Document emRgv3Kzdy3ezRwDqbb37Rk5p

P-1 a . 3 715 921229CCM05>*3 SUMMARY: This I n v e s t i g a t i o n vas conducted In response to a report that a 17 year old female experienced severe respiratory distress after being exposed to the fuses from an aerosol fabric protection product that she was using to treat a new leather Jacket on 12/27/92. The vlctis was hospitalized overnight and treated for the synptoas of chealcal pneusonla. PRg-mclPKHT: On Sunday, 12/27/92 at approximately 12:30 P.M. the complainant and her boyfriend each purchased a new valst-length brown suede leather Jacket from the "Wilson's Suede and Leather Products," retail store located at A-1009 Port Plaza Kali In Green Bay, WI 5*301. . 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 p r o t e c t o r 16 sold in a two can package, d escribed as a "Leather Care Starter Kit." The complainant and her boyfriend agreed to purchase four cans 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 J a c k e t , th e n w a i t 30 minutes and 6pray a n o t h e r 1/2 can on each coat again. of {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 c o a t s w e r e s ub je c te d to rain or dirt, to 6pra y them a g a i n immediately after such exposure. The complainant paid $19-96 for four 5 ounce containers of the Wilson's Leather Protector product. The s t o r e clerk, vhose name is unknown, 16 d e s c r i b e d aa h a v i n g short brown hair, and being 20-25 years of age. This clerk provided no further Instructions to the complainant and her b o y f r i e n d as to how the product should b e 'applied to the coata, and he did not suggest that the product's fumes might be hazardous. 921229CCN05l3 -2 - IB C I D EHT: Later that sane day, 12/27/92 at approximately 3:00 P.M., the 1? year old female complainant and 21 year old boyfriend hung each coat on a h anger and suspended the hanger from a clothesline in the attached and enclosed front porch of the family*a 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 ihe porch where the spraying had taken p l a c e u n t i l 30 minu t e s had e l a p s e d at w h ich time the 17 y e a r 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 9 minutes. The complainant's boyfriend was not present during this second application. .. P h o t o g r a p h s d e p i c t i n g the c o mp l a i n a n t *a r e e n a c t m e n t of the m a n n e r 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*a May Be Harmful." She felt that the unheated, enclosed porch vac 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 v e n t i l a t i n g the fumes. The porch area Is 26 feet long by 6 feet wide by 7 feet high. The porch has two pedestrian doors that p ro v i d e 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 dlzxy. The complainant's boyfriend suffered no 111 symptoms. 921 2 29 CCH 05 i*3 -3 - POST IHCIDEKT: The complainant's condition continued to deteriorate, and she vae l a t e r t r a n s p o r t e d to n e a r b y Community M e m o r i a l H o s p i t a l in O c o n t o 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 t h e f e m a l e c o m p l a i n a n t is a J u v e n i le l i v i n g a p a r t from her parents, she was asked to obtain a parent's signature on the "A u t h o r i s a t i o n for Release of Nam e " and "Authorization for Medical Records Disclosure" forma, and then return the completed forss to the CPSC Milwaukee Resident Post. When these authori z a t i o n s are received, the medical records will be obtained and forwarded as an addendum to this report. SAMPLBS COLLECTED: The co m p l a i n a n t still had two full 5 ounce cans of the "Wilson's Leather Protector" product remaining. These containers were p u r chased from the complainant as a CPCS sample, sample no. R830-hho8, and were later forwarded to HSHL for further analysis. A c o p y of the s a m p l e c o l l e c t i o n receipt I s s u e d to the c o nsumer is a t t a c h e d to the end of this report as exhibit "B". A copy of the sample collection report is attached as exhibit "C". APPLICABLE STAJIDARDS: T h e h a z a r d o u s substances labeling requirements detailed in 16 CPR 1500 may apply to this product; the adequacy of the present' w a r n i n g l a b e l i n g c o u l d -not be e v al u a t ed as the p r od u c t 's actual content Ingredients are not known at this time. PRODUCT IDEWTIFICATIOW: Product: "Wilson's Leather Protector" fabric protection treatment; 5 ounce aerosol container, described as black in color with red and white lettering. SKU no. I8998O O 3 . Date c o d i n g Ink printing on the bottom of the container is apparently smudged and I nc o m p l e t e states "Cl 2". 921229CCS05^3 -U - M a n u f a c t u r e r : Wilson's Suede and Leather, Inc. Minneapolis, Minnesota. ATTACHMENTS: Exhibit "A" "B" "C" "D" P ho tographs d e p l e t i n g the c o m p l a i n a n t 's r e e n a c t m e n t of her use of the product in question. Copy of the sample collection receipt Issued to the complainant on 12/29/9 2 . Copy of sample collection report number R-830-Ubo8. Copy of the original consumer complaint. U.S. CONSUMER PRODUCT SAFETY COMMISSION ' m :< - J .- ~ 1.AAEA l *& i rm .f t oe k o v io u m . TQ ?- *)3 J2 *9 - <<iV -- ;t OS-V3 . -7T c rj-jfc rs W B F - *' .jjv,s!>..v* t:?.`i.-sijh- -:i.tf'-.**: ; ,' ~ .MMnS.MNKR /a :; / . j / y v / > j; '/ , - 'b V . CITY # C STATE ff M f Z|>. C iA ) T <v .U s '-' / - . % SAMPLES CXXXECTeO lO ncrtir JU ttfU u H & r U o J & ' U ::r A t i s : * ay th r r foM rn H fri/km *> * ^ -, ' ,. ;*k c M fcnriag (M p M m a ( i M ky <k C < u w u r i ' r W id .liM r C-- nm ri-- paraum t la SccOm tH A a f t t t C w a w r ' F r iK tS k M j A c *(1 3 U .S .C m rfc *a ^ frc tia 'l< > > ril r*^ H i R la n S M U a c * A 't(U U J M X U M k jM 4 w S K ... *KH1UU A C - j l ^ ^ <nrt4td.Sr^UnatHlmktrt-- telatkrCTkTKMef ^ ' ` ^ f r - T 'P S 'Z 's U * 14. SAM PLES w e r e :__ . / PURCHASED ^ * r K M lK fl -i W. . . N M flM tf r 4M C O LLE C TO R .. '/J> & / ^ j _. _ ... ' ........ RCCOPT FOR SAMPLES P-7 Flag u . s. cossnKEa paooqcr s SAMPLE COLLECnC * [2- Dlte 'c " wawpAa <CVOSV3 w MVWtt/k. hz. [ 12/29/92 n_il R-830-4408 _[___________ ____ [t 1 PacuMntirr - hodoet Baaa ' (4h. Model [4c. BEXSS (S. Assignment tif. fabric treatment produce ' C o m p le te f o r im p o rt sam ple* | Wilsoa's 3oz. J ___________ 0952 [7. 105 192122903(0543 (a. Boors: - im re o f E n try b . E n tr y * & < i t ; ________ : -J 32672 [a-Activity tb.Travel 2.0 mor c . Countr y o f O r ig in : r_ _(9a. Bone 10 [9b. Collecting IS 4 . B90SA coda ' e. Custom "-s-n-i 10.i $ 10.00. ICJ . . . : .. - .TOCS ( _L root |11-1r-etIanivloivcaeluvealaupepr.oofx..$lo1t0 _ .00 [12,. Size of lot f two available ...... . from cooaumcr Minneapolis, Ml. . ^ 'v S s o a ^ s ^ S ^ ^ t^ a .. i "fort "Plaza Mall _ J Broker ' | A-1009 Port Plate Kell j Occrnto 54154 IP C ' jp^reea Bay, WI. 54301 fjpg 1 6 - S u p p o rtin g doer-- u ts f t e jd a J a. Xmvolcm * ft d a te : H/A c . S h ip p in g r o c o rd # ft d a t e : __________________ Jb. pate Shipped.: _ d . I f f M e r l t e l n n r ' i >,' t i t l e ft d a ta :_____ 1 7 . P tn d y t- T`[ r T n f f . CTti W . - . ' ; Cs :v --.-*n.--t-*----"- --5---o--u--n--c--e----a--e--r-o_aol cao.<eo*wf- 18 - lu s e n fo x c o llt c t lm i ft a n a ly s is -XH5& X CPSA EEA z m USA E/O to IBX# 921229CCH054i- 17 year pid feaale suffered respiratory distress after --- i __ualoa the product): content and ih?Tini Tvi! 19. Staamaxy o f Field Screening Koae . 20. Sample Size, Method of Collection: Sample coos lata of two' unused can as described ia 117 above. .. .. Two caqs - packaged.together in a black cardboard display container. Sample was . obtained from consumer at her rsideace on 12/29/92; it remained in my possession and in the locked CPSC office until shipment to the Sample Custodian on 12/31/92. Sample 21. Identification, on sample -830-4406 DBB 12/29/92* (22. Identi fieation. on seal f"-830-4408 Doania R. Blaslus 12/31/92" 23a-. Sample dmliveifed to ( 23b. Dace Sample Cuatodlan via P.F. MCE______ L 12/31/92 [24. Orig. reporc/reeords sene to r FOCB TnboratnrT/Offiee: ESEL f 1 HSBL fX 1 C O M f 1 CSCA. [ 1 .OIHEa f 1 26 " -- - . vaa shipped fa a cardboard box which was sealed and identified es under .*b9v; sample itself was tagged and identified as described' in #21 above. Sample was mailed via P.P.MEE to the Sample Custodian on 12/31/92, to be forwarded to farther analysis. Sample collection receipt, copy of original assignment 2 7 . B e l a t e d . S a m p le B- 8 3 0 -4 4 0 7 28a. Collector's name, titlEft employee * ( 2Sb^.Collector's signature ft dace Dennis . Blaalua, Invescigetor. #9003 | 12/31/92 29a. Is rlm u i' d e l e & employee a (29b. leviewer's slgnetore ft date Oiscrlbucioa: Ozig [ 1 lab f 1 Fiscal [ J Data [ J Bdqtr [ J Other [ ] CPSC Form 1C (Barr. 9/91) p.8 TOx* CONSUMER PRODUCT INCIDENT REPORT f i / i f /? 2. C/vosV Taf? UH BTaor OcOnto Falls, Wl. 54154 ~ n M S R M g w rim M A o N on tUMB. IKuWfca rfAOriauUfltts.fUMm^>*i espandent's girlfriend was.applying'an. aerosol leather protector treats*at to her newly purchased leather Jacket; vlctla bagan experiencing severe respiratory' dlacraaa .Tter several mtoute* exposure to Che^p'roductra fuses. Vlctla wee ~Immediately transported to a nearby hospital for treatment, and remains hoapitaliaed to data. -- 12/27/92 .P H J U W M l W m W W H ; r -- V f --mm-i* AMD sOtstY raapIrarnnr dlarras TM U U derpjolapxay leather p ro te c to r __ R- M w i U W h W, w ii M h B r t ^ Wilson Lasther Company Klnnaapolia, PN. ` a.wasas wtoouoTnawiaan.I TO------ mo___ a>vn,i w a o n w n _____ ___________ io n i IO RAFTW TH * 'i >'Vanik tH&m&hTMriUSN r. 9 W *T . s lrlfrie m l Wilson*a Leather Protector 5o s .. c a a - . e oeAuarmmtiil'cMdhsePho Wilson's Leather Product! Port Plexe Shopping Center Greeabay, Vfl. - ' nwnucrnmcHAMD yJ W u X pate s u tn a a m 12IlT/ST^ ana one day IS OOKSmOOUCTHAVIWWMNa if so. M ore_________ ;_________ I . HAVK YOU CONCACnn M MAKUPaCTUaSer 3 ____ n o _ CONTACT THOyrr OTMBW . * NOT. OO YOU PLAN TO ro_JL_ n o . is impfiooucrsTetAViutAaun is maydm uea toua nnmbywthnaa V t t __ L m o____ if not, rra aoponm oft Ygg. NO. wm 12/28/92 POH ADMNMTHATION U gg . i a a a a B W S M i ( Dennis . Blasloe, KKK-P Confaiu c > 4aiaaq<2e /i/o 543 S ' V^V-^ CC- C Ovv~i J&C&fii,. - <rc a MM *WTL* XL SOCUMBffNa n 0136 a. moaner caaan G ? ? 