND MEDICINES UMdltflorprnaipfondlupsaMar AeYw lJd wfiprar~ipfanonaa.parW irw rldoompMb~ach COMM llifAt710tUKi BR15lH OMING WORNAMM LISTED GE M LMEOF W R%IKJYBfA 1NIE Cf OF~lO ~ '" ' ' qAC.110616 ~1fF561F~J11~ CHARGES 4. .' . .. . ., .. . ... Uli;' o Of) l~- f~- - . , . .. - - . . . _ . .._ . . as 1 . . .. - . - .' :'r... . ; ' ' aw~ . . .. . :r.'' . ..C.. - _ .S 11 old x se O .. _ ~ . .~ . ~~ ! t . . . . ._ . . _ . _ . .. . :; : .. ~ . . . - . __._ . . ....~ .,.r _ y~& Mw RwwmqAwsiaTmna -- ... 2" 25 CfltJi IN'~TQ~Vr PIl ; TN ~II DONALD L ADAMS 1 7 80 WARNE .1-!IGRHEh TN 353- 3?`t ? ^x''n C523135 O11 CF- F. tc:-lT,. :qCiw-.rIN 0 :'! S TABS AP~.? f oOAtT.rE 5 ,,ia_c/s_~~~u:/C,F~r!f_ Lei. TM-1 1 e _SF ELiN '-- . ' - ~'~~L~K~.1}IOP1fY707~AA[[10T[Wt/ ~ . " 2?2-6 CrJ' : rl!r~ ~'i F'`v ~t :eai_w ;a? N . .. - ' mum DONALD L ADAMS '' 11 Mc'n!}'H_T~ six Na C523136 0 k ('1 . ; -'t~ - _Z 7 L.. . ~ . T . . i TOTAL UIIIGS ; TOTl1L ALL QT}16t G1ANG~, S TOTAL S Z AL I' RA p . 48 NORTH 930111 aa40667 rrYvy rirw .~ ~w ~ . 3960 NEW COVINGTON P 405 6 attac~leAt 4 l MNPHIS TN 38128-0000 INSURANCE PENDING : --` {. .II .I . .I . . . .II .~I .II ..d .di .II .. .It ..I.I,t . .J! DONALD L ADAMS 1780 WARNER AVE MEMPHIS TN 38127-1335 N11TL ASSOC OF LETTER CARR ~METNOD I ST IiOSP I TAL FAV*BtE AM P .O . BOX 1000, DEPT . 9 7 WL 7a MEMPHIS TN 38148-009 7 **0 ACCOUNT NO. PATIENT NAME ~nr~ss~ wrE ascwMGe aAa mrcMtwr aM AMOUNT OUE bUE DATE [ER23798234kLD L ADAMS 2/25/92 2/25/92 2/29/92 251 .50 1/23/9 PAGE 1 OF ?MIS A ip UrEM NT Of VOW ACCOlM(T. IIETAo TH6 tORflOM FOR YOUII IIEIAIIO S Cl/A11QE! OR M1fMd1! RECEIVED AFTER TNE SWEMENi DATE WILL APPEAR ON YOUR OUT f WF1NHfi. ACCOUNT NO. PATW QfT NAM Aowtan M wrE as0ui+icE DAM s4 TE~oai AMOUNT DM DUE DATE F2/25/9212/25/92&2/29/921 251 .50_01/23/93 1 ER23798234 DONALD L ADAMS p/qM HOSPQAL CODE DESCWPTwn AMOUTN 12/25/92 000089 ST PA i L ATERAL 65 .50 12/25/92 000682 RAN 51 .00 .00 12/25/92 000783 LoOD GAS/ART 80 12/25/92 013567 RGENCY RM LEVEL II 46 .00 .50 12/25/92 027883 NIPUNCTURE 4 .50 12/25/92 027883 NIPUNCTURE 4 If YOU HAVE ANY QUESTIONS . PtXASE CALL PATIENT ACCOUNTING @ 726-8375 (MON-FRI 9 :00AK - 4 :00PI~[ ) TOrnt 251 .50 OR VISIT US AT 1211 UNION AVE,SUITE SOO .PLE]SE KEEP THIS esnmozw STATEMENT FOR YOUR RECORDS . INSURANCES, IF SHOWN ABOVE, ~ .00 HAVE BEEN BILLED . YOUR AMOUNT DUE AND DUE DATE ARE ALS O SHOWN ABOVE . THANK YOU FOR ALLOWING US TO SERVE YOU . 251 .50 .: ~ . : _ ME'MDiS'T p . 49 ;~_~_"~7LST +eCic:,L 9301 1 j*O~0667 ~ : attactynent 4 a , ~ '">FV~""E . E R28798245 "E AS ' "~E'u~000000 E9(a'~3Ylg~ gC `!~ M 1187-002 r NQ REFER- DR . '2 l9~saML wwacwa aw M ~ s alrllEa ~ , oneAl ow10ES rwasrt ~rio ' i:a . -. ~ ~ i ~ ~ ;..E tGC~O~. ,~,,CE A~..X MOf .,EO ;, ~a u ~ '_ MEW rn sWi .oum.o Rks~cN .~rc wn DR n CARR ..': . - ~:: . ~ . .i77i1- `'%< i iw< -~i:r'~ !D~M+ ~ - ~.:,~M[ IKDA `3EPit .: sER Carrwrt ' wQ~lr nn .E y~ ~ DIFF 9REAT HING/LNH AIED CHEMICAL TM ~ .~ ~ Ulm ~ rNrarx fir ' - _ h. 9u _ e--- A ~ 4 4 ~~` i ~ . ! F i `\ ~ i ~~ ! ~-~ ~~ '~~ f~ wc rr c L . ! " 1 . ' -+' -~ -~ . i i . ~ . f I . . cow K . CL JRi[ i' IlwESyp11 - OL . f ^` ~ ~ CJ\ ~( _ J , ORiaFt~ir ~. -.d . .~. . Y~UI ~ Qrrr - i K . ~.t1 . +aets ~ .J .v /J s._ _ ~ 16 rr c*m aiRM Amaw mnsutT o~U.nE ow-mrEp AT 1Y Ya cAU$1 HOME OFF" .t .-:~_~ - Nw awg .a ur (7C+w.3e FOAM jr rwo ~a~. 3 . 16 ~EE aa am oN[,MwoE .rA~ . r F o1~ F NO .ETYEA .r :~ I o u .nC77p. a iFar . .~ , .. .~. . IIOIOE S1fF ~qMT~Ef M .' I . . .. . /- Yf I p . 50 , 930111CCIt066 7 attachment 4 E A 23198245 0047 11a7-o0P. AoANS . ooRALO C 2'01 . S T YERZOSA 001 7OR9 4 P. 1780 M A A N E 11 AV E MEMPHIS Tx 12/23/12 e 1iEiWorrWJxwA/&odrS6u ,1,e EMEMENCY DEPAIQMEWr ROOM N[JMM R TIME BP T P R EQUIPMENT. a LABORATOFffl 3 d l/6 ~'/ A/ - ' ? /'7 QBSERVA'IIONS 1 0 w a b -* A 4A +!o lo--' digv /~y Gk ~6 /r.~JGc.- ~o~tc~ic.,f s~~ts .S~r+O1lGS - a D~ u a!l~.. .~ dap 4tM ei G A.-O . lirf z v 7(a.fce- ' s r~~a co~i Pu 9S` SsG.r1r~ I3 d o~ - 37 6K9- f A t far Z- SIGNATURE RX r[ Ais SiGNATURE ertnu ts II4L4xE Dun-UT ~. . . . . .. . __ p . 51 ~~~~ t.r~wnrwr~~w~ ~ ~~+ I AVE MFl1~tX~t~o4, ~~ (!01)7~f'TI 930111pCN066 7 LABORATORY REPOR T .1 ~' ; ~ uMSMAMEII attachment 4 cwwia a wwoqs 0"m2OR OF lArOna .~.eyr'o. ~, '~ . tA1111o t~ otiL AUK 7771 1R 7 ~ ~ t~lfitMa FoorNa Am ~Q oocaawswW a :;A1fAii`s' ~F3UNA.(.A t: 47.i.t ii7' r ~';'~l!~ : :~ i :?:~;~=P~'~isRZC3`i~s~~`1T=~~=~~~+.~`r : .a . ;~. .,. -~, ~yr..~ ~. :.r 22 KY. t1f :141 : n'i ~ ~ ~N ?:. ~,~n,.. ... .:"~'. .N .f. . r ... . , ~ r~ _ `~ ,^,.~,~ . . i; - -~ . s t '~ %1 9 ' to _~ 'tS_ G .~ _ . .4 . i' ,.t:~ :i . , ~ .3 ._ . . . . :t~ " r.:, .. _i ~t: ;; ~tt `. y it ~F~ 9 FiA Kip ~tt~f ._~y { . . ti .. il 1. . :Q^ .% !.!~ . '~ . li il .- ' ~ . .. ~{' ~i _ .. .'Y`'~ - II~ij >~~~ ,, ..}.~,"wa._= ~.. .ra+ .*r:7 .wc-: ~Z; ~;`ty. : ~"~ . ~s ~ . ~=~'-;`:__:~'~ ,~ ~*:;:: s .< . ti~'kb~a/Y7:f~r^v +3^ ~s i: ;a :. . ~- t. :r. ~. . :#. ~._~ . . - .L~ . `i,~~ ~ ~ 7+ .. .t ill p . 52 ~ ;. -~ : ; 930111 G1CM667 attadaac.nt 4 ' X-RAY PROFFSSIOlVAL SERVICES 8Y: ~ = MEMPFYS RAdOLOGICAL PROFESSIONAL CORP ~ ~ OAOKXCGV C u . us k u 23796246 00471187 16-72-74 North Radiology ER v AaAMS, DONALD C . Age 17 WM Sam T . Verzosa M .D. 12-25-92 CHEST, TWO VIEWS : Heart size is normal . There are prominent interstitial markings noted throughout both lung fields present, and the possibility of an interstitial Pneueonitis cannot be excluded from this examination . No discrete focal infiltraCte is seen . Roy Kul p Printed : 12/26/92 09246 cc : Sam T . Verzosa M .D. FAX If 371931 7 R/tlav Y6~A Risi ~Oo Ac p . 53 . --,---- 930111pQI066 7 . attachment 4 . . J Y tJ7~i u A~ ~ ./1 \ ' O '~ A : ^. ' Z lJfJ a ~ fit QF . -',..- 0 ~ C~ Sl ~ > 3 O pt '_'?! Z c CIU ~~~ o tit 8 = i~ : s~? F ig ~~~ l r 43 3 : . ~S t r~ r~70r q F . ~ ~~~~ ~~~t~~~ . s ._ p . 54 1~ 930111aC1Y0667 fm Mae attachment 4 - :ts.'`~ ~ ~ MtIENr AFTEIMME. SHEET " Ea".2o "Ds.3O 1N 98A2- L4D 5o 004o 7118E 7 ":..~~ ~rA~RCaRES~r DR E R 2 0 5C57V A 2 017 The trealment you woeiv~sd in the Emergency oapt is an 1780 WARNER A Vr 001942 enm wqerwy trcatment only. It b ur ax4par * i4y to me yaw ~~j 1 S~C~~ phyaicon for toMow- p and aorM'ira4p prs Mw mid msiaa any R!1 22Z25"92 . xvO1"*""b and - O =rY r*w2wwft Yo +rse and take No welptt bsertrq. E-33'4423-Al this tam vdlh you to your doctor. FJa+rtla aNscmd aocasmity as much w pow" tor days. ba pack b affected am ktxmNOerMy )a wa1d, for axcessiue sw .u. ny, t.,mbneea or t U8h oCloraNon of ri,pers or loes. You has been na/errac `!o Or. for kdow-up care. Md e an appoirwment 10 no your Pt+Y ocian in days, An x-ay wro perioreed and a Prefr * SrY tnletpraMon wae mada~. The Iliad feport wl ll be made by the Radobplst if OW dp Ill's r~c clw~pas an rnads, you wr0 be notified at the ootrpNarw number you geW Rsw+ap am bandage If too Wit or loom Re+wrap at Meet arx daly. The Dros crOtion you mashed contains p substance toot may make you drowsy. Oo not dri~e or drink alooNoLr83e taking this erclkatlon. -- - 1'he p reaotptiort you recaked contains a aubatancs that tends b upaet your ab M edL Do not take medication on an empty t0oetach. A laboralory test iepuiritq se-eral days for compietlon was prtormed The raadbs wM be brwsrdad 10 yaw docto r YOU may be ezased from w ork or school for (not to aeed 24 fnus. For time beyond this period, approval mud be obtained firam your Omafe physiden Cr campaay pNyaio}an_ You may return to work or achooi today. 