Document Ddvwm5y97m9n8BLznBgde72E4

Dear S ir, I n com pliance w ith y o u r v e r b a l r e q u e s t we subm it h e re w ith d e t a i l s o f th e ta n k c le a n in g o p e ra tio n s a t C anberra A irp o rt su b seq u en t t o which two of our employees} and became ill. " Two 10,000 g a llo n underground s to ra g e tanlcs a t C an b erra aerodrom e f i l l e d w ith w a ter were b e in g pumped o u t and c le a n e d i n t e r n a l l y . Pumping o p e ra tio n s having been com pleted on Thursday, 1 9 th June, the c lea n in g o p e ra tio n then commenced. - One ta n k had been com pleted and th e second t a n k p a r t i a l l y co m pleted when, on c easin g work on th e evening o f Bri.dau 20th June, complained of . f e e l i n g i l l and r e t i r e d w ith o u t a m e a l. On S a tu rd a y th e 2 H ^ ^ i e c o n s u lte d D r. A. H. H art o f Queanbeyan and r e p o r te d v o m itin g and d ia r r h o e a . G a s t r i t i s b ein g p re v a le n t in th e d i s t r i c t , D r. H a rt, a f t e r c o n s u lta tio n w ith D r. A. J . H arker, had him adm itted to Queanbeyan D i s t r i c t H o sp ital to ensure p ro p er n ig h t a tte n tio n which; could n o t be g iv en a t h is h o te l. , _i ' / ___ ___ By t h i s tim e , a second man B having developed sim ila r symptoms, th e p o s s i b i l i t y of th e i l l n e s s b e S x ^ d u ^ t ^ t h e c le a n in g o f th e tan k was c o n s id e r e d ,1p a r t i c u l a r l y a s i t had been s in c e a s c e r ta in e d t h a t th e ta n k s had a t some p re v io u s s ta g e c o n ta in e d a v ia t io n s p i r i t . * ; On th e m orning o f Sunday, t h e 22nd, Dr* C. R. B ic k e rto n B lack b u rn o f Sydney, H.3.Y. m e d i c a l 'o f f i c e r f o r th e A s s o c ia te d E th y l. Co. L t d ., vras n o t i f i e d in view of th e p o s s ib ility o f poisoning from th e te tra -e th y l-le a d co n ten t of th e a v ia t io n s p i r i t , ; some sn iall accu m u la tio n o f which m ig h t have rem ained i n th e ta n k sludge. ; , ' ;. v Drj. B lackburn d is c u s s e d th e s i t u a t i o n w ith D r. H ark er o f Q ueanbeyan, and H enna's c o n d itio n having l a t e r in the. day d e te r io r a te d , i t was decided th a t he should be sen t by ambulance im m ediately to th e Royal P rin ce A lfred H o sp ita l, Sydney, where he a rriv e d a t appro x im ately 12.55 a.m . on Monday, th e 23rd, accompanied by D r. H arker. ' W 0021495 N 24599 He waS a d m itte d by D r. McDonald, r e s id e n O4- m e d ic a l o f f i c e r , and was v is ite d by D r. Blackburn a t approxim ately 12.45 a.m . I t i s u n d e rsto o d t h a t tr e a tm e n t commenced im m e d ia te ly . The ta n k s w ere p u rch ased by us from D is p o sa ls Commission end when purchased were f u l l b f w aiter. A t e s t c a rrie d out on 3rd June by our Branch E n g in e e r, M r. N. S. P a n to n , gave no i n d i c a t i o n o f g a s . On th e 1 7 th Ju n e , a f t e r w a te r had been .pumped out w ith a power pump th e ta n k s w ere a g a in tested fo r gas w ith negative re s u lts . . . The two o p e ra to rs th en proceeded to c le a n th e ta n k s w ith w ire b ru s h e s . -The men were n o t equipped w ith s ta n d a rd T .E .L . equipm ent b u t wore rubber boots and fa b ric g lo v es. T estin g app aratu s was kept on th e job and i t was a rra n g ed th a t i f th e o p e ra to rs found th e atm osphere becoming f o u l, gas masks would be s e n t by a ir m a il. The men were in s tr u c