1- CPBC I O W 171-gu)' P-9 Exhibit "A" XDl* 921229CCN0543 Photos of the enclosed porch area where this incident occurred. m p. 10 *- * p. 11 Exhibit "A" IDI# 921229CCN0543 Photos of the opea window providiag some outside ventilation (left), sad a front view of the suspect product as purchased by the consumer. ' d Exhibit "A" IDI# 921229CCH0543 Date coding narking oa bottom of containers (C1292.) /v6^ r x v e s p. 13 Exhibit "A" IDIf 921229CCN0543 mito w J / i _vn_u_m_o_FiocstfiToncow Mff ,,Thi...s., .i.nvestigation vaa initia11ted in response to a rep, ort1 that two alatera, ages 10 and 19, experienced severe respiratory distress after being exposed to the times fton an aerosol fabric protection product they were treating a new leather Jacket with la their basement. Both victims were treated and released at a local hospital emergency r o o m . _________ ___________________ rtoeuwaHMK) hone 1 orr a GilletC Mtlll W1 EH Wilson's Suede and Leather, Inc.; Minneapolis, HI. Wilson's Leather Proteceor(5 os.) S u e as above. I l `l m ,aoof all parts m *iTMHen multiple 011 0 MM H M TOOaCLSfWMCS fOMSSSOttCfK.O :i l i ] treated, at E.F.. | and -released -- ... 1 I chemical pneumonia -EB victim a w u w nwBw__ CO onun I MHnssffXrJeO rHii .CMHOURCt SL MWIKDIY YR MO OAV "" u v m [T7> * erse mayml* wethams oac may noto o c u m my mm 0:OAK See attached narrative. Cr 7 ( N R ________ i w w p r a is f i i w w a s / a y * o o l mo. a o u -o c p 921229CCN0544 SBKMhRY; This investigation was conducted in response to a report that two sister, ages ten and nineteen, experience/ 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 "Wilson's Suede and Leather Products" retail store located at A --1009 Port Plaza Kail, located in Green Bay. 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 02 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 aix 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 mioht be 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 Jtwftory singlc. faKilY residence. The basement is unfinished, though a portion of the basement area is used by the te1 Xe?r old sister as a playroom. The area where fc "V* treied \e described as being approximately 16ft. long if,"4 , lde x Btt- high, and is adjacent to the home's gas forced h ^ L f KnaCC* There are several windows in the basement of the !per"i?'od that this incicleiTftchocwcuirnrdeodW.E opened during the time 921229CCN0S44 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". Otoe complainant felt that the open basement area was large enouah to preclude her from having any problems with the product's fume s , 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 Photographs attached to the end of this report as exhibit "A" depict the complainant reenacting the manner in which she sprayed the coat. . wnicn 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 downstairs from her bedroom also complaining to her mother that she foit 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-XMCTDEMT; The girl's mother suspected that the victims were having 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 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 end to this report as Exhibits "B-E", are "Authorization for Release of Name" and "Authorization for Medical Records Disclosure" forms sign Joy the victims. The victims did not wish their identities revealed, except as necessary to interact with other investigative government agencies. SAMPT.F-S r o r .T .R fT K n ; Of the two five ounce cans of "Wilson's Leather Protector" 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". APPLICABLE STANDARDS: The hazardous substances labeling requirements detailed in 16CFR1500 may apply to this product; the adequacy of the present warning 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. SKU number 18998003. ' Date coding ink print on bottom of container is apparently incomplete, states "Cl-- 2". MANUFACTURER: Wilson's Suede and Leather, Inc., Minneapolis, Kn. ATTACHMENTS: . A " Photographs of the product use reenactment as well as photographs of the product container itself. Exhibit B - Authorization for release of name forms signed by 921229CCW0544 4 Michelle Rodefer. Exhibit C - Authorization for release of name form signed by t-h> parent of Lindsey Rodefer, a Juvenile. Exhibit D - Authorization for Medical Records disclosure for* signed by Michelle Rodefer. Exhibit E - Authorization for Medical Records disclosure fora signed by the aother of Lindsey Rodefer. Exhibit F - Copy of the Sanple Collection Receipt issued to t.fndw Rodefer for the saaple'f "Wilson's Leather Protector" obtained as a saaple. Exhibit G - Copy of the Saaple Report, saaple nuaber R-830-4407. Exhibit H - Copy of the orignal Consumer Product Incident Report:, dated 12/28/92. Medical Records pertaining to both victia's hospital treataent 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 "_ 'TG*4-t?Jtx2 9<t*,o"vy U.S. CONSUMER PRODUCT SAFETT COMMISSION AUTHORIZATION FOR MEDICAL RECORDS DISCLOSURE TO WHOM IT MAT CONCERN: You are hereby authorized to furnish the United States G oasuaer IVodact Safety G xnoiissjoa n il iafacm atioo and copies of any and a ll records you o s y have pertaining to ( my case ) ( the case of Belaadnship co 70 * including, hue noc limited to, m edical history, p hysical reports, laboratory reports and p a th o lo g ica l s lid e s , aod X-cay reports and film s. (Data) (Vim aaal case r o w n o . m t- ___________ -- W*,*/ " ' U-S-consumer pnoouc Ji nh'ihz <?S'/*/ AUTHORIZATION FOR MSMCAL RECORDS DISCLOSURE TO WHOM (T MAY CONCERN: You a re hereb y . . . r W ; T>a to h n i i h the United States G x u a a e c f t oduct Safety Commission a ll Infonaacioa and copies of any and a l l tc c a tja jo o ^ M ^ h a T c pelt* in ia | to { my ease } . '-(die.. in clu d in g, but not limited to , m edical bistory, physical reports, laboratory reports and p a th o lo g ica l s lid e s , and X-ray reports and films- (Date) (Tlnni) p. 21 U.5. CONSUMER PRODUCT SAFETY COMMISSION 'tyjc 3 /n w- tv-4 1KM KO F E TITLE OF INHVMUAL ct/osv*/ i^^ *-- s j.? S - * iftM P U MUM8EA S. CITY / * 0 STATE (M m itZ if C*d*) .: .. w-uisiiftff-t' - -- ^ X V . . v>. Nl . M l I l f D i c j f l i < Im l I | ; -iWiftr:^ r - T i r s ~ -- .:*---- jc J, i v n ' w 4 i - 4;-'**>1 * /*-V*<-''V*<Ar .. Yi:.' / V*"*'j5-***<*- t -- ' - - '-. , r , `r.-)?*! *> ...................... ..........-- M U F L E S --------------------------------------- 11. S AM PLE S W E H C "' l ------------ . m o u h t mmammo w w m A. NAME (M M a r < w r/ g ^M C H U e "c o u e c T o n ^ ' CP3C POAM M ). M ) 1 1 W N M M M D fr. W FrtFW fO fc- M M W . *-.- * /y v . M i -_ _______ __ R E C 0P T FOU S A U F U S 1 - Flag ri,iJl'c " /A/ay/ya. TJ_ S. OOBSOHER FRODPCT SAMPLE rrniTFXX TQX+ ?A/*5 C*t C SV^ [2. Data Coj-lectc<H 3. Sample type & cuaber As. I r w k x c |h m [ . 12/29/92 -Il-iJ Physical F-830--4407 I _____________ {[__1 Pacu--n ta rr "(Ab. Model [4c. HEXSS [5. Aislpeent ref. fabric treatment product 6 . C n e p le t* f o r le p a r t s a p lc i t . P arc o f E n try ; b. Entry # & data :______ ( Wilson's 5oz. JL________ j 0952 ( 7 . JOS -j 32672 ^92i229CCM0544 [(. Hoars: [.Activity 2 .0 fb-Travel u n r c . C o u n try o f O r ig in :_______ _ (9a. Boom SO [9b. Collecting RO. d . BSOSA. co d a :________ jI <i'Chat Cantare 10. ..Sop Coat ~$0. -- ( l l . / I m h * Tilne of lot;,. _L - [12 .'S i r e of .L lot , f retaillvalue ppror.~$5.00 f o^e availablef rm consumer { -Minneapolis, fcH. =. - d S & t s & a t o S & i.!M ''"Port Plain Kail : ( `A-1009 ^prt Pli.zi'Kall [ChlittT'VlT 54124 IP _ ..... ygrfreca Bay, WI.-543... [jpa . ________ 1 6 . S u p p o rtin g fttarlaj: a. Insolca # & date:______H_/A _b. Pate Shipped: e . S h ip p in g re c o r d # & d a te : _____________ d - A fg d a v it e ia n a r'a n an e, t i t l e A d ate: 1. t o s o n fox collection analysis needed: FBSA 1 CPSA m PPBA RSA__ . P/D to ibi# 921229CCK0544 (10 T.O, a*d' i9 yVo. Buffered respiratory distress'after ^------------- ,,,,using jhe_proaucty; content an! labelln* a n a T T ? T 5 - CL 19. Suanazy of Field Screening: ` . Ho q c ' 20. Sanqpla Size. Method of Collection: . Sample coaaiacs of one unused, ca'a as described la #l7above. This can was one of a too can set .packaged.together lnz.biack cardboard, display container. Sample was . obtained from consumer at her rsldeoce on 12/29/92; It reoalned in my- posaesaloa and In the locked CPSC office until shlpeenc Co the Sample 'Custodian on 12/31/92. Sample 21. Identification on sample "-830-4407 DFB 12/29/92* [22. Identification on seal . ['8-830-4407 Dennis . Biasjus 12/31/92" 23a. Sample delivered to [ 23b. Date [24. Orlg. report/records sent to Sample Custodian via F.f. MCE______ f 12/31/92 F0CS 25-lahoratotT/Office; E5EL [ } BSHL [1 1 CEBK f 1 CECA f ] OTHER f 1 **!"^^*,, w*s shipped (o a,cardboardbos which was sealed and Identified aa under f22 .above; sample Itself* was tagged and Identified as described'in #21 above. Sample was mailed'via P.P.MKE to the Sample Custodian oa'12/31/92, co be forwarded to afaceS ^urcber analysts'. Sample collection receipt, copy of original assignment 27. slated Semole F-83Q-4408 28a. Collector's title & employee S [ 28tyv Collector's signature & dace Dennis R. Blasius, Investigator, #9003 12/31/92 29a. t a r l e m r 's name, d e l e & eo^loyee # (29b. Reviewer's signature & date Distribution: Orlg [ ] Lab [ ] Fiscal ( ] Data [ ] Bdqcr [ ] Other ( - ] CESC Form 166 (Rarr. 9/91) x.HumcfmmsHaotr *h"i`4 'h '" CONSUMER-PRODUCT INC t/'t 2- Glllect, HI. 54124 Sespoadeat'a two daughters, ago 19 _ahd 10, were la the fcfseneac of their hosie treating * aew lesthcr.coaf with ea acroeol leather protector product l 'Altar aeveral adnucan of exposure to the product'* funet both individuals .began experiencing aaVere respiratory distress, including 'difficulty braathlog, coughing, and tightness in their cheat. Both vlct^na yera treatported to e local hospital, where they were treated and ~ r e l e a a a d . V ! ".