1JSTR!lCflON13 FOR CARE FOR SU'RJRE3: (1) Uake an appok>timent to aee your doc0or a+ 1 2) Keep aWrh ea dean a dry. (3) watch for inkction . see yaw doclo. it redness. swaNMV. or dninaps d walops(4) It you rehrn to ER for auhrs m movaf, you must txinp this bin and come between the hous of 8= am. and 1190 am. KdSTiiUG'T10NS FOR CARE FOU.fyWUJG HEAD KWRY: (1) Eat MpMty for twenty-lour hoars, No ssdatlwas or alcoholic arirca. _ (2) Awake patient every two (2) hours for the next twelve ( 12) hours. (3) M any of the AodowUnp symptoms acar, cooled your docfor imr adletety. If you are unable to ntact yaw phyafclen, rohrn b the Emergency DsparOmnt br asektanoe. A. kwhlUty to amuse or awaken pationt B Yab4Ity to mow amn and lege equally C 1kbnYfkw, mwubfoM menttf oorNWloq, restlessntss, double vision bkr red vleior4 draiiapa of blood or claw IqM from nose or ears. - C)- Seoero headache urwelleved by medication. 4anwaotion, +eca'wed Medication recekvd In ER DISCHARGE 11APRESSION ~~~~~5 onitA PASTFA)craNs: IQ~~ .. . i-,00C 'Y' m61s Qs qu~. 9d t~ror~~. ~ ts Abe ~ t~LrZc,za~ Mr~,,~/ 4~s. It YOU am' not much improved in -hours or. if you become .wx at ar ry birne. contact your pHystaan rig R away. It unable to Mach your chYak iar+ . atum to the ertnergercy deoartrnent 1 undetatS~d thew irotructions and aacept iNem: n . .,. . ~. p . 55 930111 0CM667 PLEASE attachment 4 06 10- SFrNO TO PATIENT* *******'*"*` 9 56 0 STAPLE 1N THI S PLEASE FORWARD THIS CLAIM A4A YOUR INDIVIDUAL INSURANC E CARRIER*"THANK YOU* TO Gw ci ~-' +ca ACTP9 0 948641 ARC534 P CO s ;H EALTHlNSURANCE CLAIM FORM 606*,, y 1 MEdCA1~ IYEOCAO GuMPUS CNMIPYA GROW ~~ /EG O ta Nj9URE03 to MAMA fdi MpGiyy W new t , A. (sse 7pw 41 i86139 6 ~. PA /tNE Nr~a lylne. MdM. M~Yf 1 r~ lMq~ SEX i tN5i1NEOS MM.e &M Nrr irw Iwwa Wr. rwlu ADANS DONALD C o 1-4 7.tu flX r 4 . Af1ElIP6 AODRES! IM..lwMl E . MMIIflIBATIOfWW TOOIS~ ADAMS DONALD L . N9URED9 AOONESS YM.. SaNn 178 0 WARNER DR : cm - 0 x.el .o u+^ , a+? 178 0 WARNER D R STATE t PATENT srwtUS OiY A~ MEMPHIS T spq]X uolwO aw.. c- MEMPH IS TM I~ rw cooE TELEPHONE wwo . An .. Catla zP ;,00 f j r_ .E71oME t.luuuoE AI~A c00E, IS ' ~ 38127 ( 98)L 353-3332 38127 9Yk 353-3332 ~ p ;L onmiq OY NAM KMtNY1M. NYIw YW4 1!E A TO 11 . 04SIq1E0 SP'OL1CYCwm*,/aOA XEG RSJ~ U. 32 2 a OTHER UaSUllLO'S POUCT OR GIP aM6EN a fiMKOVYFNT. 1CIHr1EMT ON NEV10US1 .< 11yY11[030ATE O/lNJN ,~ ~ 2'N~ on. ND CMEw ~AIINEtrS OATS OF aRTM S" 0 . AUrOACCJDEM[! PLECElSw> a E1MtOrlRS MME - ' " ~~ ~' ~ ~ YI 1 f l-_: j e ErPLOYEN19 MANE OR SCHOOL rAYE OTME11 ACCbENTT WUIMKCd RAn MI** Or. AOGNIw MAW vivE5~ ~ S SEND TO PATIENTr"'w~wiwlwTia+w,rS w~~ s wi1AAqCE Pt1W NAM OR PIIOORAO NAY! 10s NESERVEO 0.0L OC~L USE e IS Tiqi ANOT~p IEALTN ~ .~i1TP~Mrf 6 -irs :: x/o rT... ,....r .vcawr rl.>t,a. AUD O&M OF FORM af10NNOMlPd11L 1 10 SWEO'SO0 YflMOREO 1af0rilONAtW1E/rawa 12PATlNTy01lAi1T q1YLlOf[/161(~?~yW1AftJAE /rArU ti1~.drYw6ul .r ./IpMr1~M~1AOYatrY p~ .wi/ .IMw6iewwMabhYnOMfiErMO~llf .iafllrln~vlr U OIOM Y~a 1 MM OMM P~yOM . d1q p'7 ft 11R b~ft~ O1Mw a or. pow-ft iLapR J~l/IIIWO 1M~OM wp~IH! Mw~ SIBNATURE ON FILE SIGNATURE ON FIL E sKYan-~ oAZE a~lEO _ 1_ T 1 a. DATE Of CtMqEUl. 4NEtf IFrM~q~y OR ts. I AiIfMlKS IMD S/AE O00p 9Ya.AR l1NES5- tE OATEi ATIENT yic~liE TO PqYf wCt11UlEMT AIqN 1 0o n~ avES/~$roA7F', u . r+r ~w oo TV w O TO 17. wU+E Of 1ffFERM1 MIY3ICYW (M OTItR SOUIICE t)a LA MIWEAQF IIEfEPhl10 PNV9R7M1 a. t105PR~ >~ OtwB MAW TO ~~EMf~ v~5 I e~i.C ar E *' `r` 1tlESEAVEDfdpI.OGL mom m.OUTSb_Up , TO sCtublOE s ra - X- :1 . a #"TUNE of s wuav (ABATE ITEMS , .:a 0n . TO "W i+E ar LMt ---- ~ a.~uE0lauot,Eww~On a ~ ~~ 466 4 ft 23. P1U011 A )IIIOIK7AilOM WNiEJI 9 .t s . 1 N 1 1( Z f XT4lIOFElqY1CiT,A Pl~p iTp fEi1VCl.t.011lU/IUES ~ RE>lFAYEDPOR 0 Mu 00 `/7 E OD Y+f ~ ~ FAM~UwwlrOlawlMrwp COpE E C7MNOEE ~ F/m* Mb con IOCKIME 12 2 8 9 3 99284 1 92 6~ i_ o 12 28 9 3 7182 12 28 9 8 3641 1 6 0 12 28 9 A 8i91 1 32 Yi i { La 99L co < u d ! laEfloIL TAX LO. MIMBEM 5611 'M 7x Pl1r. AGCOWT Ib. V. Pr ~' 21 . TOTAL CMMIGE AS. AMOUNT Aq 30. MtMICE ow h? 7 621 4 68266 l18 4 2517C No s 187 0 s 91ONA11YEOPINastCYWOltlPlip . . J& pM1EANDA0011E56w uOfrACLtTI Si11Y1CE4WE11E 33 .1NYSICMNS O~E4n~ " ~pR1ESAZV000E wou~0ua0EeiileesoMC~EOE.mrls 11F+oENE.l0 . l+w Ll . .c " wrwwww .r" . w www.t A~'~LETT-RALEI6H INTERNAL f{ r 5134 STAGE RD SUITE 3 0 9 SAMUEL T . VERZOSA .Ni. @iiee n,fe.c MEMPNIS .TH 38134 _ :;"ED 1/11/9 3 nnre aw + Gap. uvPROVEO @TAUA~uwtX ONwE'atAC SE:Rweewel PLEASE PRIHTORTYPE 90/ '?"7/ n t .,_ fiQ~iM'~ .JAA'C~ .1n 7020~Ma OAM~R~' .S02 p . 56 NALC Health Benefit Plan MW Wav+y Court. waeean, vkqinh 22003 930111 QcM66 7 attac,Eynent 4 . CLAIM FORM FOR UNASSIGNED BILLS : .~ .-(..:s. .e. nefds will be paid co memberj ~ STATEMENT OF MEMBER ~' QmipIMlNbfandls~t~N~Nbiobqdlpl~Ma~dqa6e~MeAr~ur ~ O o*011osFauMOE .FA00FUMs . ; :. . ~ MEMBER INFORMATION 2. PATIENT INFORMATION SOfJAI. SECURITY NUMBER T -~ OPUMWff MAW WrM 1 +waWiw 0 MwaNw MMnwr o -- - ---- . --_ ._ - PATIENT CODE WK Q 001 670 an taru~o~ M d~pp nk~t.d to 9 1 YES 3 3 .3 NO N y.., yiv.: %AM ORtG CF .R.1 ~ r L roYBMEeS O S- I w' waK .r.n,. ~,~,~n u suaE o~aaeo 0 _ 3 Workata' Compensation o 6~ D~t.otamid.nl.d.Qta~isandoomp.ns~bncl~im/_ J 4. AflddarAal InJury - ~~ O Dat..plaa.anddhgnosb 1,3-S- /__~~ ~ a - l q i:. . ,..oi Ls / 4 daip mrw.d br ~huM iAO haaxx.7 YBB u No u pr,I f~6iy (a6iopdar~? Y89 ~ NOO ~~ 91 0^~!. ~{arN~,~sM y.. . waur.noe oomvany's namo and aedraa. W . i c.,.,~ ~ ~ . .:~ M .- 7=,., r' .~ . 5. Medicare $ co `y u` ~l 1Mdican Numb.r ~ Ei1.cWa data: Pitt A_!_! PaA B_!__J (oil Other pro p medical u Y y+r. hhauanc. iu.d trough actiw .rnpoym .aJ YES 0 No (3 S`t~ der"amuvraW Is this an HMO polic7R YE9 0 NO u .. -3SlP! Name at person to whom Issued Relationshil; to Patient Nano at organization or employer tivrough which obtaine d NoSwru at Ye11Gk1 NsuRANCE Name and address of ah.r in surance oomiaY DENTALlqURANCE: - - 773 Ei(.ctM*dm. Cancellation du._J '1" Y a yE l to a Po6cy ~ - SON Only u Family u _ 6 ) t v i~~ ~h Nam and address of other kisuranes compan y EN.diw dat. Powq ! CancelleflOn dat " Sell Only u F.m/y 0 i auMroeii0 any hoktar of medical or other rotated infmmrbn to release to NALC Heath 9enaR plan any idonnatloa in regard to "nall or my few* thia or any nl atad claim. ai p+~r. /-/ C - 9 3 ~~~ .~- t-~-93 u.. Q.w f atti7y 1ha1 Mw abova IWarmaNon 8 oort.at, UW tM i ~dos.d azp.n..s w.n lnaar. d tfa namad ( am a member in good standing of NAlC. WAiW11G:MyinlwAondfab.atat.mstcrwW ~ J1 ~(~~~r /- / Y 9 3 A~r~s aoa~r. . - q~ or ~h6 law purishaw by .~ t~m~or both. (10 Us C- S.dlan 1341 *ud rak 5 us.C .) cf 1 11,01 p . 