te d to use a shovel f o r removing th e sludge in th e tan k . * The Branch E ngineer was m islead by th e f a c t th a t th e tan k s had been . f i l l e d w ith w ater and d id n o t check w ith R.A.A.F. th e type of p ro d u ct which had been s to re d and overlooked th a t th e re may have been le a d in the slu d g e . which rem ained in the; ta n k . Subsequently, on tinearthing vent lin e s from the tan k s, which in c id e n t a l l y were c a r r i e d underground f o r some d is ta n c e , c l e a r o f th e runway, i t was found t h a t th e y w ere choked w ith some b lc k m a t e r i a l . ' I t was f u r t h e r d is c o v e re d t h a t th e r e was a 4 4 -g a llo n drum b u rie d in th e ground to which th e v e n t p ip e s were c o n n e c te d . On b e in g u n e a rth e d t h i s drum was f u l l o f what ap p eared to be a v ia t io n s p i r i t . l\To p la n s o f t h e i n s t a l l a t i o n w ere a v a i l a b l e and th e e x is te n c e , o f th e 4 4 -g a llo n drum ;would n o t n o rm a lly have been s u s p e c te d , and more P a r t i c u l a r l y th e f a c t th a t i t was f i l l e d w ith a v ia tio n s p i r i t . . The above in fo rm atio n i s re le a s e d to you on th e d i s t i n c t u n d e rstan d in g that i t is treated as confid en tial. - .. _ . . v :V, . . .: Yours " fa ith f u lly , ' t h e c o mmo n w e a l t h OIL RSEIHERIES LTD. ' k. t " " - - '* ' sgd.: D.E.BALD?JIN ,; ~ - C hief Engineer. 0021496 / m st COPI 18th Ju ly , 1947.. REPORT ON Ttd 1E3. POISONED WITH TSTRAETHL LEAD CR IT 3 DBRITj IIVBS ' - Ji&iro em ployees o f th e Commonwealth O il R e f in e r ie s L t d ., we exposed t o TEL i n th e fo llo w in g c irc u m sta n c e s a s n a r r a te d t o me by th e men co n cern ed and ; v e r b a l l y by o f f i c e r s o f th e COR company. Two ta n k s t h a t had n o t c o n ta in e d g a s o lin e f o r upwards o f two y e a rs bad been found to c o n tain w ater, i t was th e re fo re , pro p o sed to remove t h i s w a te r and c le a n th e ta n k s . The ' w a ter was removed, t e s t s a p p a re n tly re v e a le d no g a so lin e and th e men p ro ceed ed t o c le a n th e ta n k s . I t h a s been s t a t e d t h a t th e second ta n k a lo n e c o n ta in e d TEL o r i t s d e riv a tiv e s but no c e r ta in in fo rm atio n i s to hand on th is p o i n t . I n t h i s ta n k th e men p ro ceed ed to remove th e , sludge using no p ro te c tiv e devices o th er than rubber knee b o o ts and canvas gloves - no r e s p ir a to r s of any k in d were u s e d .. On a c c o u n t o f th e 'fum es' th e men c o u ld n o t s ta y lo n g e r th a n 10 m in u te s at':-a. tim e in th e ta n k , so one man would f i l l a bucket w ith sludge (u sin g t i n cans etc to scoop up th e sludge) w h ils t th e o th e r would h au l th e f i l l e d bucket out by a ro p e . They took tu rn and tu rn about in th e s e o p e r a tio n s d u rin g th e d a y . One man, R. IS23TA, ac q u ird d a number o f a b ra sio n s on th e backs o f both hands w h ile scooping' up th e slu d g e . The ta n k was c le a n e d on 20 JUNE 1947 and b o th men a g re e t h a t R.KDJ'JA had th e g reater exposure. Both men developed c l i n i c a l e v id en c e o f TEL p o is o n in g and le a d was found in s ig n ific a n t q u a n titie s in th e ir u rin e specim ens. T heir h is to r ie s were co m p licated by an epidem ic o f 'food-poisoning* which was p re v a le n t in th e town (9,uecnbeyan) a t th e tim e . T h eir c l i n i c a l h is to r ie s and treatm en t a re s e t out below, th e m ild e r lease is given f i r s t . - . aged 34, a m a rrie d man w ith 2 c h ild r e n m s ad - ' m ittejd to R oyal P rin c e A lfr e d H o s p ita l, Sydney, under my c a r e a t 1 0 .3 0 p.m . 