\.""T:r"' -- -- ... -------------- ---- .. r a im r ____19 - ntaiy- T***1*nm nttrrar distress - -aerosol spray leather,tprotsccorV: 1 F VtahicaWwNTh*M Adw^Wf. NIM H B*n0WW^daugheragTMelg lHMr > 1 nneapdl'ia^ MlI' w *a tM i unniw T m , * t f l r o n ****" " * " , Y M ----- n o JE-- rvo,nrtNoiiAPnni>ff ttG K M tn ___________ Vllapa'a Leather Products Port Plata Shopping Center Greeabay, VI. tt mxucTTuaoinaeDd faw,JL twmpunowno n t r n W tarn pue day m .o o a m x w o r m M t w u e M n u a a j n r 80.Herr:________ .________ it. H m u m e o N M e ia i u a u w n c i u n T W - J L NO. CONTACT 1 M M T o n _______ .V NOT. OO YOU P U W TO T B ___ NO_ ia tjn mooucr m L M H L w a ta iwwauaaYouHMMewnHnat HMD? a r n o ____ 8 -- N O ____ r not, rrsoB T oam oii as. nan 1 2 /2 8 /9 2 nraunwAcndn-- C.uc/' MmamaN 2: c <- (,' & ^ CraOMJNMmpM,- nn ipEninnim mu Dennis >. Blaalue, fcXE-BF W l 0137 .TacoucTcocacaT j re.: f/ 1 : wmaTma /%** r-yszr-' p. 24 e*A&/" . 1 9<icvisyy U . S . CXNSvHER r e c c o c r s a f e k o c m u s s i c n AoraoRizxnoH p c r beizase cf n a m e Thank you foe assisting us in collecting informaticn on a potential product safety problem. The Product Safety Ctaunrission depends a n concerned people to share product.safety information with us. We main- .tain a record of ttils information, and use it to assist us in identifying and resolving product safety problems. - We routinely -forward- this information to manufacturers and private labelers to inform them of the involvement of their product in an accident.. situation.' W e a i m give the information to others requesting information about specific, 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 bottca 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 indi cated your preference, please sign your name and date the docuaent on the lines provided. . - ISbu are hereby authorized to disclose sy name and address with the information collected on this case. M y identity is to remain confidential. * p. 25 ____________________________ 1 a / * * .* cc.a u 5 W n.s. c c n s c m e r raccccr s ts ts n ccmrssicN A D X B G R r z m C M PCE RELEASE CP HAME H > ank you for assisting us in collecting information on a potential product safety prohleja. T he Qsnsuner Product Safety Oonmissian depends o n concerned people to share product.safety information with us. We main tain a reaocd of this information, and use it to assist us in identifying and resolving product safety problems. We routinely forward- this infdonation to manufacturers and private labelers to inform then of the involvement of their product in an accident situation.' W e also give the information to others requesting infocsation *bcut specific, products. Manufacturers need the individual's name so that they can obtain additional information on the product or accident situation. Wtxild y ou please indicate cn the bottom of this page whether you will allow us to disclose your name. If you request that your name remain conridential, we will of course, honor that request. After you have indi cated your preference, please sign your name and date the document on the lines provided. j I fou are hereby authorized to disclose ay name and address ___ I with the information collected cn this case. j ^ / j W y identity is to remain confidential. * -39-93 cm*) u. p. 26 Exhibit "A" IDI# 921229CCN054A Additional photo of the instruction and warning labeling on the product container. p. 27 W ilsons LrATHK r'PQFCrOR Exhibit "A" IDIi 921229CCN0544 Photos of the suspect product. p. 28 Exhibit "A" IDI# 921229CCN0544 p. 29 Exhibit "A" IDIi 921229CCN0544 Date coding laformatloa on the bottom of the coacalaet; states "Cl..2" AjG,4Tzr('S I I iI j I Exhibit "A" IDI# 921229CCN0S44 Above: Complainant and her slater re-eoactiog their use of the fabric protector product. Below: Photo of the product in question, as purchased by the consumer TREAT M E R IG H T p. 31 / 1. GAMENO. 930111OCN0667 2.MVeSTOATOffS10 8 11 1 x omeicooe 8 30 *, DATEOF vn MO OAT & OATS i I --- 1--9 2 1 2 wlNvHtUrTnEaOxnoM 51 in OAT -12 <8 MAR 41993 V EPIDEMIOLOGIC INVESTIGATION REPORT . o ftcooBfTowcQMWjMwT On 12-25-92 at approximately 0830 hours, a 43 year old wale and his 17 year old son suffered chemical pneumonia after entering a room in which a leather protector had been applied to a coat. Both were treated and released at a local emergency room.________________________________________________________________ .LOCATOf____ Hone (Niece1s bedroom) aa. m n moovct Leather protector m aeoONO amoouct n/a 50 10 Raleigh il n a te Tennessee HZ m . liw M iw e ham .moo.Mu m e w .W ils o n 's L e a th e r P r o t e c t o r , * 5 02 U N U p A ctu M i * tam tss .' Wilson's, Minneapolis, Kn. 55426 * uANuncnmnA n/a a. ocwvou is. MOV AMT m jo.TTACMuam Multi K NAMAT7VCSe*I X SGCJUm mmmtkMlem** :i 0MA& KHMi * UMOOMM l< CMSFOSmON T SR IS. MlUflYOIMSNOSB Chemical pneumonia(vapor inhalaHrnl 00 iy .- W 0MXK1W(HiiW. MnS Victim H. CASKSOUACC |1 | ts. TVKMVfSnBMION o r sie im icu n o c > | I I oroc* 9 1__ 1 a. nevieMDiY IS. nwe IfPIT i *2f --- 0 Newpaper 05 Ifo b sCf*9CMAY OPCLOSSiMV MAMS CMC MAYMQTW riftg MYMAM a . weoioMu. ofwcs omcctcmnone* Narrative begins cn page 2. O -3(0^S7- |USSomCMM< AMOACOmOMAt SM0CTSIFMBCSSSAAV) APPPOVtD FOR' IISE TEH0BB"5/31/ 54' 3041-0039- p. 32 930111CCN0667 a t t a c h m e n t #3 U.S. CONSUMES PRODUCT SAFETY COMMISSION AUTHORIZATION FOR MEDICAL RECORDS DISCLOSURE TO WHOM IT MAT CONCErW: You ate hereby authorized so furnish she United Scares Consumer Fboduc: Safer.' Commission a il inrormatioc and copies of any aod a ll records you aiay have pertaiaio^ so ( .ay c a s e ) ( die case or ilsiacioaship to you including, but not limited to, mediezi history, physical reports. laboratory reports and parhoiogrcai slid e s, and X-ray reports and ribas. ! 3H 3 Ji hU (Si|aiwc} (ViMnil ose oiim m o . it 930111CCN0667 P re-A ccident TTie victim , a 43 year old m ale, lives w ith his w ife and 17 year old son in a onestory sin gle fam ily dw elling located in a blue-collar w orking cla ss suburban com m unity near M emphis, Tennessee. The victim , a tetter carrier w ith the U S Postal Service, said prior to th is in c id e n t he had n o t m issed a day from w ork due to sickness in over 10 years. He said he has been in excellent health, and*was not on any m edication prior to th is in c id e n t He said he sm okes cigarettes, averaging d o se to tw o packs per day. and has done so fo r som e tim e. He explained th a t the day o f the incident w as Christm as Oay. He. h is w ife, and son w ent to h is siste r's hom e fo r Christm as breakfast, as th e ir custom had'been for several years. He said they arrived there a t approxim ately 0730 hours. A fter greeting fa m ily and friends who w ere there, he said he w e nt in to one o f the bedroom s, w hich had been designated as the "sm oking area" to sm oke a cigarette. Tim e w a s approxim ately 0745 hours. He then returned to the living room and kitchen area and ate breakfast The fam ily then began opening gifts. The w ctim said his niece received a new w aist length leather coat fo r C hristm as from her boyfriend, who w as there. The coat was in a garm ent bag. W hen she opened the garm ent bag, the firs t thing that fe ll out w as a can o f le a th e r protector spray w h ich cam e w ith the c o a t He said she showed the coat to everyone then took it to h e r bedroom (which was the room designated as the sm oking area). ' Unknown to the others, the niece's boyfriend proceeded to spray th e leather coat nwtl`t"iVliftreer'tf5mec-i~^1t1e1aaiathlr protector spray in the niece's bedroom, as it hun9g on the The victim seid he w ent back to the designated sm oking area and sm oked another cigarette around 0630 hours. A ccid e n t - " The v ic tim s a id he noticed a peculiar sm ell in the room when he w e n t to sm oke a second cigarette but assum ed it w as caused by stale cigarette sm oke. A fter leaving the room , he said he fe lt a pain in his chest, and began coughing violently. P o st-A ccid e n t- h<Land *" * fam ,,y teft N s sister's house around 0900 hours. H is w ife bm e th y am w!d home- ***> her husband and her son fe lt so ill. they m m ediately w ent to bed. She said they w ere com plaining of shortness o f breath 930111CCN0667 coughing, che st pain, fever, and ch ills She said she telephoned h e r sister-in-la w and found o u t her niece and nephew w ere also experiencing s im ila r sym ptom s! A fter ta lkin g about w h at w as occurring, they both realized the on ly unusual occurance w a s th a t the niece's boyfriend had sprayed her new le a th e r coat in the sam e room th a t had been designated as the "sm oking area." The w ife sa id she decided to telephone the poison control cen ter fo r advice. She w a s to ld to take he r husband and son to a lo cal hospital em ergency room fo r treatm e nt She said th e y arrived a t the hospital around 124$ hours. Their tem peratures w a s a t 102 degrees F Both her husband and son w ere exam ined by physicians and diagnosed a s experiencing chem ical pneum onia. They w ere treated, prescribed m edication, and released. . . . The victim said he continued feeling very ill until he began taking the m edication. He rem ained a t hom e recovering fo r three (3) days. He said h is son w as hom e recovering fo r 4 days, although he continued to cough fo r the next 10-14 days. The victim said w h ile he w as being treated by the hospital em ergency room sta ff, a t le a st tw o physicians and one nurse questioned him on w hether he had in te ntio na lly inhaled a chem ical fo r drug abuse purposes. He said such questions w ere Insulting and contributed to the discom fort he w as experiencing. The v ic tim 's w ife said several o f the fam ily m em bers becam e ill a lte r being in the designated sm oking room on C hristm as Day, however, n o t a ll o f them sought m edical treatm e nt She said she subsequently contacted the