57 930111 CU4066 7 CLAIM FORM FOR UNASSIGNED BILLS attadunmt 4 NOTE YNweYnpdWulardoeM bbofat~x+tXdura6bnMdnl~qlipnw+lMe .llp~nan,~chiuppwala~d61<ta B*anYwdiq>o lk db arle d..eatQ/on el sNV~o.. pd.da nra. and dluq. tior wd, swAo * Y i4eWrsan .~ h7~ 6ltu tel~l at baean~ n,.Pl.n .litaoo.pi .nralindawnfd pra~fawln.sir+l.iilroan~eon --! ' , . KudutiiNanm ea I p 1yi pwrry ~n tlix d~ ttrir~bn d~ ban w>st b ilrJldd tor ~ad~6i>tubmael PF lESCqF1101i0RUDSA11011EO1CWS tlwClartarpnsuiptlondnrrpanclaadclrw t3~t~oahpwodpionaoaaywab~andaen~p~wq~f! ta4an 4TlJId101RMi N41 ~IIOwNO 1~GRW11oN tJtt@ t1Ba~ ~ 10(t11JM~ NA1EdFOR1G OIAGiw~~liNB447F611ED1 p{AqC> M ~ _ E.~ a,~. : t i ~ ! Q ~ t fill 1 I- g . j U! v/~~ CZ r _ ~ - at O bfuldoccowt Uenw+rwyMaioTn w>t - 2926 l'at'?NGl'Ort f~Zt : 392-?~'3% ~ Ills T N M01 Df]NiALD C ADAMS 1780 4Jrr^.NES G 4 hl MEMPHIS TIC '.353-393? lax"O~CS23133011 CAP.R ERYTHROMYCIN 25Oi'6 Ts:ES - APSOTT-ROSS*000?4-b3-'6-_i 3 - ^ 4n i IuL % Cr-:LLiM11 TMt3? Hr ."r pnn 12i 2';/?2 s e-39 ELl A , -- ~ZLitL~ttrrre-'12+e PhaaaucyMerica?nws - ! - arca2F.2u5 ICcOVT*NN^uTQM f:t : RL __ . ~ D~NALO C ADAMS 1750 -- H MEMPHIS i'F. r `- Rx"ck ~C523134- ! c.~c r l ~ __ S-~ 4~?t~ :~_ ::__- .` ;, ! DA +: I~G 1LL -- ! _...~ TOTAL Ofil[i4 i .. 7DTAL ALL Oi11EA q1ARf73 i TOTAL i y 9~' p . 58 Mff ur7o .,. : F rawaw .d.IW Ar a METHODIST 3960 NEW COVINGTON PIKE MEMPHIS TN 38128 9 31111QI%7 NORTH at~~t ~ DONALD L ADAMS NATIONAL 1780 WARNER AVE MEMPHIS TN 38127-1335 INSURANCE PENDING ; ASSOC LETTER CAR METHODIST NORT H wucepc-qo P .O . BOX 10g0, DEPT . 9 7 w om rVrD MEMPHIS TN 38148 - 009 ER2374824 DONALD NA M C ADAMS ~o~7IYCGWRNQPATEsapwaat o~towwa[ o~ oa~ AMOUNT OUE DUE DATE 12/2S/9 12/25/9 91/86/9 B .QQ i~ . , t-- ~~. / : METHl7DIST OttTE~. . i : ..:4 :~ P,A ~ G , . E; ~:1L;1;.,tOF l _sl1~~E'1C~MTdFM01111 IIF~1NlliltlOll1101f 10U111iC0110t , ~w .v '~ :. ~ : . '' -~ 171A~tili 011 MMIiiMliillCdlllO AriBl tll~ OIOE WtL / I%~fAlf ON 110M1l1!]CT inqFl~lf' :: ~j. a'~~ r' AiCCO!@YlNQ '3i~~`~;~;;2M~IfT.NAME .' ~6Y.~s ~':FC:rSt /IO~w~iaNOAR orbui~0[Om O AMOUIfTDUE DUEDATE n ER237982 4 DONALD C ADAMS 12/25/9 12/25/9 si/86/9 B .Q Q DAtE :: ; .HOS~to~t.COOE "~# r,C~s - -:~~,: r:- .' . OECCNpi10N AMOUMT . . ._. ...w :T 122$92 ' . s'13567, ti?i~:'_ . i ;. EMERGENCY `RM -LEVEL 11 -~ 46 .08 12259P l . . ;;HEMOGRAM . . . . 51 .08 :122592 . ... .783 ' .BLOOD GASjART 89 .96 122592 27883 "VENIPUNC?URE . -4 .58 122592 27883 ` . VENIPUNCTURE .. 4 .56 122592 89 . CHEST .PA'B LATERAL 65 .58 122992 6168 NATIONAL ASSOC LETTER CAR 0 .00 FOR INFORMATION REGARDING YOUR ACCOUNT, PLEASE CALL ~ 251_50 PATIENT ACCOUNTING@ 726-8375 (MON-FRI 9a89AM-4s00PM) . onram 251 .50 0 .00 E.1~ 'HO.D..L.. ST p . 59 sr.w~Lrw~: y - -MM~ " REGORDS 9301 170Gi0667 ~~ attachment 4 ~ - P11RT 1 GENFqM. OOfdDIflONS OF E1AEAfsFNLY IMDICAL TAEAfW l ]JT - 00ll5ENf 10 TFiE4n4EM !d ~rt Y~ w. lo~prf i WAw~ ~nsr M o+ ~I Ob~lir rr~is d~ ar dwit l1~M'r~ w~ ~ .rr d w .. .fsl wM rA .s wi~.-. a w Asior A mags OWN= 7)~ r6nywl oqMM~ b ly ~t~~ Rw a a~'wMl it M1 -IS LYe~Mry Yoo Owl N~aY~i, to~rlK ~ry~ d PbM~R~MbbNd" ~ v AM@~ P~r*A ba#y, SO M A~MIO a" NrAm 1MWM/rrlhr~yw~r~ so" 4"Po Or om . d~Mrl~yre s O rrwaer bWrM~thrN~irr~ard~M~d~adrd~itN~rrMra~w+.ar~+l i ,~~:~ICIY~A~~~Mi0~+A1i1~OrrM~Wi~/AI/iba/y4~ATMdda04tsOdi~OYM~wM~Y~YiirAorlw~aaly~MM~I ~~ ;~`v.rMO~sesw.M " .tiw. a .rebr .wrw ..rW.R .wwr~ :l.drerU.r 6. ..wmwrf .w.v+n +a. b Sar sm+rerrw .a d~M ~~I~ f NI~~ Iwi~ w~~~ b . ~1/~~Ii~~ I~I~II If ~dA~+iPil ~Ibw ~rf/O b01M Ldar 4 Mi~lfllYrler . CL au ~ra 9 ti . esaa IS oew V. Mod 9 wK ~w~ oft" M 1 d ~1/ ~ oft~ drN t M/u n Oawrn al * O"" ti' MM r IS M++ ar so IdIM daiwl w.a .i . ..ru.. rr IS 1~0/ 54t /it1f~ d 1~1~ : a II Fif F#XP L RELEASE OF M#;0F*AAT10K A3SIGNL*Nr OF RiS tFANf E BHdEFli$ AM FlNANCJAL ApAEE MENi A. tY M~M~r. 4 f~Nab b MN~a ~r ~M~ONY AMe :y~ ~f6 ~r idw~ M ~!~ Mit d lrAM O N brY lR ow-got Sofro" drYw/Ydmem iWiait~di#IA` issues b+AiR I IYb~M~w~~M~1#~in~Ara~IMM~M/r4~~walal stow 14,. a4... 0ra or or y~~ tirAwMiWr I r XMblft 30 of Val ~,?I IV Aatla owl" 1 b0rYr~ ~a~Mr d~Mo/ ~r MM6wM+rr4 port i wwM Y S . rWl~~r AwbqMr r Y~uwMf~Y~ v twYi ry I~wr~ iuafr W~aY ~Yi~ lw~wt Mt spawit of F/4d i/MI ft M smi es bolrf d b pYR bs* le 6w AI/ /ipMrt tiiy W rr1rIMA U .nf ry d b~ik ~ prio IiAo IL Wden4me =WIN" Avg% "anvor off he for"WINNOW of posiva or of anown IL seMl~a e i~M ti iia d M ~~ Mibf~+Y~ wb how" w ~MY. larw~ M1q 1r .iw ~4_s Mre*R bYYf b 1bfi~l aiwfwrblr~Yl ~bib ~1b~~WYi Ylw~Mlw1~1Y~i~Merr1ldwd~+1M / M1~bP ~r4W 0 n Y pWA~MiI mMQ~wI rr ~~ i.rw ~PM~/ q M M4Y1 vA v Ai~ b}i /rY/~ lan~t M!M d M oead w1 r, W Or L~wv Y wrwM~d ~ i~f brMl~ If am tl iY~ U~ U. fM7M~w1l1~wiLMdeArMwviww ri~IiA~rAiw/ridM~~~r~fYY~1~Mw1M~~w ~e syY~+bw~tYN r~W e~ibr~ t Mdns (fl001 ~ MtMY~oK ~4pt ~~welwl d Mb~ewi4 Mnl. _ U![ I NDONOW ~ 11yR 1E/!E WA I M al MM INW 1 IEM A4 FORSAONa W O IdkWORD A GOrY S I 001110204141bt OI TIME AYEMt APO Om lOmOOsO Gt7l O010w GF A0MINIm1 am IOCQ11 . O Z116 l1 QW T Qi CII.Y AYIN01@D f w iwdar brwar riwe ~am p~~ d ~wr rtlM. ~~ e~t.v ~ ~~4 wes Aarow+rr ~arrdaA~ eMr d .rft ~ lwilr rawrii. M aiati a uft major 4"brft lli e WifA o rCb/ iirOMdaAp~Yf Me4~R MnIM 814101000 !M 1Yprr~YM~ br Cape" b 1A /Ur M AroAnrli lllOb~Wy Sls~+w lar Aw.s ~I cis IMA WWF/y W~oARb bdHdYrl c WIN am {flat 1080 iWm awfidwid No Asia, at - now.m . .a .omm. OR w "NAw"oIr ri . .. .U/ .. . o.L Naaec ~a.~.a.~ e~a ~ oA MAW NO 471 187-002 12/25/9 1P 1942 VERZOSA SAM T 2 :51 2379824 5 Bff WME MGtA11A O~ i1T1 AOt A! M ao .c o.nAr A19S DONALD Y 00-00-0000 0o/r1 ,, %1971 . 5M 1 sit I N 901-v53-R33 2 Wr +m~a~ - u~ ~ aaaaa Aooncse - uE : 30 WARNER AVE MEMPHIS aMeic awa ewM :CORM S TN 38127193 5 1DENT UHlc - MEMPHIS _YN 00000 WSUM BAMOWS /NdE lldtt /OIA OAR rRWlt Afll40506 11N d de IBM= 00 I DENT ~M ~o norMr arrnoB+cYn+EMear IbJ~e 99-999-9999 0/00/00 23798245 M~.ex aFwwNS+ .oa1~Wa h5 19m. DORACE 01-357-4619 tiRANDFATH 0000 0 RMW A r Noawp. Wr o VAR IM~1o NSa1.E AVRY MCJSd{ M YN! W*Mff now MAO" , M3 DONALD L 412-8-1396 J ATHER j 1620533 901.- 3-333 YiEN6 JA~ - tf! 2 R d;C[ MK+AiII /1qNfc ItYFI I 3 WARNER AVE MEMPHIS IN 38127 - :s54423-A 1 999-999-999 1O/t LETTER CA R`T~"3 -""E UNk ~ ?[iSTA SERV CE Of MEMPHIS - TN 00000 .R.e'AmoSvaSl OC: OF LETTER--. EARR .61EtiTL'YM ~kIlN SST QC :=OF c pR .. pMS-.s ; : ~' : _ ~ DONALD . T"dQ~7R.3~'" Oct" ~...s. c" ~10-86=-Y39~6 - :,;,"A oW , 0/001 14 10-86-1396 P .O . BOX 9668 SCOTTSDALE AZ 65252 - ' - ~ ' '- -- '....:tz:.-'._ : . .;.:w:r.i~~+y.:ai*a~wr.~- ~ ~~;y::.,"^~+:~..=. :Yz:l'i;+r.'~';:;.n~ :}~'~;' :- . A :Y :,- , .R=.~.t~=.:::~ _ .. . _ . K~ a.r ~OI MMK11 ~Gi7 M11~Y~ ~M71tiVf1E1 .. - .- ~a an env f O[ i OQ n/0~ ~ ~ . Ciro" p . 