22 JUNE 4 7 . He s t a t e d t h a t he had a m ild a a s t r o -- in te s tin a l upset fo r 4 days and th a t h is d iarrh o ea c e a se d 'th e day b efo re adm ission. His importancesymptoms were in c re a sin g in somnia, in c re a sin g an o rex ia, weakness and tir e d n e s s , and trem or in v o lv in g h i s u p p e r lim b s more th an h i s lo w e r. He had co n - . s u ite d th e lo c a l D octor on account o f h is g a s tr o - in te s tin a l symptoms b u t, becoming w o rried o v er h is insom nia and w eakness . . fo llo w in g ' on'th'e 'fum es' in 'th e ta n k ''o p e ra tio n s, -he proceeded to Sydney on h i s own i n i t i a t i v e . On a r r i v a l he was met by - COR r e p r e s e n t a t i v e s and a d m itte d to h o s p i t a l . On ad m issio n he lo o k ed t i r e d and w o rrie d , he was v e ry a l e r t m en tally ,-an d had m oderate.trem or of both hands. His o ra l tem p eratu re was 96F, h is -p u ls e r a t e 66 p e r m in u te, and h is , blood; p r e s s u r e 120/75 mm Eg. IJo o th e r abnorm al s ig n s were found. He was c o n fin e d to bed .and g iv en a l k a l i (p o ta ssiu m c i t r a t e ) in dopes s u ffic ie n t to keep h is urine a lk a lin e , o ral calcium la c ta te \v<\ barbitone sed ativ es, and flu id s in la rg e q u a n titie s. 2 :3 -d im e rc a p to p ro p a n o l o r B r itis h . A n t i - l e w i s i t e ) a s a 10fo s o l u t i o n in '.t o i l and benzyl-benzoate was ad m in istered by in tram u sc u lar in je c tio n . ' "c.- /as g iv e n 4 .4 mg/kg each 4 h o u rs f o r 4 d o ses and th e n 2 .2 mg/kg tw ic e v ^ `>?* ly t i l l 28 JUNE 47 when he was g iv e n 4 .4 mg/kg each 6 h o u rs ; on th e a llo w in g day -he re c e iv e d 2 .2 . mg/kg each 6 h o u rs . Prom 30 JUNE t o 3 JULY in c lu s iv e he re c e iv e d 4 .4 . mg/kg tw ic e d a i l y , from 4 JULY to 10 JULY i n c lu s iv e 2 . 2 . , mg/kg tw ic e d a i l y , and from 11 JULY t o 14 JULY 2 .2 . mg/kg once daily. .... . h Though h is g e n e ra l c o n d itio n improved and he took food and f l u i d s w e ll he could not sleep w ithout sed atio n and remained r e s tle s s and b rig h t. These l a t t e r symptoms in c re a s e d from 25 JUKE to 27 JUNE when he was becoming a l i t t l e f r a c t i o u s - q u ite d i f f e r e n t t o h i s c o n d itio n on 24 JUKE when he had s e t t l e d down w ell;. From 30 JUKE he whs r e l a t i v e l y q u ite and th e made an un in te rru p te d recovery a p art from a m ild in fe c tio n in h is buttock follow ing BAL i n j e c t i o n s . : '. ' The u rin e was examined f o r le a d end th e fo llo w in g r e s u lts were o b ta in e d on 24 h o u r sp ecim en s!- th e specim en c o l l e c t e d 24 JUNE c o n ta in e d 0 .0 9 mg, th e maximum amount of: 0.79 mg was found in th e specim en c o l l e c t e d betw een 27 and 28 JUKE, and by 5 JULY o n ly t r a c e s w ere p r e s e n t . D uring th e f i r s t fiv e days in h o s p ita l h is o ra l tem perature ranged between 97 and 98 F , h i s p u l s e was 52 to 60 p e rm in u te , and h is . b lo o d p r e s s u r e was l i t t l e a l t e r e d from th e e a r l i e r f i g u r e s q u o te d . An o c c a s io n a l s tip p le d re d blood c e l l was seen