lo ca l new spaper and reported he r fam ily's reaction to the leather protector spray, and found out tha t individuals nationw ide had sustained sim ila r illnesses. The v ictim 's niece w ho owned the leather coa t w as visited and she stated she also becam e ill and w as treated at the local hospital em ergency roam . S he said her boyfriend, however, did not becom e ill. She said he purchased the leather coa t and spray leather protector fro m a store in the O a kco u it M alt in M em phis, Tn. S he said since the incident, he has subsequently purchased a second container o f leather protector fo r her coat, however, it w as a different size (7 oz ) and contained different la be l statem ents. She provided th e origin al container fo r m y exam ination and perm itted m e to photograph however, refused to perm it CPSC to co lle ct it as a sam ple due to possible litig a tio n . The room designated as the sm oking area in which the spray protector w as used w as exam ined and noted to consist o f approxim ately an 11V IZ area containing furnishings such as a watarbed, tw o dressers, and a storage b in (a diagram w as drawn and is attached). The victim 's niece stated the leather coa t w a s hanging on the outer fram e o f the closet at the tim e the leather protector spray w as applied, and le ft a t the sam e location to dry. She said the room tem perature w as set at 73 degrees F The w indow fo r the room w as dosed. There was no ventilation p. 35 Product Information: Product 'Manufacturer/Distributor Product Oode -4930111CCN0667 leather protector, product in black metal spray can, 5 az_ size, labeled in part: w***nXS0KS L E A T H m PROTECTOR** CM/TIGN: VAPOR MAX BE HARMFUL. CONTENTS I M M PRESSURE. READ CAHEFUIiY OTHHl CAUTION ON BACK PANEL. NET NT. 5 0Z.**WILS0NS MHMEAP0LXS, MN 55426**". Wilsons . Minneapolis, Ms. 55426 "292" stamped on bottxm of can Standards Information: Product is subject to 16 CEU Part 1500 under the Federal Hazardous Substances Act. Attachments: - 1. Photographs 2. Authorization to Release Name 3. Medical Records Disclosure 4. Medical Records 5. Poison Control Records * Diagram of roan '* Assignment jymocgsE 930111000667 attad iiHt.4 M (-1 OOWtOE Mwgnow // vi> ..! \ v r f. ? 5 _ J ^ g' - 1 s 4 = ~^f><-s.c # ATT/ MA. Ut /^ 3 P & uM : POSTO*A#0 -, WWCUOH VDMQCNT . V\ ooaryoFcaMmimMvm IONE ^ or sa or s/iUMnj^| ~' / ) ( t) h u ,.^ n JZ Z , _______________ I 1/ Jcowin^cKDKiLoc/re^TO, TIME /C itd 930111030667 aLta-lmerfc 4 *O1A7R*O0*2A0H30*SV.1A3NRD8ONO2ENNR3EA^LDAYEL0 1 6 8 0 52 3 0 003 14- 037 02 1 3 wrwPH METHQDLST. VkKrtow W batAMbadeJbuAre EMERGENCY DEPARTMENT ROOM NUMBER 7 -- 3 MEDflSM.SSBENrS T EQUIPMENT. A LABORATORY OBSERVATIONS IO fa * fy p f /t / a f f r t .U i, Q y . a t o / 6 5 i Q & L - -A s > ^ ________________ M & udW i ( & f . i d i yu ,,& Vr-I_l b < tA d fi^ *+ -r\ SIGNATURE - 't J m iiu J FML13tO10/87 INITIALS SIGNATURE _ INITIALS INTAKE OUTPUT ~w G +J w -------- \ - #. iNmniKP OAAM Miruoco. p. 38 930111031)667 METHODISE MIMESMUPNHIIOS.NTVAViEtip4 . wip*7r7r - *:2 '>4 LABORATORY REPORT abfcadmont 4 WtESftHMOCMF.UC WECIOROFUiQMSOfi K*rnt99i*A\m*dtVatAn> 3( 622 0 5 3 3 G H2HEDUEf.'K 1 / : `j(> 1 2 / (D Cl AOAMS.rowAGO L 16^05:13 * ... <tS! bl'M 43Y M fiOHK, 0 - ;-Mi. *0v: v.L f<1'. .^ Ail**fMW$7a*rt-k.r':r"'iAT?U-}.-mIj:i.-n''r"i c"Vo-'s'' .. .. AETKRJAI. RH -- ; . ARrmAJV;pro?.,.. n?,. : ARTOilfc'liri? : ; \ art 'sAfifp&roiH ; = ART BASK HEKJCir. . Atrusw. Hcnn . AIR . ' ... 1 RltHCfliRRiirfS '_.-Z\ ' . Y '-.TIMK lrfieSs*l<RiCKlifj) U...,; TEST HMiFOWiKi);-? . .. J-.*- . v-*.:. i... ** *<* * 4. - ~,mt i''*y *'* 1V / ^ N / g ? jt3 s I.O A H iF B O S m ..... . -- i.KF ui \ ih si-4-i 85-95 . 73-sB ?.5>-i*L;r a w L K T E B u m n ner-R u i f . ..&-TTiv,^RoH.(BKeMHCcH-A:..:"*tJojprhaJtKt..-vw. ^^*5rv--i" : ; . . tCt> Mifil Hc h H tn h n " " T V ' ' "' ' - T . Mf.Hr. siiJinn : fi.Ar>:t.Kf <Tnrc .. Rt>a . ; .. . MPtf . . .' . ; : DimTiKKTIAl, , . .;- . S1.XDK HO. '. ... : . . stu; HfweaiPHij. r.yMRHocnfTE / . i : Aim ijTRnpHu" .MOKnr.nrs '^sZp-sg' kns^WHt^s ' " C IJ. MORPHOIOGY 14 10 .Wt. . ;b#-ft-1AftilBu.`%&3t..;*&2y; .,3?.^r3 fiO-490 .;; 'nWA!H3 11-5-J4.S ... . , . - . . . - 7 . 4 - 1 0 ' . Q.. . -. ; " v ,v .50-70 .?o--4o V r vi. ; ;. 9-5 ; y ' ^j*V^**l*~. KSnMh^iLiiJXV KOHMAU : ..' *' *. . *..v 'C-T7^-'ll .- . 11' ::l m u m : no. iOS*AMO. .CE *t'X OCCCS'S KA.M[ p. 39 . X-RAY PROFESSIONAL SERVICES BY: MEMPHIS RAMOLOGICAL PROFESSIONAL CORP. - C` S___M 23798234 01620S33 16-72-75 North Radiology ADAMS, DONALD L. Age 43 WM ER PHYSICIAN 930111030667 ahtadront 4 a KAwmeiT oriwonuiar ER 12-25-92 CHEST PA AND LATERAL: Heart size is noreal. Minimal chronic appearing densities are noted in the right upper lobe. No active infiltrate is seen. Roy Kulp M.D./cv Printed: 12/26/9 M ETHODIST p . 40 s t m im e n t MEMPHIS RADIOLOGICAL PROFESSIONAL CORPORATION t u id m. n o u n * aw F.o.tz n Union />.. tu li ts o tr m w k u . tm m it * - * * ? ti: p o i) 7 in > a ' #C C O iH T H U U O l PAH8M7MAMC pMcajrt v m c m m h v ic c n m m o OATI o tfc n m o N AMOUNT S *7.1- . * '. is /? /? ? ..I ; f . c r if if f '- n v ? t.s n ? L-Rr" v *-> f : l E ',,- 'w<m. c te< u.T H r e w c v r ( iv r o r - - - a T O ir - . : : r :<F i r - r f ; < r r " , iu <r P 6FW .. . - i j i . oo J . \ M* :) II you hiv NNiMUatf wtiNn UM MM TO<yi p N iw <ttrBr4 Ih l* fU m m tf*. KTATMMTOATI OUONOMOOM LOCATO* TOTAL CHAHOM AMOUNTPAID j. i :; * * v` !; \ t *V SSCTB '* V account n um m n AMOUNT OIM .'S ; ^ D o ta c h & R a tu rn w llh P a y m a n t TA7M NT o *ra V. patent nam PW VtttU X* MOUJftN. HMLFOHD, JN. W U W A tlC N O JOHMU.OOMON P N Y W .O W JQ N Q .J6M N I n o m r u - oockkft N O M ATI. L A n m . VIVANO H M A W , JN. JAMUW .OQAU NOT JLP. JN. ALVW A M M R , O A W O .ttO M ft v x rrN .a N .ro N w u ia m i. n o u n . JN. NKMMV 0 .1 1 7 * pnamkd. pan ni NOMNTN.VVWNOOOH TQMMT1 NOWICN NOUA H. HMfONO, OL MANX W, VtATHQVT N MCHAV. PUMNO JAUC* R. MffCHUM U .T M IA M O O ** MCNAM.A LIWW W U l HAN W . JN. UNOAK. CX M p io M o a ia rom TMDVTCVrTNAkMVIVTM <--MAMON* COMMUNITYHpjm Ai. m w pm i now wcvw n. a t h o b w ia u ) W nM ntO VW N Q VtTN . |ACmoaDMOVfrA R E M IT P A Y M E N T TO : MEMPHIS flAO lO LO Q ICAL P C. R S S tk M tiL E PARTY INFORMATION J '' '8 0 \W ~ ' N S * '' s " " TJ p.41 * AOAMS. 00N A L0 ' DR. 0 HONE 1 7 8 0 WARNER' AVE i. M EM PHIS H -3 TN - GENERAL INSTRUCTIONS: AFJ^ CAn e sh eet 930111000667 a tta ch n a rt 4 ITmBeIMwQmM 2- 0 4 2 "0 0 1 7 2 3 METHODISE PATIENT AFTERCARE SHEET 1 2 / 2 S / 9 2 The treatment you received in the Em eigency OopL a an E -- 2 S 4 4 2 2 -- 8 jemergency treatment only- H is vour responstoSity to see your ' 'v . Iphyaiglan far follow-up and continuing care. Vbu must make ary '' j ' appointments and n ecessary arrangem ents yourse* and taka . No weight bearing. ' doctor. . Elevate aflacted extrem ity as much as p osaU e lor------- 3-odays. . Ice pack to affected area btermitlentty for_____ days! J .... W ktcfifor tuacessivo .awobng. numbness, or bluhhtxifcsam oj^-fingers or toe. .^ . >bu haw bean referred to Or._______ :__J L ---------- taltow-cp care. Malta an bpointment to see your physician in__ L--Tdays. ' l( 'r ' . An x-ray w as perform ed and a preliminary interpretation \vas matte. The final report will b e made by the Radtotognt If any significant changes are made, you wV b e notified at the telephone number you listedl --------Re^ftap ace bandage if too tight ex loose. Rewrap at le a sf once da#y. . 'w r i l m presertotion you received contains a substance thatt tmraay make )you drowsy. Do not drive or drink alcohol write takkxj I- -i .` . The prescription you received contains a substance that lends to upset your stomach. Do not take medication on an empty stom ach. - . A laboratory la st requiring several days for completion w as'performed. The r e s jts w ii b e forwarded to your doctor. .Vtxrm ay be excused from work or school for---1-- ^-- tntK to exceed 24 hours). For time beyond this period, approval must be obtained from your private physician or company physician. . Wxr may return to work or school today. - INSTRUCTIONS FOR CARE FOR SUTURES: -- -- i? L ^ an aporiintTiont.to a ee yput-d .. (2f.Keep"aSfchercteam frdry. -- (3) VW ch for Infection. S e e your doctor > redness. (4) V you return to ER lor autore removal, you must bring INSTRUCTIONS FOR CARE FOLLOWING HEAD INJURY: drainivaeTtevetxte ' -*1- ' ' form and ooma betw een the hours of 6.tX) a m and 11:00 a m . (1) Eat fighty for tuenty-faur Inure. No aedathea or t (2) Awake patient every tw o (2) hours lor the next I drinks. 2) hours. (3) V any of the b lo w in g symptoms occur, contact your Immediately. If you are unable to teach your physician, return to the Emergency Department for assistance. A. tnabtRy to arouae or awaken patient. B. fnabSty to move arms and legs equaty. ' ^.j C. Vbmiting, convutaions. mental confusion, restteun eoa, double vision, blurred vision, rfrainaga of bfood or clear Squid tromnooe or ears. .- Q. Severe headache unrelieved by medication. r.; Prescriptions roceivred /ri DISCHARGE IMPRESSION . ( ; t \ M edkation necelvegJ In 6 1 i. OTHER INSTRUCTIONS: / C r^n ({a s h c - t f JL . ( 2 K' h f , --~ f X - - jJ r _____________ L> r_ - *f vou are not mtKh enproved In____ hours or, tf you becom e worse at any lime, contact your physician right away. If unable topvach your physician, return to the emergency departm ent" . Y. --"T'vr I understand these inaarvettons and eoccpt them: INSTRUCTED. C'i-'K-' .D r7,_ f f l . $ u.(. / a / .N urse D ate. t 2_ p.42 M E H H S I 93OT1XUC667 tfcaiirent 4 mu mol H C io MEPK.U RECOUPS rwm-1 aacRAL oaNomoNS of emergency medical treajvcnt - o o tse ir to T re m e ir M M vC * jwyw* j-y y 3"-WMPBMS bayi Rff^r mrrTftnr^Myi i T ^ Fin 4*9 uorbartiiav . ___ ,, . .. florawnvCMi Mibn*MfariMMk| cniw Mm -- W M M ffw w I IPIM U r -- i dfe^rtfivCt'jlaNCSp^M^* tw m tm m * * * * * dbrMhs ` )<-- n i-- *ro-- ---- -------- -- -- ----- - * - --------- - -- -------- - -- ---------- ------------ ----- -- -- o iwiiitii - HART L RELEASE OF INFORMATION. ASSIGNMENT CF INSURANCE BENEFITS ANO FINANCIAL AGREEMENT > w y M *a<innfMtl m M w ft*WM m*km mmmrtm.wmtmmfrotpmmMm m Mm aaptay M MMn Ih MlI mtMHMM t M n M # a n * mmbi tpp%fcg Mr 9** NMr MaJMIw WtJMCM i*wB MM MMrMM*bHrrMM fMcMIMMioIm vfMfMmVMMtMf*|tfmflmMOi Mmmr f Mm*MMMmimMfmcoIrbfMaill AtoMmM*MMM MMMTMMs pttSmmutCMMvM* MMMMMMrtotfMM**fti w*.M*ImmMmMMb mMMhwtr IM lMM C I NbMbl MBf NiMl -- ^ r i<rf ciwinil-.iTT-iT-*f-^"`^-r-"----r y--- ~-- r--^ f u f f |ta00|O -- m .