60 146-2180i oATE : TIME. AAPCC COOPERATIVE POISON CENTER REPORT I~~~ 1 Ica066 7 ~ . attad~asent 5 I~wsop ua k 1L-~ CA" T,n b" +N m vbw"r,MrvM~ s".rno- rRYMo. W ~oarww r. .r4.r vwrww . ,. ~ ~ . ~ . ..r. W . .. s w. ... . a wr. .rr, .. .. a urw... s ..r~ a .r... a MYw+Iew.r a awr. t, Mr.w+ L Vrwwn . PATIENT Tilephone no.: Jlddnu : Relationship to patient: Telephone no-, (9~' ~ ) O Sell u F~tl~et u Mother ~OU~sr ~ ~ 3 ~ Z- Zip: Address: O ""!phis ~~]( u rno . ~i . vWipht J 1 ~"1AyrD Alt- -u k4 Z~P' coilmr. Se : : it 0 Femafe C, Unknown $U. of Caller Sift of Expo.we sertin.n[ M.dipl FlisMry ~H ~~ ~~NR knewe aMeraict J u O v u :hock her e if patient is pregnant a 0 Medical history unknown u MO name & no. : u MOSTANCE DATA iubst.noe Nfoakpi.ea u He" Care Facility School O Odw u Unk+wwn 0 {nwunt .. ..al,tr Me ,ulaciiire. vV)~5z~ LO-6 3~8' --~io~i j irt,. of / since .xpowrs: 1 ' arte Of exp Mw: a r.,..na, o oar.. u o.mw O el..iss.. u r.W"WW o u*,w . u w iSTORY. ASSESSMENT, SYMPTOMS A CALCULATION S ~as~~Ee~- C~ller's Sus ~ G.erc in rz)~m ~uc~ 11.tory wltrt.ased4 .!mbutq wrill .d? Other s?) O No gem produce suspected c~a~- u:os ,~d z abc~e ~~ ~ cucr9~a - i p s tay ~ wo5 ~ r .~ ~,vc ~ u.u5 (~9 5trc cAsc, ~ ~x n ~lu C rn ~ ,y f -fir m 59 U *-Y ne bJeetlre eamplalnis/obhctlve Ilndnps C No symptoms at tlws lim lair 9 CU9 9 09 11~) {X cr ~ ~~- b"; c~k{. ~ rea k A"= E~ ~ cai~ C C ~ 1g~ tsessni*nt (syatPtom . .xp.ct.d? rationale?) Cw ~'{h~ , Initial assessment (choose one) 3C 0 o ..,b,k-*c ~- }yCF- C sr~ow+.c u.a.~ea - ~ .~ .1: - - r n -: p . 61 Fad,ity: MANAGEMENT PLAN, FOLLOW-UP NOTES AND OUTCOME time i data each enw ) Treatment suggested, 930111 CQI0667 attac3alrant 5 Code: .. . Symptoms to monrlo.: ~ V'\ , , o ~ - ~ . Follow-up schedule: f t S~sT~2 W~-~~.~ "l,o L . 1A SiSre R. e 3 ~rs . Naz4~i~ . '~i3" 4o c V ! S~~ ~ 'ST ASSi ~ ve-Ir\ ~ , Z)bntk~. . \oe.tke_r ~'-~ , o~.~,~e ~ ~ ' -~-Vi ~fl$ a~ ~ ~ l~rG~;~ ha M~ ~ 3f ... RTAlJTS/NEBpIIpCES USED : 0 AAedical dk qcwr !7 Ottrr tonsuhan c C To-as 01 OM,e. a :O dY' . - FONM --- ~ o r ~ J r. .. .. . .. ...._ - . p . 62 ~930111 OCZ1066 7 SOMERN POISON CENTER t t " continuation. c tacimm 7-4 5 cj Aae Ada= IV srx,e kbn.+Of k Ten JM03 ~ Patient tiatle s = : ~~ ~s . ~ . Locatica : . -~ . _ substance : DATE TtM s Phanw aneber 3 - 3 33 , . . ... . NOT" M831 0 9 OATtO ANO IOMlO ST FLIbON MAKING aulaggs eb L // s cavlt ot~a~- ~.-~s " 6J : lJ :s ec ~ ~ :,(~ ~/ ss= m~ . .. . . ~ . . . .i~j4~J~~. .. . 3~ i io~{`j ~, ,~ 2 . : .. :; . :~:, ~ s :~.;:-.: ~~:~. / / . ~ / . - .. . .. . .. . . . J . . - ..f \- 1 . X1 .c.4 ~. P4~1 ~'~~ _ . . ~ : ;~'_:} ~~ .. ~:-. . : . ~ ~ . / / _.~ . ., . . - = :.CC :i : . .~ . .'Y : ~_. .'0~7~:. _ ~.},,~?? ' . . .- . ~ '/ . . . . . . . - ,?('e~'t~:iY:~ . ~~t~~i..~n :w`-A~.~'zi~~f-`~-'_~Ai~~ ~i"^f7'~~ ~"'~~:}:'t~'`S.+,= ., . / , / . ~ ~ f r3''''- ._ : r:~ ~ _~ .': . . ' ~~~',~ .r . . . . ; ~' _ :~~s' T',6 ~,.~.e : . _ . . . ~~ .~.~~ ::~ `' , .~ ., ~~ . - ` ' ,;;1:~R~' .`F}a-c~ . ~ e~_~iY . . . ^~`Y ~ . , _' . 1~:i~tP ~ .L,r: . . - ^ . _ .:~ :a.tr- : ;, ..' -fp^ ._'~~~~`.-~'i~J-L~t~,ii=P.'.i ~ _,~r.',,~+~~,y' ~ . '_ + . . i .~y,. ~ i l ... e~$t ~s~~.?~A :~_:Y~ :yaT'q1~!'.: .~~~~!~-- . . '~27 : ' . . . . . . . . .fn3- ' :~~:~~'u~ii. -.:'Jc'~'' . j .- - - - : - _ =-,-- :~~ . . : ~, . . . _ . ~ _ . . . .^ a4 :i. F:~ ;/:' - _ - .}~.:r_ ..:~t .'~yiw . . .. .j . .~ .. ._ ' - ~- ~ - . . . .. . .?=-~- -.+~'j~S_ . . . _ .. ,~~ . . . . . _Ki~.I" .. . . - ~yi :~~ ..x ~-4:'.~~~_ . . . . . , . . ! :. 'j .~i4 ' ; i ~' ~ ~ _ . .. . .'L~~ . . ._ 1 s ' < - . . . .., ~::~: : _ .:,:~: . -=,.: _. ~~ . . ., . ' i - ~~ _ -. . . . ._. .. . . . . - .! .~r'y . _ _ ~ . . .. . y . ~ 2 :. ' 1 S . ` . Ld p . 63 930111 aQN066 7 attac hment 5 AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION VIA TELEPHONE TO : Peter A. Chyka . Pharm.D . Executive Director Southern Poison Center, Inc. 848 Adams Avenue Memphis . 'IN 38 1 03 You are hereby authorized to release to the US Consumer Product Safety Commission . Tennessee Agent : Janice Mitchell to investigate incident. the case data that involved the fo llowing person : K~.r ;~ l~Glar~'~ ~ Dc.rt.~l'1C~ k: vw-- My relationship to the above person is checked below u Mother u Father O self )(Other. please de .scrlbe LqW f ~ ~ ej~ l1 -h )OL :AC: -i , ' Verbal authorization given by telephone on the following date : Signed X14 7 Date c 7/ 19H9 For Poison Center Use JDate rect C ase no. p . 64 1~ 621.8021 f]aTf : ' ~E : AAPCC COOPERATIVE POISON CENTER REPORT 93o>a~o66 7 attaclroent 5 utc trrE(n McwwM # Eowr.7v .w RFASONIIU(o '~ w++^h! (w +r! 1... .w w.ri+l r...~r~w """"~ wr...q a Sr' C~ I(-I ~E' ~ I~S ~ ~ ~ c~e..:..~....,.w ......i ~.~ r. a a. a.- ... .. : . ..... ~`~ . a or" I7. Yr- a o....r.~r t. r. .. ~a w. . ~ v.. .. PATIENT DATA CAIiER OATA ,~,,. ,w,nK ~e~ ~J - Telephone no_, RsYtionship to Patient: Addres= Telephone no . : ~~cm5 u sea u Fathrr Modw u Olher 3-33 ",-4- 0~o~ Ija ,wenax u 1A.moha A W- n G mo. 2~. Vdok +t 196 ~fbs ~o kp. IIa iCounqr. Sex: 'xNWe G fenuie u Unktw~wn 7o rtm ant kMdinf History: Healthy -, No dv~nic meds No known _sgeraies ( eG7i r! ( i (ALUAq sift o( caller Si.. of Exposure i . . ~ Nesida+u u tlVbrkaace u u J Health Can t fyelity u u school lack here if pswen is p.pnont 0 MO name & C Medical history unknown fl Otha no- 0 Unknown u 0 UYSTANCE DATA Anton" . ~wunt 1 Y\ ~lPd TiJ~I~ is. otJSiwco eupoa,n: ~ b F' (~ VA of Expoqrw Dippuo . 06 dkoaVNYd OOn+1r u dnwd QSa/s>winp u Pa mrvvat u Unbawn TDN1: AS5ESSNIEN'f. 8YftAP70MS i WllCU1 .A7fONS ttay (ydM.ssed? amount aerMed2 ofNer proaucf>hrledms?) u No other 'products suspected u OtlNr - ga9gic jeedw eatlpl ts/obJeedve dndUqs C No spmproma at this i+ne _ ~ ~ Q~~~{ ~ J (G-o- ~V~ iL.~ l. l1 ` 1c r ~U J Gc~`A Y'O~ tsament (syn+ptaros eipeeted? rati e~) ,w at. .isrneaN (CAoose am) C ~Xpr w~ C Arrah~...c i F-11101- 'we ~ Sreewr.e vve~r~cu = s,~. .e.s....~ . . w a . . .. .,, vt~ 1~~x'r.tt.rt~ 3 . p . 65 930111 CU1066 7 attachment 5 Fwar = - Coda : MANAGEMENT PIAN. FOLLOW-UP NOTES AND OUTCOME- (Timw i daft "Ch entry) Tfealment suggested: . . .. . . ~ 5ymptorna to moalwr. ~C S Q c ~ Follow-up schedule: ~ c - t4 r C)C. QQ~c- Z ~S1A~ sPC . ; d~~~s S'lSTP~A~ c~3e'v-t ~n- tioc..U s ksTet' T`o trrL.J '0620- it, ~1c~~ f~ ,(A.S . A4-^~ , ,S'~ ~ ~4ns . N.aekiv~ . ~. ~k '-~ ri ~~~~ 1rv`~r . ltF~~r spo I~u c.- "s~- sa~v~ csJ~#- 40 '2-9- . ~ ,j ~,QJ,,~ Sdc ~s oy~ ! -b i v s ;s ~ `t l} Vol ~ix~o>~~ s scf~ was ~ ~ . -~~- ~ ~(hc, ti~3 s. e~\..n ~ i .~i.Et~. ~ ~ ~~ ~'~'~3~ r- ~ a~.''~i uZ ~ rv~l~s '~} ~~ .c~c>-`J ~ r 33 ip., k,- , 35~ i Gv 4, r,.D Q 3 r , INSUIrq c /RESOtJpCES USED: u Msdicy dGisctur Q Ott . cowatent 0 Texts L] Other -a~x~ AM _ '~ ti ~ 1 (1~n fORM -^- 1 -2 04 5 p . 66 ~ ~~ . SOUi1-IERN POISON CENTER s1e Adarm ,Muern,, &Asmph lt terx,.:..s JSloo Substances : :,; . :`~? '; ;.' 930111a~67 attac hment 5 = Continuation of . r.tient Ham : Locaticc : = Phase . number : 3d-3 3 3 3 7- 18 T! TIMR N OT[1 MYST NN OATtO ANO i10M/d rT Fr1RiON MAKINO F1NTN1[F ! 7,qA,40Nj' '-' t $ =3m 1;r~J~ -o~~ ` -~ ~----- a+-. ~ ' / / ~ '~nv c~ /2 ~-I~+~ !.m o . 4 t - z ' sa~1S f . Y31 /q-J. 15 bi Ad&-- in it / / ~ .J . ~ :~' . . . - ~_. ,'~ .- :e . . - . _ w - .. . . . . / / ~' ; .' "_~' -c;~_r . _._ ' ~ . .`~r .~; / / 1 / / - . ~. , . . . ~ . . . -. . - -? ~_ . :Y:, ~s. . . . . ; ya;._ . ' . - / / / / . . , ..- . . . . . - . -~.Y- ~. ....