on two o c c a s io n s , a t th e tim e o f w r i t i n g t h i s man h a s 'j u s t been discharged from h o s p ita l. . , aged 30, a m arried man, was adm itted to Royal p rin c e A lfred h o s p ita l, Sydney, under my c a r e a t 1 2 .3 0 a.m . on 23 JUNE 1947. His h is to ry was com plicated by a m ild g a s tr o - in te s tin a l in fe c tio n th a t had been p r e s e n t f o r 10 days becoming w orse in th e l a s t 4 d a y s . He had been a d m itte d 'to Queanbeyan H o s p ita l under th e c a r e of D r. H ark er on 21 JUKE 47 f o r h i s . g a s t r o - i n t e s t i n a l u p s e t. H is a lim e n ta ry symptoms had la r g e ly d is a p p e a re d by 22 JUNE 47 b u t on t h i s m orning he was m ild ly c o n fu s e d . He had a s h o r t e p ile p tif o r m f i t ab o u t 1 .3 0 pm and m s b ro u g h t to Sydney, He com plained o f insom nia and d i s t r e s s i n g 'dream s, a n o re x ia , w eakness o f h i s l e g s , and a c h in g o f h i s upper and lo w er jaw s; '**0n ad m issio n to R .P . A.H. he was confused, 'co u ld n o t r e l a t e th e in c id e n ts o f th e day, and was c o n s ta n tly s t r e t c h i n g h i s lim b s and w r ith in g on h i s b e d . He s a id he had g e n e r a l abdom inal d is c o m f o r t. . He was found to have tre m o r o f h i s hands and many sm all a b ra sio n s on th e kn u ck les of both hands, h is blood p r e s s u r e was 120/55 mm o f Hg, h i s p u ls e r a t e 64 p e r m in u te , and h i s o r a l tem perature 98.4F. . ' He was c o n fin e d tol b ed , g iv e n s e d a tiv e s , an d , a s h e c o u ld ta k a 'n o th in g by mouth, was given in trav en o u s s a lin e w ith 5 / glucose and, l a t e r , in trav en o u s sodium l a c t a t e . S ubsequently th e u rin e was k ep t a lk a lin e .w ith s u ita b le doses of potassium! c i t r a t e by mouth. . .: BAL was g iv e n in tr a m u s c u la r ly i n d o ses o f 4 .4 m g/kg f o r 4 d o se s a t 4 hour i n t e r v a l s and fo llo w e d by 2 .2 . mg/kg tw ic e d a i l y t i l l 27 JUKE 4 7 . W ith in . 14 hours o f re c e iv in g th e ra p y he was much b e t t e r , he was n o t a t a l l con fu s e d , was s t a r t i n g to ta k e f l u i d and i"ood by mouth "b u t he was s t i l l r e s t le s s and a c tiv e though s t i l l in bed. H is a p p e tite re tu rn e d and he was most c o o p e r a tiv e i h s p i t e o f some r e s t l e s s n e s s t i l l th e m orning o f 27 JURE O' c 9' * J A , , . ' V ,s ^ r-o '.o ' /VA' - 3- when, he became hypom aaic. He esc a p ea from th e ward f o r a few m in u te s , and, 'on b ein g f o r c ib ly re tu rn e d , had an e p ile p tifo rm f i t l a s t i n g 1 .5 m in u te s. F o llo w in g t h i s he was c o n fu se d , d i s o r i e n t a t e d , d eluded paid h a llu c in a te d , he was d i f f i c u l t to c o n tr o l, he t o r e up h is pyjam as, and liad to be r e s tr a in e d . . He vTa s g iv e n s e d a tiv e s and h y o sc in e and an in tra v e n o u s i n j e c t i o n o f h y p e rto n ic ` g lu c o se was a tte m p te d . 