**-- MMCMMUh m w MM > . . . ___ 1 W H U M M M M l OH MM SOM M M UC A Q M MMOF. M IM MVOflT OR OUUT 4UINAOED C f im m m * m im ra m a M cocRON c r w in if ii m in * . i f i --N w e--f y i f b C y f f W rp w d f N inlart gjgrfA I f W I M iMifljllllWilirfaciiMHR W J Off UMT MUMMR R J. 2 0 5 5 3 -- 001 MCKrNM ADAMS |M M M O O N I VA IM mwawowwe a# NUMMR iMffNn *=E" S54*tt;i-E 12/25/9<! r r 17 2 3 NOM E_____________ DB____________ :2 47_ ____ 237982 MOOWtC IMQ/SSN* O C C M M H MC MS I SS, aa hLl_D O N A L D L __*10-86-1396 i; LP51?42 4? _ t u . 0 OTHER l-IM 1780 WARNER AVE NO PREF n-iNa MEMPHIS 901-353-3332 TN 381271335 US POSTAL SERVICE .ETTER CARRIER ADAMS D0RACE UMK miuiM '>99-999-9999 0 0 / 0 0 / 0 0 rHMHMBI >01-357-4619 FATHER MEMPHIS TN 0000 00 23798234 00000 M B A H/wr HQSNM.uar IOOMS N M M MC/SN #. M NRUMT ADAMS DONAI D L 4 1 0 - 0 6 - 1 3 9 6 ________ !E L F _______ 162 0 5 3 3 W M ACQRCSI-- IM9 ir^Gcr.NMBi 1780 M A R N E R A V E _________________ MEMPHIS TN 3127 E-- 3 5 4 4 2 2 -- 8 RHQMCNUMKR 901-353-35 NOCIMCWiaua 999-- 999--99 US POSTAL SERVICE MEMPHIS NAT_ A S S O C 8F= L E T T S K CARRl NATL. ASSOC QFTJEXTERi "S S S C r p o c a z o H ^ -- . O O /O O /O O ._______ ,, 1 4 1 0 - 8 6 - 1 3 9 6 i P . a . B O X 9 6 6 8 TN 00000 ~e-.ftfc. ^ ^ P O M A L P /. 13961-"S S ^ O SCOTTSDALE AZ 852? 00/00/00 p.43 A^Mievec c rjt-c ts ocu PLEASE DO NOT STAPLE iN TH IS AREA SENO TO P A T I E N T * * ---------- 0 5 0 PLEASE FORUARO T H IS C L A IM TO YOUR I M O I V I O U A L INSURANCE 930111CEN0667 a tta c h n a rt 4 5 C C A R R IE R *"T H A N K YOU" "C* A C T P t > 0 4 0 7 8 1 ARCS34 P CO 542e H E A L T H IN S U R A N C E C L A IM FO R M o n e s I6 K IM 0 1 U ) . NUMBCA - EL (FOR PnOORAMM ITEM l| ItA L T H flA M IL M LUNG [~ )flu < fc > rw p |i a>MorsSM p ~ ) fw r a . t> is n ~ w w sw [~ [y o i 419861396 iCAnENTSNAue|UMax. Nata.VMM tout j f < B *r^ w o A T e MSUREOS NAME |U H NOML R ia Na m . M W . M M t AOANS DONALO L ~ o 1 fATCHTSOOIESS|M..SMM> 1 7 8 UARNER OR 12 5 4 9 " H X Fn t . M T K N T W LA T IO n S M E tt> H SUHEO *>p - 0 .PARENT STATUS MEMPHIS BP CODE 38127 _ lV s * Q u-- i Q x < TEU PHONE AncAM t a iC m ( M ) L 3 6 3 -3 3 3 2 E*torMQ> i l.<5M1^<0N0<n0MNeLAI>TO: JP A -HS. PQHr t l D r NSURGO-S AOORCS5U l. Sm a ii 1 7 8 UARNER OR TATE MEMPHIS o r CODE -U LE IRAEHONE IM C U M AREA COMI 38127 ( 9k 363-3332 I I . M SURCPtPO UCV GROUP OR FE C * NUMBER . o th er M s u n s rs po licy o n g r o u p mum OMTMHEfllN0S0UREfEfrSQATCOFBfltfM cn - n Fn t EMPUTVCfTS NAME OR SCHOOLNAME . m p lo y a r e n t ? (c u u r c n t o n p r e v io u s ) v ts o V A u ro A C C M N T T P lA C C tS W M 322 MSUHCDIOATfOF w OD n .12 6 49 " x " & (u o to v u n nauc on school name * c. other A c c o firr r *> -- L < .S .-F fS - M V . S p l i t s cNSURANCE PLAN NAMEO ft PAOOAAMMMAE rn INSURANCE PIAN MAMCORPROGRAM MAAE ^ i v* s _ Tqa KE5CNvSibm.5bAl.USt AtAaAC KO E rU NM ETON COAINATl6An M ^ TW5 FON! U EAtlER fioKAU TM O N O iO FERSCAfStCN AIUR E I a M a h a a a A a v a M N a i m I I m M|W0WliwqMW.)EHI8giWipyiMB8H>irW|NlMM8fBl8Itii|W fWWHyW aaUM--BUM S I 8 M A T U R E ON F I L E 12 /28/92 ________________________________________________ OATS________________________ SEND TO P A T I E N T - /VAf.C* .S THEREANOTHER HEALTHCNEPIT PLAN Q tTd a *o iK u w ivim a M A .IH a . M u te r a n authohizeo per so n * s u katu h e i i IMiiwMh m MnpwapH|jon SONEO. S I 8 N A T U R E ON F I L E *!K S S ft | p i |O M u r r iA c M M W PRSOlMMCY'UiPl 1 PHVSOANOROTMER BOUNCE 1 RESERVED FOR LOOM. USE ' T- 1S.IF PATENT MAS G tv c n n s ro A re CAMEOR CBRUR UMES3. mm o o yy I f. OATES M n fN T M M U TOWORK M CURRENTOCCUPATION FR O M *** " To"" ^ I l f . 10. NUMBER OF REFERRM O ftffS IC U N 11. H O SPITALIZATIO N OATES RELATED TO CURRENT SERMCCS MM OO YV MM DO YY FROM TO a o o u rs o E tA * scm aases 21. D U Q N O S K O R NATURE OF U J tE S S O ft M J U ffY .4 R e L A Y E rrE M S l.U 0 R 4 T O 1 T E M 2 4 E a Y < J N E | - , 466 0 i L. 1 > I 22. M EO C AO R E S tiR lfS S e N COOC . ORIGIMAL REF. MO. 1 23- PRIOR AUTHORIZATIONNUMBER 114. A MM OO YY U U 12 28 9 ^ Bc O FWa Ttp* S 5 c B S 3 * B rB I6 S E B ^ H S u F N 3 B M OO YY fis s e (Cr M a Um m C N u im n im i c p t h c p c s 1 001C IE "_________ c OMONOBS CODE 3 . 992i *l F SCMAROCS 0H ro rra n OR UNTTS R r -- ~ i tu o COB RESERVES FOR VOCRM f 92 ( ' 12 28 9 | 3 1 712i l 12 2 8 92 1 2 2 8 92 ; 3 3 6 4 l A ; 80819 l l 1 2 2 8 92 3 i 8S2^ l EM 621468269 Cx T1 UGNATURE OF PWVSOAM OR SUPPUER MCUXNNO OCORCESOR CREOENTIAtS 1 2 * PATENTS ACCOUNT MO. 1843119C 3 *. H A W AR O AfiO R ESS O F F A C U 1Y W HERE tfR W C E S W E * " ` 9 < f A w ( iw M m * r (te a l T" C C .< y ,+ SAM UEL T . V E R Z O S A .N -j} -t t o 1 / 1 1 / 9 3 TATA ' r <.v ia r r S 8 1 J. 1 32 . . i i i ;1c 1 25 1 2B. TOTAL CHARGE AMOUNT PAO a t Ba l a n c e OUE * 212 3 i A Q /^ n c u Y s ic iA K i s3 4 T ic,< y 7 T ,a 4 F 7 ( p o N ts i. o c a x 8 AR TLETT-RALEIG H INTERNAL MEO 5 1 3 S T A 6 E RO SU IT E 3 MEMPHIS.TN 3 8 1 3 4 ^ CRN. T p.44 MEIHODBI ER23798234 RAHil JO O NAL RHVSCMM ONE DONALD L C fcC R R M CHGL 1 u rn D & HOU8C S*ff PATIENT/ADMISSION A fiC s MS UNIT NUMBER 1:5 m 1 1 A 2 A533-001 i14 t s u m jc s * 1FM V S 0A N FE E 1 - 930111030657 attachnai: 4 n fc Uu ChoK.VmMa ^ >0000 ICFERNM G RKVSICMN q j HO R EFER- Df?. 1 OThCB OM ROES i1 1 . .A ..... . ,__-1 !Si,i y f 2 3 ' l E-354422-!= 1M Q IW r M O 1---- ------------------- /omtimi fhvsicmi smiw.uon owe our ft H CARR `'PA CFWUIMT BOUGHT or PRIVATE VEHICLE nvcKT rnone MAWl '.;'M*1I^,' gS?* **' B IF F B R E A T H IH < 1/1M H A LE D C H E M IC A LS tOOmOMAM) I9CNOCOPYOTCHABT MTTHMneKr -r ctum o p a c t on. coNomoM o n B C M M tac/T fw apcfi BOOM * _ * c o w rv u if w crscns on r no k t t w m HOURS. o o o o O s tfw e n m s o n a 13 c u n o t jlNOU* le w M1SCVW3 WWXNO jlM f AQ w w eow rt M M iw ti jitfiv o M i ew eow rs W < w i :: L 285t>'-d fc#>fLLlf / RALEIGH IMLSriAL nEOtCIftE PC h P n o fft 51820H2 93OT11COC667 atbdnat 4 UUMt. [tfal Boovao* v ` J ^ fiY v ild A d n in 's -dt- UOT7<a M 1__ M U R. 3 5 H 3 -i ; c< (A rd a v ^ ^ -&r'4cit>'4 *** ' ' I'B '? r--2--: ' _ ,1 : n 3 ) 3 S M ,mG T Z ' i 8 y SUB TOTAL i| ~" o 8 ^ D "" f e ] TAX BO3 SALES S U P 1 3 * 9 d? CUSTOMER BAPOHTAMT: RETAM THS COPY TOR YCU flftfC OROS COPY W c n \+h *ccv* vjl>c . m 1 X`* fCcriv^ .hu Cc "u ` *-u3- i_" i I r p.46 93011NXN0667 attachrent 4 N A L C H e a lth B e n e fit P lan 20647 WavertyCourt, Aahbum, Virginia 220TO . VIMFORM FOR UNASSIGNED BILLS - (Benefitswfflbepaidtomember) =".v . a.X vj* (703) 729-4677 STATEMENTOF MEMBER' ^ q ' S3P O a ^ e W a a tfB H io fM fc n fire id tiM lM e itfM c S a to M k rfM r H ; - ` O C e M O C F C H M O E C F /W E U -5T- 1 MEMBER INFORMATION....... .............. 2. ----------PATIENTINFORMATION " " '..<v aJL +.i'- .ri4 '.. ................... . SO C IAL SECURITY NUMBER ; ?* Cv'-A .-C'J.'V J-----J - I h I i o l - U ' l f o l ^ I I K x ^ - - ...... . aetom etrsTAius: acme *L 'm turrurr o -sumwoaeieAMrr p ( * P r i^ n . PATIENT COPE "L* I t f 1 .................. J-- _ f W n J A L. - X / iL f w r ^ _______________;_______ *U1" U I 1 ~1 T C o l i ) A / " n t r D r \ - - " iM r .iV M c iw f = rw Z ~ 7 m i 'z c r - z z s a ........ " < 7 ^ I p ____________________________ KunOMHFIOHIIMa * M..A..W...T..AL-ftA-lU- S IIMlWm Vpc `M--M__C __ OW.OMO.E--D a_ . Ara chargea ralated to " . Ofcovered by: . . . 3. W orkers' Compensation YES NO yes.give: ~ ' .. .............. - -- - r i- " -- - - ----- L -- ' -- r ` rW erfepridaoLdbcnoslfid compensationdaim * ~p\ B f* \ y / I I c e L g j/ ^ . 4^ 4. Accidental Injury -v r Dme.ptace anddngnosh [ B i- J .. 7 .'? `/ g.l,^ [ ! ,>.*-- -- U J2f I tS & s l y Une/- f r i * L - * L i \ r h r , bdOTOweedtyrotadautoraurance? VESDNO^ TTMpar*ld*)r (subogrton)? NOC ^ y-- nem eend address VaJ~t \ Je f.la lriL r-Han't- t f n n S ' t l v i i j f IL . * * ^ K i n c f l ^ t I t j , -c ry 5. Medicare Medicara Identification Number ' B lactiva data: Part A I---^rVartB --- A- 6. Other group m edicai/ dentalcoverage . ' * yea. la Insutanoe bauad through active employment? VE9 NO la ttile art HMOpoCcy? ...VES D .NO O ............. ................................ Name ot person to whom Issued___________________ '__________Beledonahip to pedant <tfa.hej S*H -3S-(. ` cf Name a l organization or em ployer through which obtained HOSPITALOfl UEDICJU.M3URANCE: Name and address d a t a r Insurant* company LuiltrduSt DENTALNSUtUNCE: ( i r 2 L I l & J ln a Elfectbe.date. Po6cy#_iZ_ Cancellation dale _ Salt Only Famy Q . v ,u ^ U J i l*r\ir teerfA Name and address d o ta r insurance company _______ IT - r r c i n r- H lertVe rH + ~/ I Polcy * ' ......... ;................ . CsnceBatlon d a te _ _ _ l/ _____ L S a l Only O Famfly O I authorize iy holder of medbal or ether related information release to NALCHeahh Benefit Plan any Information In regard to mysal o r my fam ily necaesary lo processing thb or any ralated derm. .............. " ' ' '~ V ~ * \ A s t L / ^ . -^ 3 I c a n ty th atthe above Information b correct that the enckned expenses were incurred tor the nam ed patient, and t a t I am e member in good standing o l NALC. - c/ JM +-T-JS.--------------------- I A '3 . 3 WVflHti:AnytentorialU se statementorwSM ndn ap es enlstlnnrelativetothisdatm b avkiM on of tie law punishable by a Cna. Imprisonment or both, (la U.S.C. Section 1341 and Tide 5 U.S.C.) OF- 1 IM I p.47 93011KXN0667 . - CLAIM FOfM FOR UNASSIGNED BILLS dttadmrt 4 _, ;*i*J*" NOTE: W hw>qctalm^<to<^.bopaaqr.~-ray.**lnw* 'i lt<y<pn<fc-qpn<.