~ '.y_ . ~~ ~.-"+;l:+,`?:.T 4~',~'. ~~...~.~:.::.~-;_ . ~ _ .~5==- . ..rr . . . .. - ;: . .~ . s. . .. . . ~~ ,.^ ..n: : . . . -:'~ ":' ~i" :r{4 " i7' ~+^~ ~y. .~ :^y1~r .:.s a.r.r~;:. '~.i* : 'L . ' :.~..-1~:,~~ .~ ~-_ .f : . ~}~=ryv ~ ' .~'.:CsG.' : . / /~ . `_ :'Vr~ ~ `~~Ra'~'`' ?~' ~~`T5~'~~#`: . . .. _ r~r':"' :.' ~~~ " r { , . . .:- . . . ~ , - izY ;_~ . . . ,~,.t~, ~~4~~~_ ,~y .~c i.:~: R .~.-r'1 i: : . _ : ~.~J*' ":, ' :'1~',.e . / ~ . . v~ . .~.-i`~'+!l~ ::,'_~7h~ . :?~~jffi . . / / . . .. .. . '-ar' . . ~'~` .~nti :1 y!G7 as ... . .. . . .~a~4 :}` . - / / J . ' ~ ~~ , - ~ : - : :~3'. .r'~~_[~' ' : bti.'i~_,-.' 't.b,{"~~i::!T+1!g': ~: _ ~~:7:... . :~f3t.~'. :: Zr, . '" r. i~'{? : . 5,: ._..2 ~` ` ~ ;*~!n7 "^~' :~:~ ;;~'~,.:~~~ . 'y. '_.~ .Y~ =.~ ..s'' ~'~~~~~a !R,~~[. ;:..Sw' :_q+'~.~i:'f~~'~'j.' -'r / / / : / s _ ., ~ ,-~a~'`~,~~~`"~'~r,~~:!~~::, . ~.;_~.:<.,...~*':~v,~i~. _ f _~'~=a' ;. _ ;~V: ....it..--3:._,,r.i..~-~ '~" ~ ~c~ :_ . -~::[,.sf.. rt.- .x~,y : :F L <. _ ,. . . .~ r f :^r~. . . -l:-"~ - . ~ . :~i:e~:.:..' : ~:~~1-'"?'-p,~+'v^__~ ~ / ) / / , / . ~ ~ : ' .. ~ : " . . : ~ ~ . ' . . . . :s:+.: r.~=`r.m~ ; r"ir*~w.~:h .~aa ti Y'r 1~~~:'~-_ . . .. !k. ". ~ f' J~ "~t~" - . :_ '~'-~"'M ef' .. . - ` .. . =~~,.54:-'~. F ~4:~:.' ~ . .~};. : ~: -1 ...L j ~ -. . . ~~, - .i ,- . ._,y. - . . . . . :'~- ~, . . :. . 'i' . ~t . ~ .- .. .r- , .. .?~ - . . ~ . . . ~ .i''~:f..-.,`=-'L4t.~i.^! : : .tt~'??~~_ ... :.-" -: : - . a:~: : .' . . . ~ . . ~ /. _ - . . .- , ~ _ .. . . .~ .. ~"CJ!~.' r .%iE;~ -~ f. : ~ : . : .~ sf- r:- -_: .__. _ . .. ~ . :~~.~ :f~r~ "~.h:o.Yl1"'.. . . - '~': : y `_ :... r_.y. :y :: _ . . . . . -- : , - . - ~ .. ~ - . . .- ":. . ._ . ~ / . ' / . . : =~ : _-,~ . :. - . -.~. . . . . p . 67 d . t! 930111.0'N0667 . attachai 2nt / 6 Diagram of Bedroom (where leather protector was sprayed) ---- ~ - -- - ----- -- ~ -------c_1 .o_s .e t . .._ xx ~--- M leather t was haz~inq on the frame bf this closet ! ' m '~ X I F` S rf - ~ . . ._ -_ . . '~ ~ I rt O- - - . ~ W1 dw ~ClOSed/ --'-------. Not to scale . p . 68 930111 OQ40667 attachment 7 Mrc,zAav.G>NNa so=MLCJZA , UCU ~'~,'~;. I CWHObO. .MT. .. P. IsPe.M 0 t eo~i Dfl "Y zo~ ~3ti ie~rJObb7 DEC-30-9 2 ~ - . -o04s:u- .re:.-. to:_~--sP- ..r.ay . leaves 2 7 . :peop~ e i11 o unters snbmit iatormation -, BYy J]on Hamdiioa ^'i : No o nsumer has died. r. .- _, n!! ~. ~~- -.m :Felu sonm :'c:~n-trS oi icexatcrraec:eitiiveadt Several members of a btem ~ hundreds of eaqs since Christ- - - ~ Mer!3 }~g maZ ~ ~r~tn' ,~7e(~pl! z tYpor ~If :pCOpf-' RatiDn~lidc ~ OOttghiIIit~lGa. lhorftleiS~ ",W h0 fe~ ailL Orei the holidays bleath and Other I11-Zik! sy[IIqalter'y4n toms after jexpoaure-Co the yro 41ea~ther_~~ rotectoF;poisoncontrot 'duct -Wibons add the problem of cff uTs sai d~ay. -&eems to be a petroleum.based ' Iten' Adami; -41, of Prayser substance in ' new .five-ounce said her husbaa.d, her son and a catu of its leather protectaat ~ niece were treated in the emer- - Chyka said-the spray irritates gency room at Methodist 8ospi- the lining of the Inngs, causing tal North oa Guisbnas Day after . the symptoms. * : .sgendiug-time in a room wbere a Carey Adams, 17, said he rem- leather coat had been sprayed had something was wrong about with the product. 'They couldn't ?S minutes after he left a room breathe when they came out of in phich the product had been . the room, +shqsaid- asedlsl,]tatKproofaleather cost . '- iDn~ioodiy;1Wflsons ; Sueee .na J'-either Co. in St. Loais 1[gyivlaernigasssat.aqrutie+dtrhauars tgiinn=. ," he 'Park.- Minn-, -recalled na,aoo sald_ "ft . worse and cans of leather protector spray +aorae." his father- from 600'stora it operates, in- and others who had been in the cludung several In Memphis. room alto began coughing. He The Southern Poison Control and his father are better. he Center in Memphis has - con - said, though they still cough and fit med three local reports of ex- are congested_ ''= . . .-: postu e to the :pray. said Dr. Chyxa said people who think ter Chyka, executive director of ; they have been exposed to the the center: . 7lvough Sunday * spray or have questions should . there were 27 confirmed reports call the center at 3 286406. Wit- of illness linked to the sptay, he - sons is encouraging consumers said, adding that the number is who purchased the spray to re- ilkely to rise as more poison turn it for a fail refund . p . 69 930111CCN066 7 attachment 02 U .S . CQNSIMER PR]OCK'T SAF7;'TY CCMMISSICN AL1IB0[2IZA1'IQN FOR RELEASE OF NAM E Thank you for assisting us in collecting information on a potential product safety problem. The Consumer Product Safety Commission depenft on concerned people to share product safety information with us . We maintain a record of this information, and use it to awist . us in identifying and resolving product safety problems . We routinely forward this information to manufacturers and private labelers, to inform them of the inwlvpment of_ their_ prod Wt _ .i;i situation . We also give the information to others requesting information about specif ic products . manufacturers need the individual's name so that they can obtain additional information on the product or accident situation . Would you please indicate on the bottom of this page whether you will allow us to disclose your name . If you request that your name remain confidential, we will of course, honor that request . After you have indicated your preference, please sign your name and date the document on the lines prvwided . You are hereby authorized to disclose my name and address. I 1 with the .infornation collected on this-case . . 1-1 My identity is to remain confidential . 1 f 30-93 (Si.gha re (Date ) w. ..r ...rort r.. Mc ."M nu_ .e4n. p . 70 930111aCN066 7 attachment # 1 Photo #I- This photo shows the front panel of the 5 oz . leather protector which was used to spray a leather coat on Christmas morning, the day of the incident . \ Photo 02 : The leather protector was sprayed in a small bedroom which was being used as the "smoking rooe' for the family maabers vho smohed . eoth a 43 year old father and his 17 year old son became ill shortly after entering the room . _ -- -~~ ~ . .~'~ p . 71 930111 C1CN0667 attactment 01 Photo #3 : This photo sl ows the aiarkings on the bottom of the S oz . Spray can which states "292 . " ~,, . p . 