3AL was a d m in is te re d in d o ses o f 4-.4. n g /k g each fo u r hours f o r 5 doses and follow ed by 4 .4 . mg/kg tw ice d a ily f o r 2 days, sub seq u en tly he vas g iv e n 2 .9 mg/kg 8 h o u rly from 30 JUNE to 3 JULY. ` By 28 JUNE h e 'vas manic and th e o n ly .improvement was in th e d im in is h in g v io le n c e . However, by 30 .JUNE he was much improved - he was m e n ta lly much c l e a r e r , much l e s s a c ti v e , and vas r e s t i n g . From t h i s tim e u n t i l 3 JULY he vas much Im proved, h i s a p p e tite in creased , he was m entally c le a r, not e sp e c ia lly r e s tle s s , but complained o f in c r e a s in g p a in s in h i s m u scles and abdomen. By 3 JULY he had o b v io u s p a in on a tte m p tin g to s i t up in bed - most of h is m uscles were p a in fu l to move. On 3 JULY th e dosage o f BAL was in c re a s e d to 4 .4 . mg/kg w hich was c o n tin u e d t i l l 4 JULY. H is m uscle p a in s r a p i d l y d isa p p e a re d and h i s c o l i c a ls o v a n ish e d . The dosage o f BAL su b seq u en t to 4 JULY t o s as fo llo w s : 4 JULY - 2 .9 mg/kg 4 h o u rly ; S- 13 JULY - 2 .9 mg/kg 8 h o u rly ; 14 JULY - 1 . 5 mg/kg tw ice d a i l y . By th e e v en in g o f 14 JULY he had re c e iv e d 2 34.9 mg BAL/lcg (160cc o f th e 10) j s o lu tio n in b e n z y l-b e n z o a te and p e a n u t o i l ) . Some to x ic symptoms w ere o b serv ed fo llo w in g th e u se o f BAL. E is p u ls e r a t e ranged betw een48 and 60 p e r m in u te u n t i l he became m a n ia c a l b u t t h e r e a f t e r shelved c o n s id e ra b le v a r i a t i o n a c c o rd in g to th e dose o f 3AL b e in g given. H is o ra l tem perature was u su a lly below 98.4F. E stim a tio n s of th e le a d c o n c e n tra tio n in th e u rin e were made whenever p ra c tic a b le th e maximum 24 h our c o n c e n tr a tio n o b serv ed was 0 .5 0 mg, o n ly t r a c e s b e in g fo u n d on 9 JULY. Ho g r e a t change was o b serv ed in th e re d and w h ite blood c e l l c o u n ts . 0021HE 499 In th e c a s e o f ICSLfilA i t i s d i f f i c u l t to a v o id th e c o n c lu s io n th a t 3AL was th e s i g n i f i c a n t th e r a p e u tic a g e n t and t h a t i t r e l i e v e d h i s symptoms when g iv e n in s u f f i c i e n t d o sa g e . I t i s my o p in io n t h a t 3AL was r e s p o n s ib le f o r th e v e ry s a t i s fa c to ry r e s u lt of th e treatm ent of th is man's lead poisoning. C0:.-3\T: ; . BAL a p p e a rs to be an e f f e c t i v e a g e n t i n th e tre a tm e n t o f le a d p o is o n in g from th e a b s o r p tio n o f TEL o r i t s d e g re d a tio n p r o d u c ts . I t n eed s t o be g iv e n in h ig h dosage and fox' a r e l a t i v e l y prolonged tim e . The ex p erien ce of th e above p a tie n ts would suggest th a t a regim en such as s e t out below m ight be s u ita b le - BAL (2 :3 -d im e rc a p to p ro p n o l); 4 .4 m g/kg o f body w eig h t each 4 h o u rs t i l l th e symptoms have d isa p p e a re d , th e n 4 .4 . n g /k g each Q h o u rs . f o r a n o th e r 14 days.. The dosage should be dim inished g ra d u a lly r a th e r th an suddenly ceased u n til ex p erien ce has shewn th a t sm aller doses are adequate. I t i s su g g este d t h a t th e s ta n d a rd BAL o in tm e n t be k e p t in hand in a l l p la c e s w here th e r e may be s k in c o n ta m in a tio n and t h a t i t s u se to be o b lig a to r y when th e r e has been exposure to TEL on th e s k in . E x p e rim e n ta l w ork w i l l no d o u b t, i n d ic a te w hether such itherapy is e ffe c tiv e . . ' L a s tly i t would a p p e a r to be m ost d e s ir a b le t o a d m in is te r BAL in th e r a p e u tic d o ses to a l l p e rs o n n e l who have b een exposed to TEI, and to b e g in such th e ra p y a s scon a s ,e x p o s u re i s known to have o c c u rre d r a t h e r th a n to w a it f o r symptoms o r th e d e m o n stra tio n o f le a d in th e e x c r e ta .