*ttilihilylttinl d b to . Btum dgrat><bi an d d o aip iM of9Mvio*I p ta ^ m im a n l^ g tte a cftM < fcsi M ca l*d a n a lU b . Eritertetri atbaltara. Th PfanwOlaccapt data bm M di prova TM lnfcra6o ! ^ *v o > 0 - _ Manotwilnsuraroacoaipany la prta^ on Madrine. M r aiptanatoflofpapmntbrra n u t ba Inducted terad M oA nA ted . .. . *" - > :j * v" . . ' PRESCRIPTION DRUGS ANOMEDICINES Um ONLYfafpfwaipfandnigndm xteirm .at--d ip fia ip ia n on Mprdtro fidcompte Mxh cokaan.AntCH MUG BUSWOMNGMFOMUIIONUSTEDB&JOW. p. 48 METHODIST. " ^ S ^ N E W c o v ik g t o n p 4056 MEMPHIS TN 38128-0000 - NORTH ' 930111CCN0667 attachment 4 INSURANCE PENDING: DONALD L ADAMS - 1780 WARNER AVE MEMPHIS TN 38127-1335 NATL ASSOC OF LETTER CARR ^ ,, ,, J E T H O D t S T HOSPITAL r ^ T p T o . BOX 1000, DEPT. 97 (*y*ajE MEMPHIS TN 38148-0097 ACCOUNT NO. PATIENT NAME ER23798234 DONALD L ADAMS i ---- AMOUNT ENCLOSED AAMSSaOMDArcet|ooOc9CCNnAaIiligGcCoD*ATtlkj|ssfATCMCNTDATEI AMOUNT DUE I b U 6 D * T E | 12/25/9281122//255// 99221| f2/29/921 251.50 t1/23/93 J PLEASE DETACH UPPER PORTION AND RETURN W ITH PAYMENT A PAGE 1 OF 1 m s * s w rw ttM T o r your account. r etu n th is portion ro n youw e c o n o * ____ --------------------- APPtAfl ON YOU*NEXT IW rtM EK T. ACCOUNT NO PATIENTNAMF ER23798234 DONALD L ADAMS |DMSirWBATE|oCXJIDAT*jsiATTMNTOOT !l2/25/92L2/25/922/29/92 251.50 ,01/23/93 j ' DATE 12/25/92 12/25/92 12/25/92 12/25/92 12/25/92 12/25/92 HOSPITAL CODE 000089 000682 000783 013567 027883 027883 CHEST PA fc LATERAL BEMOGRAM BLOOD GAS/ART EMERGENCY RM LEVEL II VENIPUNCTURE VENIPUNCTURE 65.50 51.00 80.00 46.00 4.50 4.50 L IF Y O U H A V E A N Y Q U E S T I O N S , PLEASfe CAL L ~ PATIENT ACCOUNTING 0 726-8375 (MON-FRI 9:00AM - 4;00PM) OR VISIT US AT 1211 UNION AVE,SUITE 500.PLEASE KEEP THIS S T A T E M E N T F O R Y O U R RECORDS. INSURANCES, IF S H OW N ABO V E, RAVE BEEN BILLED. YOUR AMOUNT DUE AMD DUE DATE ARE ALSO SHOWN ABOVE. THANK YOU FOR ALLOWING US TO SERVE YOU. TOTAL istim vcm ci METHODIST: 1I 251.50 .00 251.50 p.49 .CiTTffXXSr. S * v r t*** . E R 2 S 7 9 8 2 4 5 Eii'JI;_____________ DONftLD roBiU-miM 5 - - 1 0EK2P S A L - l\Jr .IE3ICAL 'S C S C i [MS UMT MAMBI .ifk_ 47118Z.-002 ***^ 'm j m Z .1 -. 1 -/ 7 * 9301UC010667 attachment 4 MCFOMPU t n O M M 0 0 0 0 0 0 NO REFER. PR. ir a i mol t t E-33W4P:? <XM MO t i t i l :/ U L . I j J fH ` T \u r j ? V- " -.r , ' z r iz z f c : 7 .I T fi U .,, ' .. . . M H M M S ffiN - #5 ' -/ f ;/ ` '* f * * - - - ' i: * ; i . j ; ; / ? ;gT K lC s . e c t * \ 4n --------------------- ---------W - -= ' JL & 41 O hr^ i ^ S Cs pCf J C /jL & r * ___ 4M QQNSUL7 <***____ OOMMQ6____ weg w______ m u cmifl) home ornee <-*r;'..,V'".tj -i' ` BDBUCSUP a eowoe b d * ?~ & y z . (& ) A JU a^ c^ if no irrnaf f Sicuitt r o .g e t w r w fr T Q ir t c*aw < > |n*n * >* - * p. 50 TIM E / O n 9301110CN0667 attachment 4 c " 2 3 1S 8 2 H S 00471187-008 METHCOSL AOAHS. OOMALO C s' 017 0 0 . ST VCftZOSA 1 7 0 0 WANNEK AVE MEMPHIS TM 001942 RAiwVitfiUfadrKuita 12/25/92 EMEROENCY DEPARTMENT ROOM NUMBER. 5 7 r3= BP p MECaCAlfe^Mji^SAs EQUIPMENT..* LABORATORY V; OBSERVATIONS isA m 'm JCH W - * * /7 * to /m 'b Afc C. ^ 'lA fa s t. f j p C.J ///A C A 4tta y>wci/(< A / f c i i V ifc / a t / t c K p r o t e c t , 4/1/ /V- J it ir f e t . S tro k e s - ^a/ ___ 9 H n + lt/> *+ /'* <&- Sr**it rOor*~ t<A<ne. g Ai/ ZT p m r te n j j^93_ A : f c 4 z ~ * i__ * v > /?/r' C%Jt/~Afl-Uk- <Ja * ~ J s\ Q m L L sT /jsr H& /sat: Asa T j h r * * / __ r___ k. m o S e jl A g >4) 7^- O / i , ( Z. J?l p u t A e iis ___ f ^ t* 4 + r' j i n * g>T. /^w ^ z>3J 7 SIGNATURE ffC f^ ri . 7 4 * 4 . ( i O INITIALS SIGNATURE _ v y t h * / jr J L y / 'n U M TUU INTAKE OUTPUT //> ^* p. 51 930111OCNO667 attachment 4 METHODIST. VKmomrWbatA MhKtfr ttw/* 124) UNION AVC. MBIfHR.nWIIIHr ,vi,p ? LABORATORY REPORT <Mnm3iVr'....... uUMVWJMWM C 4-71 107 r CHMU4AMW Q0FF tmecTOROFuieoAfl CD u l.hlm w;mi nj :ck no :'<[ <ii iCCtOR s .avi 930111CCN0667 attachm ent 4 X-RAY PROFESSIONAL SERVICES BY: MEMPHIS RADIOLOGICAL PROFESSIONAL CORP Cs N wirwMgnuar 23798246 00471187 ADAMS. DONALD C. 16-72-74 North Radiology Age 17 WM Sam T. Verzosa M.D. . 12-25-92 CKESTi TWO VIEWS: Heart size is normal. There are prominent interstitial markings noted throughout both lung fields present, and the possibility of an interstitial pneumonitis cannot be excluded from this examination. No discrete focal infiltrate is seen. Roy Kulp M.D./cv Printed: 12/26/92 09:46 cc: Sam T. Verzosa M.D. FAX * 3719317 METHODIST nawHaaiMiaiac I fO to 9301110CN 0667 ACCOUNT AMOUNT t -t:' z : w Detach & Return TATtUIKT DATE with Payment v v i -i.'v; PATENT MAUI COUrtt.?. <: ul.'-.rij phw cum i H 0U aK .H A LP 0R 0.jn. W RUAMILDNO , JOHN M. OOUON JW W W .O HM JONG. JM Q N I nomutucoow oft n o M m e l a it w . jn . tuwAnem.mtnr.jr. Mtnw.tQMJ mrw,A IV M J.W IM R .N I OAVWO.UOMMR M Y R . (MILTON W ILU U Jl. ROUTT. JR ROWRO o . ia t c i TRANK D. PARK! ROHRTR. YANMOUOH Tom v t. powur NOLUiN .N U M n D .n i NARK W. WBATHnLV R. M QM AIl neMMQ JA N U ILM TC M N NmuAnooM HCHAK A. HUM) DALI I . M AM IN. JR. UNOAX.COK _______ R A M O LO ttll* PON: g W genTBIimW.HOAWTM. MPNAMOO OOUMMrr MOfMTM MWHOOerNORnuKHHTAL NPTICBT m n wnanriovniHgwmL utmoaeNDviru REMIT PAYMENT TO: MBMPHII RAOIOLOaiCAL. P.C. h b ip o n b ib u p a r t y iw o w M A tio N U DNALS t. a ;i,` 17BO WAK. 'iiti (;, " MEMWI13 in 133i p. 54 930111OCN0667 attachment 4 nzuNawn men* WtnENT AFTERCARE SHEET 4E0*AaK3S1, SD8O2NA`#L5O 0 0 4 7 1 1 8 7 - 0 0 8 MHHOOSE MnENT AFTERCARESHEET C ?2;,,Sr v E"20SA 1780 " ARNCN AVE 2 017 001342 The treatment you received in tha Em ergency Oapt is m em eigency treatment only. K b v m r msponsfoiOly to so your phyaldMi far lo ftw H p and conSndng cans. Ybo must m sks any No weight bearing. j1 2 / 8 5 X 3 a . appointments and nsoossary arrangements yourse* and taka -354483-* this form with you to your doctor. Elevate aflactad extremity a s much a s possible ion______ days. lea pack to affected area kaermittBntty tor_____ tyya. Vlhlch far w casaw a s e a ling. num bness, or bU sh coloration of ftiqara or toes. . M xi ham bean ra fa m x fto Or.----------------------_i------tor folow-up care. M ake an appointment to se a your physician in----------days. - -------- An x-ray w as perform ed and a prefcninary Interpretation w as made. The final report w b e made by the h h ^ i it M V dgnM cam changas are mads, you w ll b e notifiad at the telephone number you feted . -------- Rew rap a c e bandage U too tight or boaa. Rewrap a t iaast once daly. -------- The prescription you recabad con taba. ubatane dint may make you droway. Do not driva or drink alerty -n a this medication. . . -- ------- - ' --' = = = ---------The prescription you received contains a substance that lends to upset your stomach. Oo not take medication on an e irrtv stomach. -- .......... -- =~~*~ 1' ---------A laboratory test requiringseveral days for completion was performed. The results wS be farwardad to your doctor. ---------Vtaj may be excused toxn work or achoai to r--------------(not to exceed 24 hour). Far time beyond this period, approval must be obtained torn your private physician o r company physician. ---------Vfcxj may return to work or school today. . INSTRUCTIONS FOR CARE FOR SUTURES: -------- ( 1) M ake an appointment to a ee your doctor on____________________ (2) Keep atoches dean A dry. (3) W itch for infection. S e e your doctor i redness, aweflng. or drain ai dnvotape. (4) It you return to ER lor Aura removal, you must bring this form and com e betw een the houre of 6:00 am . and 11:00 u i INSTRUCTIONS FOR CARE FOLLOWING HEAD INJURY: _ (1) (2) AE wa taBkgehpttaytifeonrttweveenrtyy-tfwouor(2h)ohuorsu.rNeofosretdhaetfneeexs totrwaellcvoeh(o1l2ic) dhroiunrkes.. . - (3) If any o f tha blow in g sym ptom occur, contact your doctor fosnadately. If you are unable to reach your physidan, return to the Em ergency Department for aaafatance . A . Inabbty to am use o r awaken patient B . InabOty to move anna and lags equaly. C . Vomiting, convulsions, mental confusion, nottessnass, double vwion. blurred vision, drainage of blood or d ea r f e k l hom n ose or ears. - D. S evere headache unrelieved by m edcattan. . R eacriptiona received DISCHARGE IMPRESSION__ r O r u J ir jis j _________ _OTHERINSTRUCTIONS:__ J *i* -for -k+ry, J ___ _________ $***' J t e / toor-<-. . Medfoatton received In ER }r\M <fs / fa/iar?!- u)i 7>r~. (Y \< t\c la + . If you are not much improved in . hours or. if you becom e worse at any tone, contact your physician right away. Munable to reach your physician, return to die emergency dapardnent I understand th ese instructions and accep t them: /> I >/i JLa. t p. 55 PLEASr 0 O' STAPLE IN THIS AOA S N O T O P A T I E N T * * * " * * * * * ---------- P L E A S E FORWARD T H IS CLAIM TO YOUR IN D IV ID U A L INSURANCE C A R R IER" " " THANK YOU" ACTP 8848641 A R C S 3 4 P CO 8S88 93011100N0667 attachment 4 HEALTH INSURANCE CLAIM FORM 68f* ui E K< O 1 MEOCMC MEOCUO O W M ruS CHM TV* OBOU * O IW R la AISURCO^ LO N U M K A ___n u im iu w ____a u < i.u M 0 ___ ||M a d k M b 1 1 lip a m r Y S S H l | | *) j | S S h tf * p iJF* 418861396 4 *0 * PNOGAAM IN OEM i, . Ip A T E N rS M A M E ( W M M F M M am . M U M 3 AOANS DONALO C 0 <. PATIENTS AOOHCS9 PM .. S M ) W T rr //> . m 7 ^ n x . PATIENTAELATCNSHT TO INSURED . M & M S 0 S M A S UM Nm n . rwm S M M M 4nU AOANS DONALD M SUO CDSM laRC SSlN a. S>aaa # 1 7 8 4 WARNER OR s^ Q ) U w m Q o p = 3 f H Z : 1 7 8 8 WARNER DR { S T A K I . P A lC M f STATUS M E M P H IS __ T i j ^ i Q X u p t o i Q OmmI . ZW COOE TELEPHO NE p n c flifla Cam 38127 ( E 3 5 3 -3 3 3 2 t rK E n M s u x t ir s k a m il m iMa m a , f * la o m MIMI /FA-Umi-- I flll-11-- f. L J s u m *_J io a ftreST i gaxbitw a tiiii ity 11.other m suneos r o u c r on c k w m u m eT a EM PLOYM ENT* fC U M E N T o * PNEV1US MEMPHIS ZPCOOS T i n-jEPK* iw a u w t * coo*! 