72 1 eacning tirlet - MedYage "i'oday Pagel of 2 medp g 'Wr TODAY Visit us online at www .MedPageToday.co m Waterproofing Sprays Booted Off Market Over Illness By Michael Smith, MedPage Today Staff Write r Reviewed by Robert lasmer, MD; Assistant Professor of Medicine, University of Califo rnia, San Francisco May 08, 2006 Source News Article: ABC News, Chicago Tribune, MSNBC MedPage Today Action Point s Ask patients with respiratory illness - coughing and shortness of breath - whether they have recently used waterproofing sprays or tile grout sealer . Note that this study suggests that even when used as directed such sprays can cause illness . Revie w DETROIT, May 8- Two waterproofing sprays for boots have made more than 170 people ill with respiratory problems, researchers have reported . "You basically Teflon your lungs," according to Susan Smolinske, Pharm .D ., of the poison control center at the Children's Hospital of Michigan here . Both sprays -- Jobsite Heavy Duty Bootmate and Rocky Boot Weather and Stain Protector - have been pulled from store shelves, Dr . Smolinske said, although the recall has not completely eliminated the problem . "You can't buy (them) but we continue to get a trickle of exposures" from people using products bought before the recall, said Dr . Smolinske . Dr . Smolinske and colleagues in five states have identified 172 cases of respiratory illness related to the two waterproofing sprays plus 19 animal cases, they reported in the May 5 issue of the CDC's Morbidity and Mortality Weekly Report. No deaths were reported among the human patients, but three pet cats died from exposure to the sprays . Physicians should be aware of the risks of such sprays, Dr . Smolinske said . When treating patients with respiratory illness, she said, "they should ask the question : 'Were you using an aerosol waterproofing spray?"' For consumers, she said, there are four guidelines : Hold your breath when using waterproofing sprays . Do the work outside . Limit other people's exposure Keep pets away . The two sprays were meant to be used outdoors . But an analysis of the first 150 cases showed that 87% had been exposed while using the products indoors and 13% when using the products as directed . Some people were exposed when sprayed boots were brought indoors before the product had completely dried . The two waterproofing sprays contain fluoropolymer particles, which combine with a hydrocarbon carrier, heptane . In the lungs, the combination prevents gas exchange, "and you asphyxiate," Dr . Smolinske said . While there were no human deaths, the researchers found, 10% of the symptomatic patients were admitted to a hospital and one man was hospitalized for 19 days on a ventilator. "We had no deaths," she said, "but we did have one near-death . " Dr . Smolinske said there's little doubt that the waterproofing sprays caused the illness, which was characterized by coughing and shortness of breath . "It's a pretty high case rate," she said . "It's at least 1% , http:/hvww .medpagetoday .com/tbprint.cfm?tbid=3244 5/9/2006 Teaching Brief - MedPage Today Page 2 p . 73 of 2 because they didn't make that many cans . " What's more, she said, some people who became ill later used the substance again - and got sick again . "One guy even did it a third time," Or. Smolinske said . OPuf ltsheeopxaimtieentrtys,o8f0pwateierentksneovwanlutaotehdaivnehboesepniteavlsalruaantgeeddinfrohmosp6i1ta%lstoor1h0o0s%pita(wl eitmh eargmeendciyandeopfa9r4tm.9e%nt)s. . Chest radiographs were taken for 47 patients ; 13 were positive for in fi ltrates . Eight patients met the case de fi nition for chemical pneumonitis . They had bilateral in fi ltrates suggestive of chemical pneumonitis and pulse oximet ry of less than 95% on room air . Dr. Smolinske added : "the problem Is not going away" now that summer is coming . Similar risks are associated with sprays used to waterproof tents and other outdoor gear, as well as with the tile grout sealers used in home renovations . Also, she said, new products using nano-scale particles - less than 10 microns in diameter - are coming on the market and "we're keeping en eye out for similar problems," she said . Nano-particles are easily able to get deep Into the alveoli and interfere with gas exchange, she said . Prima ry source : Morbidity and Mortality Weekly Report Source reference : Centers for Disease Control and Prevention . " Respirato ry Illness Associated with Boot Sealant Products -Five States, 2005-2006 . " MMWR 2006 ;55 :488-490 . Disclaimer Th e information presented in this activity is that of the authors and does not necessarily represent the views of the University of Pennsylvania School of Medicine, MedPage Today, and the commercial suppo rter. Specific medicines discussed in this activity may not yet be approved by the FDA for the use as indicated by the w riter or reviewer . Before prescribing any medication, we advise you to review the complete prescribing information, including indications, contra f ndications, warn i ngs, precauti ons, and advers e effects . Specific patient care decisions are the responsibility of the healthcare p ro fessional caring for the patient . Please review our Terms of Use . 2004-2006 MedPage Today, LLC . All Rights Rese rved . http://www.medpagetoday .com/tbprint.cfm?tbid=3244 5/9/2006 p . 74 Leather protectant makes dozens sick Page I of I Posted on Thu, Feb . 09, 2006 ~m .'~ W- _" ^,5 -- ,~ F~,N~-,~~. Leather protectant makes dozens sick Poison control centers in Midwest say 165 il l By Jonathan O . Rockoff Baltimore Su n WASHINGTON - A water repellent spray for leather products has sent dozens of people to hospitals in the Midwest with severe respiratory problems, and it appears to be made of a similar mix of chemicals that prompted a recall 14 years ago, poison control officials say. Since October, poison control centers in Indiana, Kentucky, Michigan, Ohio and Pennsylvania have received 165 reports of illness after exposu re to the spray, which is sold under the name Weather and Stain Protector . " Jobsite Heavy Du ty Bootmate" or Rocky Boot Last week, a Maryland man became ill after using the substance, according to the National Capital Poison Center . The poison control center in Syracuse, N .Y., has also had four report s, a toxicologist there said . The Consumer Product Safe ty Commission is investigating but has yet to take action . Neither Manakey G ro up of Grand Rapids, Mich ., the distributor of the leather sprays, nor Assured Packaging of Ontario, Canada, the manufacturer, returned calls seeking comment . On ]an . 3, Manakey Group agreed to recall the product from store shelves, said Susan Smolinske, managing director of the poison control center in Detroit . Two days later, the Michigan Health Depa rtment issued a warning to consumers . But poison control officials don't know whether the company performed the recall, and some are frustrated because they say the company refuses to identify the states where the product is distributed and its chemical makeup, saying that is a trade secret. Offi cials worry that people who have bought the product may not know of the serious health problems . '' If they've been using a waterproofi ng product and developed symptoms -- difficulty breathing, chest pain -- they should not shrug it off. They should seek medical attention immediately," said Rose Ann Soloway, a clinical toxicologist at the National Capital Poison Center. The pain feels like an asthma a ttack, and some doctors have misdiagnosed it as pneumonia, said Smolinske . There have been no deaths repo rted . The symptoms mirror ones that sickened at least 157 users of '' Wilson's Leather Protector," prompting a recall in 1992 . The manufacturer, Vangard Chemical of St. Louis, recalled the product . No one died . 