38127 i 353-3332 I l IN S U A C O S O U C G A O j> (W E S O N ilH C n 322 LMSMtrSOAl^flMTN !g Ilk 12 ;tc U OTHER CJURETS OATS O f WITH UM DO TV : ___ _ ! "CL C E M P LO Y E ** NAME O * SCHOOL NAME IL L qves AAUTOACOONT " c. O T H * ACCCENT, n *> 2 PLACE ISAM ) . E M P L O Y E ** M AU 0 * SCHOOL NAME lx a* ~ C. N SU R AN Se PLAN N 4U C 085 PROGRAM NAM * r~* -- 3 il t1z j a INSURANCE PLANNAME OR PSOHAM NAME M " \ D *3 M B *C S E *V 0 A O IO C A 1 u s e SENO TO P A T IE N T * * * BiicmiwioniHiiTHsNcnmMrr -5 j M E ia O F W IM l ^ to i llW B IIIO N W O lH S M ^ 12. M T K X rS O U U T N O M IO K R S O fl M M IIM E j mpmemm<tf-- lliMiflfl-- piy-- m flffpww-- A-- -- -- nniwBgMfwpMfr****Ml"* ! STO N ATU RE ON F I L E . t S ' tX o I f n i M i i M i U uwuxto-soJiuiKwaxaHiisaraBONAtuiEiwMM * r* * v tm I T . B ir.n i lo r u n o o n l i) n t n . . . r . . a ir lo . S IG N A T U R E ON F I L E I I D A TtO fC U H H E K T: i KJMa lf*mi r lK a il OH , K" o o TT E m iw rp D >IC H Ia 3.V 7 1 l a w m o w i 17 NAM E O f R E F E M M O P H V S tC tA N O * C O T * 9 0 U *C I . HESCRVEDFO* LOCAL US 19. r PATCNT*MS HAO SM C 0 * SMMA* E1MESS. cwcnnsTOATE am oo yv 17a. LO NUMSENOF AEP&M NO PlTVSCMN IS O A T U PATIENT UM AEIE TO W O ** P f C O M E N T OCCUPATION MM 0 0 YV MM CO YV TM" l a - a t g - i a M . HO SPITALIZATIO N O A T fS N C U T fO TO C U fM E N TS E N V C E S MM DO YV MM DO YV fV IO A i to ao OUTSK>= LA5' 71. DMGNS* OPIUTUAE OF 1 NSS flPUUftV (PELATE RIEMS 1.2.3 Oft TOITEM2EY UNCI . L. 4 6 6 8 J I___________ * 7}JU a . MPCAJO *ESUSMSSON OWOWAL NCP NO. 23 PN IO * AUTHOMZATON NUME* * ' TA. A UM OO OF W V C C ^ YY MM o o 1 2 2 8 92 9 P kM M Tr YV S w ia M * 1_______ 00 a w o c tm iH in . ic w v c p . a u r r u ts Ifc p a iilJ a a M C im w iM fill cpw cpca 1 o o *e * 3 . 9928^ 1 2 2 8 9J 3 1 7182^ E oM O Nose CODE 1 1 .* SO M M 3CS nr ra w H : IJ EP50T--------- 1^ eoa e s e n v e iF O * LO C A lU E t 3 ] ' 92 81 1 58 8 j1_ . i ( ............. " i ; t 1 2 2 8 92 3 1> 3 6 4 1 $ ' 1 2 2 8 92 . A , i 8881$ \ FCOEflAL r0L LO. HUMOCn 621468268 SSN EM f" j rp c 1 ' _______1 i : TC Pa TCMTS ACCOUNT MO 2 1 B1842517C 1 6= e i1 1 32 88 ' _ 27. ACCEPT ASSOPAENH , Jg at MAL C W L *N M P ) M M e . Y J HO n . IOTA, c h a n g e * 187 m . AMOUNT p a io 8 *1. IR 7 n 2 c cfl ------------------------------- 2( j >Z fl M . BALANCE DUC * J ^ r l- 8 7 -- 8 4 . iNaiJO PNIO EO NgCSO NCPEO EwnALS I C8NN PU flH M M W 8N WA*8 IH W 4PPT w r * 6 * M * * * * * * * j . * E m * E 0 ffa J j SAM UEL T . V E R Z O S A .n L >co 1 / 1 1 / 9 3 ! 8888 I*P < 0 V 0 1 1 A U A C O M C X O H U ttX M . S C H v iM M a i ** /VfJL / f if f L E T T - R A L E I 6 H I N T E R N A L 5 1 3 4 S T A S E RO S U I T E 3 8 8 P il/trn iL . M E M P H IS .T N 3 6 1 3 4 . PLEASE PRINT O n TYPE m9Of lav* FO X H H crA u e a m a o * rO R M A C M W FC "? " 7 / n i NE3 ji !+ p. 56 9301TCCN0667 attachment: 4 N A L C H e a lth B e n e fit P lan ' 20547 W avorty C ourt, Aahbum , V irginia 22093 CLAIM FORM FOR UNASSIGNED BILLS " (Benefits will be paid to member) (703)729-4677 STATEMENT OF MEMBER 3F CooyiNilititfafldtatwpiraNlarBtfarsidtprtlmfTarfsicfirifsndNisir * 0 1- MEMBER INFORMATION 2 PATIENT INFORMATION SOCIAL SECURITY NUMBER ens-iE- 3 - i i a ...- EMSUMiarrstatus; actwc HI Awumwra sumvoaANtrunwrra - ............... PATIENTCODE [ ] MMC D n n *(- L. u**a * 1I f r U .) a"r M U tv ^e 1 / - A a -twc .......... t r D rt -T W **317 a ? D o a ^ IJ l- H -Jn ir OMEWSsm ev , , -, ! - n ? - / y - 7.T RQATOCSMPTOMEMBER r ' MARCTALSTATUB oo MAAMCOQ h IMLS W OfMMCGD Q ' Are chargea relaled to YES NO Kyes, giva: o r covered by: . _ 3 . W orkers' Com pensation _ D alol00^ 111.<8^gno^^l^ndeolnpw^^^onc^rn^__ _ =_J>__^;>l3______ 4. Accidental Infury ---------------------------- T'A-*,. Jn-Xnne. */- <--V c* Li` 1 *-f-x*V } ( f Q Pata.plaeeanddlagno8ls .1 S. /^ 2 -S " / t= y ^ ^ r , l 5. Medicare ,r~o,Sl, ^r* - 'T * '' 1 S 0^rt y fn'" 6. Other group medfcal / derail coverage Q bclaira aavmndbyno-tailam Imurano? YES NOD 1M dp*yiaM y(sdbm gdbr|? YESQHOOf) ~ -1 4 * vea.insurancecom oanV au m . e n d a d d re ssl J K I E l . . . - -- i,I fArt S _ int,,pc,l T H M edicera Mumbai---!-- !------------ -------- .J Eftactive date: P u t A J . PartB Vyea. Is Insurance issued through active employment? YES NO O I this an HMOpoky? YES NO . N an w ot parson to whom issu ed __________________________________ R elatfcnshp to patient Name of organization or employer through which obtained_______ _____ HOSPITALORIIB ACAl KSURAHCE: Name and address ofother insurance company . DENTALMSURANCE: Effectue dale. CincaliM date Policy 9 ___-z. . Saif Only Fam ly Name and address of other insurance company l^ O p t^iP~-277j __r r f f r t f s n __ Effective dale_____ / /_____ Cancelation data_____ f _____ /_ P o k y # ______________ !______ IT S a lO n ly Fam ly O I authorize any ItoHer at medicalo r a fte r related Mormallon to release la NALC Health B enell Plan any Hontiadoa In regard to myself or my fam ly necessary for processing this o r any related daim. 0 IWKEaYsiritsSsa -- k.iX'3 3_gJ^VX*-h-- __ /-ifr-9J Dim PakntYsonata*hsaranttrinoPi Omm I certify that the above Information it correct, thatthe enclosed expenseswere Incurred folLthe named patient, and th a t! am a member h good stanrfing of NALC. D<s*\c*JtP 1 qCfL~r__________ /- / f''f 3 MemfierY rlsi~e-w s W ARNMG:Anyintsntiaruib ise statementarwtihi mnrepreseaM ionralafvatoM scM m isavfolafion of lie law punishable by a Ina, imprisonment or both, p a IAS.C. Section 1341 end Tide 5 U.S.C.) cr IVSt .. ' . 93011100*0667 CLAIM FORM FOR UNASSIGNED BILLS a tta c h m e n t 4 NOTE: WhanangdlBferdcigM bam tottK^durhfr<i<*^qdpBil.fc. pan.m m dih ifrlti mhntMII. Basura*ia4agnMii,4bto and dMt-rip4 w o<n4o. p ^ -- f n w n d ch g tor-- chMtWMittv V O fio iiU b fc . Entnatal tfboOom. . 11* PlanMacoaptanydaiai kraiwhichpnNfciMttasarna infoiinaferL ............... * B telm u *n acm p a tyfep n N yM tfc< ta im .M m |*raa M o f|sp n M fairaM tt in d u fcd farN eltfca a4 m M . . ' PRESCffFDONDRUGSANDIIEDICMES UaaONLYfarprijcrfjXlondrug*andinaddrwa.Uitaaohpraac<lp<anaaap*ntejut aicompMaaach raiunnirrncHo/ucBuasHOWMGMRnunaNunaianK P * (U A y | l-^^tVinri^niM fuf. METHODE! m - t-- m-,. Wftwi' IfciArw. METHODIST NORTH . 3960 NEU COVINGTON PIKE MEMPHIS TN 38128 930111000667 attachment 4 DONALD L ADAMS 1780 WARNER AVE MEMPHIS TN 38127-1335 INSURANCE PENDING: NATIONAL ASSOC LETTER CAR METHODIST NORTH MAKECHECKS P. O BOX 1000, DEPT. 97 iWNftAND M E M P H I S TN 38148 - 0097 U A L TO: AMOUNT ENCLOSED D ACCOUNT NO. NOIENT NAME ontm ottom OHKHAMiOAVC n o o w ffw n AMOUNT DUE ER2379824S DONALD C ADAMS 12/25/9 12/2S/9 01 / 0 6 / 9 i 0.00 DUE DATE - .-'.v . *,rV'- 'Vv; PLFAST DETACH UPPER PORTION AMD RtTUR.V W ITH PAYMCNT PAG^i/OF . J HETHDIST:?IW^ H * . ^ ^ ^ _____ ___ ___ ___________ _ ____ iss s W & t ^ is ^ .- LmlMmrMrcMncmpbmYaim'micnmrA "~ ^ CHAMats on M M u m n c m e i A T T n N riM x u v im M tw vousnextn nuaM r. ACCOUNTNO. ^ T N iir ^ 1WBT.NAiyiE MMMQMBMn pwniMWiow r a n m o f f i AMOUNTDUE DUE DATE 1 ER23798245 DONALD C ADAMS 12/85/91 12/25/91 01/06/9 i 0.00 1 HowuAtcooe .:* --.v*^r- PCSCmPTTON . AMOUNT 120592 122592 122592 122592 122592 122592 122992 *1 35G7?St ^ F ^ EMERGENCY `RM LEVEL II T HEMOGRAM "".C'.- ' . . . '7 6 3 " T BLOOD CAS/ART 27883 V VENIPUNCTURE 27883 - ; VENIPUNCTURE 89 CHEST PA A LATERAL 6168 NATIONAL ASSOC LETTER CAR 46.00 SI. 00 80.00 4.50 4.50 65.58 0.00 FOR INFORMATION REGARDING YOUR ACCOUNT, PLEASE CALL PATIENT ACCOUNTING0 726-8375 <HON-FRI 9:08AM-4>00PM> . OE nm sT fO TN l 251.50 251.50 0.00 METHODISE MEDICAL RECOUPS 930117GCN0667 attachm ent 4 B W I GENERAL CONOftlONS OF EMERGENCY MEDICAL TREATMENT - CONSENT TO TREATMENT 'I C f M lK R iM p M I M M M * r * C M ncMMo AC U iU9Bbsasi55SfesS5issMMars^^ k N m i m i i a M , IMirE-- c lrilH|im ml-- r>M iww-- tmn-- ih iiiiMiIS'-- -- i <* <> 8hni* l <mNi -- m t UtV mimnm w mm m m * i imiwm n > M i l i l t I i N H u m m u l MiMHI, la iiax -- --l m -- # > t o n g <M U > .................................................. bO h M i i i -- MQm n ih i n m r ii -- r i i i tir . --NIuM- Im r WaRogt--twmWwuwnpMcnootpMgppnvlMrn4wMliPmHOT--OTtmIiHOTM-- IHOOTTOT--M iOWT PHOTIHi MftaMlM im iO T ik I. MMDlnmMrtanMtpmi BWT L RELEASE OF FORMATION. ASSIGNMENT OF NSURANCE B0JEHTS AND FINANCIAL AGREEMENT ^ js m s jm g ^ v js s s s s B J i g c O T g B jyss.'s g s s c s s s s M M M h_k__-_-_-_-_____ Mn----trtMmp m--s--arftHr--MOTrk--M-- * ir * * -- -- .Iotot* -- OTP*iH-- * -- OTOTotOTon-- ot1 t ip -- * -- eRr t v i p s-- Hml<-- -- -- i* M-- -- g y -- i p -- -- hi fw mnIom i-- ot ap-- c pro-- p gp -- -- <p-- <-- -- -- p p -- -- -- OThppp-- W-- Iw-- i h -- -- i p OThrhp P -- MB-- -- tfP-- -- pW-- SlRP%lUnP * -- P-- Ppp*-- pOT-- -- -- P-- -- IM WaH*<**O>iTwPiC--S--p<ii<pl--rw--pl!X--pll*>iph--<--p>TpP|M--<H--HBpaOaTO*--ipPi<UNPiHOT-rlttpwl,iPP--Ntpb) ykMiiHlMOTpiipHiJNp^>pAM--iWHi8>------n|l-- ^OTOPT< OTppOTMPIwwh^MlwMlil*Bmaif<wtl>ai,ploMtMiUpMpM.MiipiliHwEfOcTMMHliPNtiM'iMnp*MMdipfpPritilp.mpHiPWn ><ippp|>iiP>wiMiipw>wtpmxiiHi mb> c iib h > n w t e n has a or h is se a t w o n e rom om n s r b m a copy e s , a n c n o e tr or c u y A u n oe ro 6OP TMSM O t H O T RMOOMO CQNOmcMS OP OMRSOi AMEOCCPBi iX pH ftpP yW A p IM N W Ilil iSv (j& tlA . .TSHT 4 I71m lrUv3 J UNIT TT 1<<A4<1OT1JCM l M IM w n tn iiu w sH O ta sB i 4 7 1 1 8 7 -0 0 2 1 2 /2 5 /9 2 d 1942 VERZ0SA ENT NAME new PAC IMC/93N # . SAM . . -S S " T 2:51 IfiAC 0* SHTH MM `CC 8?M M 3-A 23798245 MS RS ARRC OP S S _____________ D O N A L D ROM CAI Y CHURCH 00-00-0000 0/147l975 17 S * n 1 HJh MQMEPHNC OTHER NT X M E M - IM E I -Mfl-PBEE_-_L_M__l_____________________________ 9 0 1 - 3 5 3 - 3 3 3 30 W A R N E R A V E <WCR JDEHr IDENT M 70CTOYM HcnnwO M M O T JBJP1K MEMPHIS TN 38127133S UNK 9 9 -9 9 9-9999 P ieN E N w ee* m et mm awe 00/ 00/00 MEMPHIS 23798245 -TN 00000 ' im ' 00 MS D0RACE >01-357-4619 GRANDFATH OOOOO M m M irio a m .L M T B M A i M M i N sauM nr 13 tt- IM 1 DONALD " ? WARNER AVE MC/S0H * L 410-86-1396 " VCAHS ADOR-- - 1PC 1 MEMPHIS HeuQKXSHr 1ATHER TM 38127 N P tM T P MMST n O C M M S 1620533 RP P X H M A 4 0 I 901-r353-333 R O S M M E R -- 9ME E-354423-A 999-999--999 >0STAL SERVICE 1""" __________________ MEMPHIS________ TN 00000______________ . assoc;or jba^^^AfKjjiAT&pASsrcsoexs^ >*-- d o n a l u L * r r r ^ x z o a - - - ^ -- " S S B a g r g S ^ f f l W W Nwwr4,1 n0 -- B^ 6---^T3A9 fi Q700I 1410-86-1396 I P.O. BOX 9 6 6 8 SCOTTSDALE AZ MtOAB o/oo . *0UPf U J-- IM M M M KI mw 1462180.U DATE: TIM E: AAPCC COOPERATIVE POISON CENTER REPORT p30inooe o67 a tta d n e n c b CALLTmm MASON 1X1 lo____ < ; I 'K a t 'J k ' a `S t ^ 11. h s PATIENNT O A K U . , A Name: J^ r r j d . l l a a m s Telephon no. . ( A d d rtu : __ Zip: . CALLER DA] O M D RN Relationship to padane RPh O OHP Sa l o f i MMootthheerr /0fc <Ocher. . (Telephone no. ) ^ ^ 3 - 3 5 s z _ A d d re ss:___ Memphis - 2 . Q mo. See: 'p d e le Tfeemrnaalte W W ghc C Unknown ____ O kg. Pertinent M adical H is to ry:^ H n a tto v X W n rlm n ir n w h -- ^ N o HilOWnCfOHa Zip: . . C ounty: S ite o f Cattar S ite o f Exposure l*t-- . Residence -- 4# . W orkpiece _______________ Q ^ M c k here ifpatient is pregnant M O n a m e A no.: ________________ Medicalhistoryunknown . H ealth Care fa c K ty . O ther Unknown . O O UBSTANCE DATA iu b s ta n c e :_______ li- n 4 b r f b k r h r. Im ount . \ fvW JLxA m .g.3 iflN d M n ti: J U t u f e u m M anufacturer: V t o l ' n n ____ 'L o J b t\ * ^ J * -?Ao* jp i ? ____________ im e o f/S in c e exposurer:. I f *V ^_________ ______ ______________________________________________ o u ts o f E xp o su re : G Ingunon ^gW w M on/N ssd OOeuter O O tm u l O sh/S ting Q rs ia n u n l Unknown O W w r. STORY. AS S E S S M E N T. SYM PTO M S 1 CALCULATIONS ilstory (w ifctesscd? am bim i eerttled? other productsAdcPins?) O No other products suspected tofep- \\s sinvTusbaJicrttofwm WC d I ' I [ oxi_ S p au d t a b tw IF u ii w crJ-in P spray**/ ojos over fe>was cr -far strcfeirc)ogzrtfKs. 