0 2000 6aaenn Journal and -ire s .aetcc sources All Riglil, Reserved lat~ ::~.uc n6i., crn http ://www .ohio .com/mld/ohio/news/nation/ I 3827780 .htm?template=contentModules/print . . . 4/6/2006 p . 75 WNDU-TV: Danger in a Can Story : Jobsite Heavy Duty Boot Mate - February 02, 2006 Page ( of 4 ~ YOU CA Search WND U Site Map Advanced Search 1 :20PM EDT FOG TMP:58 Live Doppler SkyView 1 Autos, Houses . Rentals and tiAerchandise Find or sell them in. our Home > Wws > $Wcial Re~orts > D anger in a Can > TOP JObsite_H_ Jobsite Heavy Duty Boot Mate Boot MatE [ Archive j Posted: 02/ 0?12006 06:00 pm Last Updated. 02/032006 08:17 am Mishawaka . IN - Watch broadband video P "Job A ingrsea It s the kind of Prod' uct most of us have Make W t used at one time or another, a shoe ho C~ protecting spray . INFORMATION However, there's one particular brand that About WNDU Adver tise on WNDU Michele Cripe and Bob Sherry love their poisoned one Mishawaka woman and her little dog Elvis; he's full of energy, but dog, making them very sick . right before Christmas . that wasn't the Contact us FCC Children's Shows case They are not alone. Hundreds in the W:%'~ -- "~Z Midwest have been poisoned as well, Contests HDTV room . even sending some to the emergency Jobs at WNDU Meet the WNDU Team Public Se rvi ce T he More You Know Press Releases TV Schedule In a special Contact 16 report, we warn you about this potential "Danger In a Can . " Unknown toxi n Michele Cripe and Bob Sherry love their little dog Elvis . He's full of energy, but right before Christmas, that wasn't the case . Sites Mentioned on N "i noticed the dog hadn't been acting right, he threw up," says Michele . "His RESOURCES breathing got really bad, real rapid and shallow and his whole body felt cold, it 1 6 Health Resource was like his whole body was going into shock . " Ask the Exports Concerned Elvis maybe ate something Classifieds he shouldn't have, Bob took him to the Daily Email Headlines vet . Subscribe I Unsub. Ga s Price Update "By the time he left, I just started having these horrible, horrible, shivering . JobsMichiana .com uncontrollable chills and shivers and my Holiday Events breathing got a lot worse,' says Michele . Festival Guide Local Events Lo~ Links Movie T'm--s Unioue E ats Not sure what made her and little Elvi s sick, Michele called her doctor. Michele bought a common product, used to waterproof shoes, but. . . " i said the only common denominator was this spray," says Michele. WNDU Extra The spray is called Jobsite Heavy Du ty Boot Mate . http ://www .wndu.com/news/dangerinacan/022006/dangerinacan 47719 .php 4/7/2006 p . 76 WNDU-TV : Danger in a Can Story : Jobsite Heavy Duty Boot Mate - February 02, 2006 Page 2 of 4 Im Michele bought the spray at Pells Shoe Store inside a local Meijer store t o USEFUL LINKS waterproof a pair of suede clogs . Do No-t Cau Lists -5@ x O ffender e rch Michele says, "It said use in a well ventilated area and I had sprayed in here ; Un_Gaimed Pro~~rty it's a large room, I had the front door open for some fresher air . " Safe Alerrs Thinking she had used the Boot Mate spray correctly, Michele was concerned others could get sick and called Contact 16 to investigate. Bob said, "I was getting ready to write letters to the manufacturer and I suggested to Michele you might want to try Contact 16 ." Contact 16 called the Indiana Poison Center and discovered an outbreak of poisoning cases in the Midwest . Indiana, Kentucky, Michigan, Ohio and Pennsylvania had a combined 162 poisoning cases . Boot Mate made 145 people sick and 17 animals sick . In one case, someone went to the emergency room . In a phone interview with Dr . James B Mowry, of the Indiana Poison Center, he said, "That's how we sort of picked up on it because people started reporting this to their poison centers and all of a sudden, we noticed the same product being mentioned over and over again . It gave us a due that there was a problem. " So, what's in Boot Mate that's making hundreds sick? The only ingredient listed on the can is heptane . "The fluoropoiymer is probably what's going to be implicated in causing the effects . This is something we've seen in several other outbreaks of the same type of respiratory illness with other types of water proofing products," says Mowry_ Fluoropolymer products are commonly used as water repellents . Indiana, Kentucky, Michigan, Ohio and Doctor Mowry says that fluoropotymer pPoeisnonnisnyglcvaasneisa had a combined 162 irritates the membranes of the throat and people sic; ktheapnrdodu1c7t maandeim14a5lslunsgicaikrw,aycsa, cuasusining inflammatio n . To get the poisonous ingredient out of Michele's system, the Indiana Poison Center recommended steam therapy. "We were in the bathroom for 20 to 30 minutes each time, the dog and I both, just trying to get our lungs open and functioning again," says Michele . 3r . Dr . Mowry recommends you not use Boot Mate, but if you do, he says, "You should do it outside when there's nothing around you . Also, never bring the spraye d ~- . product back into the home until its After Contact 16 called the Indiana Poison completely dried ." Center and discovered an outbreak of http ://,xva, .wndu .com/news/dangerinacan/022006/dangerinacan_477 I 9 .php 4/7/2006 p . 77 WNDU-TV : Danger in a Can Story : Jobsite Heavy Duty Boot Mate - February 02, 2006 Page 3 of 4 poisoning cases, we questioned why Us Michele says the situation could have product was making hundreds sick ; since been a lot worse . "Someone with small there is only one ingredient listed on the children would of have had a much more can, which is called neptane serious health situation happen . " Why this particular brand? Meijer tells Contact 16 it did not sell the shoe spray, but a store it leases space to Pelts Shoe Store, did . Meijer added, the water protector has been on the market "three or four years", so it's rather "odd to see, during 2005, a high incident of customer complaints" . The Job Site brand is sold nationally at a rather high rate and might explain why complaints have been attached to that particular brand . High consumer usage would lead to a higher chance of problems . Meijer also tells Contact 16 Pells Shoe Store pulled the product after the first of the year. What do the manufacturers have to say ? A Canadian company called Manakey Group manufactures Boot Mate . Michele bought the spray at Fells Shoe Store inside a local Meijer store; they tell Contact 16 left several messages and Contact 16 the water protector has bee n on the market "three or four years", so its emails for Manakey. They have yet to rather 'odd to see, during 2005, a high respond . incident of customer complaints " The Consumer Product Safety Commission also tells Contact 16 they are investigating Boot Mate, which means there could be a nationwide recall . If that happens, we'll of course keep you posted . More news from Mishawaka . IN I Archive I . fu+r~ n:~ ~iitl iru~+ rfetappRittg oce~w~tur * 8 am- Coatere0 siroand you' ~... _ News I Weather I Sports I Co ntests I Local Events I Contacl Uc I WNDUExt ra .com Questions or comments about this website? Conta cUhe webmaster. http://www.wndu.com/news/dangerinacan/022006/dangerinacan 47719 .php 4/7/2006 p . 78 WNDU-TV : Danger in a Can Story : Jobsite Heavy Duty Boot Mate - February 02, 2006 Page 4 of 4 Copyright 1999-2006 Michiana Telecasing Corp . AM rights reserved. Unauthorized . use . reproduction . or nec6stn2muUon of the content of this page is strictly prohibited. WNOU-TV South Bend, Indiana 46 63 4 Privacy Policy I EEO Public File Repotr http ://ww,.v_wndu .com/news/dangerinacan/022006/dangerinacan_47719.php 4/7/200.6 p . 79 Cincinnati Healthcare News Page 4 of 26 Dengate said : "It is a n endangering factor . Nobody can be sure at this stage how big a threat it poses, but we're treating it very, very seriously . " Dengate said the department had begun treatment on the infected trees and was hopeful that the disease could be cured . Despite the threat, the species is not at risk of extinction because thousands of the trees have been grown in plantations from the wild stand and some went on sale to the public in October . Dengate exonerated anyone officially involved with the wild trees . "We've been scrupulous with our staff to make sure they don't carry anything in," he said . Experts are asking people to please "stay away ." 1/29/2006 3 :05 :40 PM (GMT Standard Time, UTC-00 :001 Trackback ~ SATURDAY, JANUARY 28, 200 6 Leather Protector Leads to Illness and Death Boot leather protectors and aerosol sealant products have been identified as the cause of 11 reported respiratory illness cases and one cat's death . According to Cadillac News : https://www .cincinnati .md/blog/default .aspx 4/6/2006 p . 80 Cincinnati Healthcare News Page 5 of 26 "Jobsite Heavy Duty Bootmate, " distributed by Manakey Group, LCC, is the most frequently cited product associated with the illness, but it is no newcomer to Michigan shelves . "'Jobsite Heavy Duty Bootmate has been in Michigan stores for several years," Rod Clayton account manager in sales of Manakey Group said . "It seems the only reason that were experiencing problems with the product this year is because people are not following the directions on the bottle . " The product has been under investigation for the past two weeks, but John Trustrail, managing director of Regional Poison Center, is not expecting a recall . "We ran into a situation like this about 15 years ago with a similar product, and there was no recall-just a warning for people to remember to use the product as directed, " Trustraii said . "I'm guessing well see a similar outcome with the 'Jobsite Heavy Duty Bootmate' product . " Both the poison control center and Manakey Group, LLC emphasize using these aerosol products as directed and in well-ventilated areas . "Otherwise not only will these products waterproof peoples shoes, they'll also waterproof peoples lungs," Trustrail said . 1 1 28 1 2006 3 :11 :25 PM (GMT Standard Time, UTC .00 :0 0 ) https ://www .cincinnati .md/blog/default .aspx 4/6/2006 p . 81 Boot-waterproofing products causing respiratory problems Page 1 of 2 . f . ' 1 t ' i 1 ~ post gaze Health & Science Previous Articles Health Medicare Science Environment rn Health, Science Environment Healt h Boot-waterproofing products causin g respiratory problem s Tuesda ~ ~j Friday, December 23, 2005 J~" 1~~(" By Byron Spice, Pittsburgh Post-Gazette An unusual number of people developed respiratory problems this fal l after using aerosol products to waterproof their leather boots and shoes, Watc Take control o f Pittsburgh Poison Center officials said yesterday . attrao vo tu heAi}t. Eight people have called the center with t . 1": breathing problems in just the past week , said center director Edward P . Krenzelok, The Pittsburgh Poison and a review of the center's records shows Center can be reached at t j.t `21. such poisonings since October. Checks 1 800 222-1222 . with poison centers in other states showed this phenomenon is widespread this season . post-gamtte'cm Headlines by E-mail Dr. Krenzelok said he can only speculate as to the reason for the poisonings . It could be that cold weather has caused people to apply the products in confined spaces, rather than outdoors or in well-ventilated areas as directed by the product labels . In most cases, people complain about coughing, shortness of breath or difficulty breathing after using the products ; usually, they feel bette r within an hour after breathing fresh air. But some cases have required pOg~~~ emergency treatment, some people have developed a pneumonia-like illness and at least one person has required hospitalization . The products are sold under a number of names and brands, Dr . Krenzelok said, and include the ingredient heptane, as well as Stoddard solvent, fluorocarbons and silicon . But he added that he doesn't know what agent or combination of agents is responsible for the breathing problems. http ://wwiv .post-gazette .com/pg/05357/626879 .stm 4/ 11 /2006 p . 82 Boot-waterproofing products causing respiratory problems Page 2 of 2 About 10 years ago, a number of respiratory problems were reported i n connection with leather conditioning products, he recalled, but "that sorta disappeared . " Last week, however, one of the staff members of the Pittsburgh center, Rita Mrvos, noted that the center had handled eight cases of respiratory problems associated with boot waterproofing . Dr . Krenzelok said other poison centers told similar tales -- more than 50 cases at a Michigan poison center, about a dozen handled by a center in Indianapolis . In one case handled by the Pittsburgh center, a man was using the waterproofing products in the basement of his home when the furnace flamed out; the waterproofing fumes were then sucked from the basement and into the rest of the house . Four family members suffered respiratory problems and one was hospitalized . The Pittsburgh center handles calls from throughout western and central Pennsylvania . All of the incidents occurred outside of Pittsburgh, in such communities as Windber, Clearfield, Northeast and State College . (Post-Gazette science editor Byron Spice can be reached at bspice@postgazette .com or 412-263-1578. ) . . `r"'; ~ . y,w : i, . -. r~'t07 ; . -.. . , ~IV tJ .`'~trJ~-1 .tiqY3~i ~', . . ., ' ' ' a ^ A J4~ Spyware Remover pownload Spyware Remova l Free Scan, awarded Spyware and Adware Guaranteed Virus & Spyware Removal . killer - S Stars Rated . EarthLink Access Not Required . Ads by Google Advertise on this site E-mail this story Print this story Search I Contact Us I Site Map I Terms of Use I Privacy Policy I Advertise I About Us I Help I Correcti Copyright 1997-2006 PG Publishing Co ., Inc. All Rights Reserved . http://www.post-gazette .com/pg/05357/626879 .stm 4/11/2006