5fCt/SUffSUfc IVUi. I<vg o4lufcrp Rw'HcfaHfr /o-/S", /fas^esiefedsr objective com plaints/objective tim ings C No symptoms at tots me _ Ccughrg, g ^ r g -x -r- jD U j,v . i- b r c .o :U * iL S rt? o A iscssfrivni {sym ptom s sx p scte ? raw ul?) Irritisi K M is iR tn l (choose one) A| wpttowtc xT/Siwipciwc;.iiwd C Sr*o9w >c m nnm 1 ri^Vt. t a ^ f.' A *' ' f C .b U CL v \ s ^ 'Trsatmnnt F a c ility .-__ MANAGEMENT PLAN, FOLLOW-UP NOTES AMO OUTCOME: (Tim A date * * d i oncry) l 0*11711"" T reatm ent suggested: AC F 930111CCM0667 attachment 5 Codm: . Sym ptom s to monitor; J C^X-ito^ j gvftAli>- , \r\ UsO K i S o/~' ` -V ./ ) FbC ow -up sch e d u le : o ? -- *"4 *.V5 A a e r 4 . S i i . V ^ o o d W Sv s t c -O. o < u * -* . ^ v*o-^ f *C ' t n *-i . S s M *- j 3 Arfta.(Voo5\i(t- *& 9M Vo VWtl -ioies W VV **& .Ti iw " lV v v=`^ T < i V><^- ^ ,MW pA i aLwro \ W W > AI V f c c A t - 1 = # - v. L \ 4 re ie io .^ c *e .. 'U u ' Wsoa* 4 r^ Ao3 W T Vi in _ jr i u ' < % *" ~ * -- < & < e e * cJUfisA- W A & ^ V ^ W U - W ^ , V c^ r I ! a&\ue \ %jCr'^h, iMir)t 3f> WU^ JL1ANTS 7 RES O UnCCS U SED: Modica*director. G T h _._. :0 BY: - S C ^ /l^ Q A F O R M ______ o L fftfo - O O ther consultane - C O the r__________ )C>) a p. 62 930111CCN0667 attachment 5 AUTHORIZATION FORVRIAELTEEALSEEPHOOFNPEATIENT INFORMATION TO: P e te r A C h yk a. P h arm .D . E x ec u tive D irecto r S o u th e rn Poison C enter, Inc. 8 48 Adam s Avenue M em p h is . T N 3 81 03 You are heSIrneavbfeeystytaiugCtahoteomrIminzecisiddsietoonntr..eTleeansneetsosee AthgeenUt:S JCaonniscuemMeritcPhreoldl utoct the case data that Involved the following person: ~f^Vv~o-Pf1 jck ^ > 7XJ-C tv*. .. V .IO i^ w S _________________ _______ _________________ _ My relationship to the above person is checked below Mother Father Legal guardian _ O S e lf ^3^ O th er, please describe f l & D iC ^ c X V i A d cO '*~!S - h X X F - ^ - r <-cfj K n u ^ . V e rb a l a u th o riza tio n given b y telephone on th e follow ing date: Signed'^rS?v >.c-rtr D ate____ 7 /1 9 8 9 For Foison Center Use Date received________ Case n o . ______________ 1462.1802 DATE: AAPCC COOPERATIVE POISON CENTER REPORT 9301n ocho66? H'-M CM LV N m tM ty) VM M Jr-*MW* i. . IM uVMm * . M mI t yyiw * m IVp*Iti low aniyt |> ~ * X Uw*h*teat attachment 5- REASON (R) (o a. I A MMm* PATIENT DATAA l l Nm m :. Telephon* no. . [ A d d ra s i: ___ ) : CAUER DATA Nsms: Relationship I d p a tie n t: i<i*l ) Tlphona no.: ftJnnS Q Se (jtf Mother ^T3 a Father O th er. mo o m - RPh OHP nAge: O mo. QK ii. $x: ^ M s lc O Tem ile Zip: \6 VW s^ht Q Unknown e^Ro.. Address: ___ _ kg. c s p K a k r t f| h fm i- s -- f y g t iw q (WorhitlQ, Q Memphis Zip: Sta * of .Colla.r yo . C ounty: . n- -. n / H M N h C M fM iiy . Sr> n n nn hack hase if patient b pregnant Q MO name A no_- _ _ _ _ _ _ _ _ n ......... C MedicaMvsioiy unknown o - Ilalm im tai n UBSTANCE DATA z^Q ^ A T -^t)nne3 3TM di*" \^V\Vso ^ o -^c na O f/S ln c a exposure: . l` T>T, JIM o f Exposure: Otngeaaioe OM uM onSNaial Ocular O d a m i Kia/Sdng fererearil D lM n e m i Other- TORY. ASSESSMENT. SYMPTOMS 4 CALCULATIONS Ilory (finessed? amount t t r t M l other productNytcthno?| No other products suspected .*=& m C o ^ i p ^ tecdve compalnts/objecthre Undings O No symptoms at this lime C-LV CCS-VV VoVs-- ameni (symptme expected? ratidhafe?) Hal asee ssmeni (choose one) C Asynipaomaae sr- CL S p Nxc*JKoS> :.Mfitrowr * yD*vO--t*Vt. j . "bu-o. V o X T ? 3 h jy c K s ^ e p ***< ^jCipdSLhrvC p. 65 930111CCN0667 T n r. m attachment 5 facility: ------ ------- --- ------------------------------------------- ------------------- -------------- --------------- - Coda: MANAGEMENT PLAN. FOLLOW-UP NOTES ANO OUTCOME: (Tim a * data aach en try) Ea a t e / h m c Treatment m ggM lcd: \\cjp Symptoms to monitor CUsfUvc*. , CW.W , -hspKte. i\ / F o lto u m p sctie d u ta : O -- * 4 .-.<5! (Va&LT i ssW r cote SPC. ;Aeain* Ti tn=u) * # o/tfi- ^'ST^ eA - uju Zj ,,-^t t ) l ^ c D s i<2>Te_r c i e c o ^ v w Xt.A'U**. H ec H c a / c P. S r & U - - jS ^ J A n s . / i j a n V u jArns . (^o l W ^jl , ^ -v> J ^ S 1* ' rr^L, 3 ^ 5 cxR^ 1 T ^ - V ( fW ^-- A-v/ \ W < A j s \\ 'f c A cv^Aix^ f ^ o l - - e (v a j >> fesWTc t W W . Sto^s c U ^ UlkIs o . ^ V - fc^ "- y is - * -ji ( C-o--. f f H 33 flry> if. . kr-i^S' q. V -- ir JN S IK IA N TS/R ESO U R C ES USED: M edical dvpctor G l*Ka_ - Q Other consultant . _ Q O th e r. AM _ . -=^n w CYa a FOAM 1 a /T ) s p. 66 Roan size p. 67 9301110010667 attachment #6 D ia g ra m o f B ed ro u tn (w h e re le a t h e r p r o t e c t o r vas s p r a y e d ) Not to scale 930111CCM0667 attachment 7 m a g n o lia O JOW W O SE R V IC E JKXSM.W 1R1) B H W nscMoo. A W i- COMMEUCJU- t f f U l IhatH t. li w tm OiUtY G tU flo a i X O T *L2>Gll\<LQ.p}0b1or] EleDxaEpCw-o30ss-9u22r7e tpoeospprlaeyill . .. . - .. - ; .. r centers' subm it Information, v? B y J o a Ham ilton ' ' :' -- Ndconstm er has died. ` . r - v ? ;3 ^ S 9 l5R*" ,el.A^*w l.- .P o lso n ;cp n trb l centers "in at " . - ... .. ; - , '. v -;'.M a s t:S ix states` b a re received - Several members o f a Mem- hundreds o f ca ljs ainee C hrlst- ; phisarea.t|am U y->ere tam ong mas v {r a n ^.people re p o rtin g T doxJm tjD f'^people ' nationw ide , coughn g / nausea, shortness o f "..who fe ll tllL -o ye r. the holidays breath and o th e r-U n -like symp- \ after- exposure ~to ' sprav-on toms a fte r exposure to the pro- ^le a th e r pro te cto r, poison co n tro l *duct.-W ilsons said th e problem o fficia lssa id T u e sd sy.' . seems to he a petroleum -based >'*. Ire n e ' A da m s,'41, o f Prayser substance in new five-ounce said h e r husband, h e r son and a cans o f its le a th e r p ro te c ta n t ` niece w ere treated in the emer- - Chyfca said' the spray Irrita te s gency room a t M ethodist Bospi- th e lin in g o f the lungs, causing tal North oh Christmas Day after .the symptoms.' Spendingtim e in a room where a Carey Adams, 17, said he real- leather'coat had been sprayed bed something was wrong about w ith the product "They couldn't 25 minutes after he le ft s room breathe' when they came out of in which the product had been . the room/Vshq said. . .. ... usedtojtaterproofa leather coat VOn^Monday, ..Wilsons .Suede given as a Christm as g i f t . and Leather Co. in 'S t Loois "Mylungs started hurting." he 'P ark,-M in n.,-recalled 270,000 said-"ft.kept.getting worse and cans o f leather protector spray worse." Adams said h is father- from 600'stores it operates, in- and others who had been in the eluding several in Memphis. rocon also began coughing. He The Southern Poison Control and his father are better, he Center in Memphis has con- said,though they still cough and firmed three local reports of ex- are congested.' ' : postire to the spray, said Dr. Pe- .' Chyka said people who think ter Chyka. executive director of they have been exposed .to the the center.' Through Sunday ' spray or have questions should there were 27 confirmed reports call the center at 5284408. Wfl- o f illness linked to the spray, he . sons' is encouraging consumers said, adding that the number is who purchased the spray to re- | likely to rise as more poison turn it for a fu ll refund. . 930111CCM0667 attachment #2 U .S . CONSUMER PRODUCT SAFETY OCWUSSICN AUTHORIZATION FOR REIASE OF NAME Hianir oc assistinQ us in collecting information on a potential product safety problem. The Consumer Product Safety Qomnission depends on concerned people to share product safety infc a rn a tio n with us. We main tain a record of this information, and use it to assist us in identifying arid resolving product safety problems. we routinely forward this information to manufacturers and private to inform them of the Involyanent oft h e i r prpdyet .ki_an.accident situation. We also give the information to others recjiesting information about specific 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 botbcao 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 indi cated your preference, please sign your name and date the document on the lines provided. j_j You are hereby authorized to disclose ny name and address. with the information collected on this-case. I | My identity is to remain confidential. Ii QtTKsfl jjjo-y-S ^ (Signature) /- 30 -S3 (rate) 4 VI i C". \ 930111CCN0667 attachment #1 Photo #1: This photo shows the front panel of the 5 ox. leather protector which was used to spray a leather coat on Christmas morning, the day of the incident. Photo #2: Ihe leather . protector was sprayed in a small bedroom which was being used as the "smoking room" for the family members who smoked. Both a 43 year old father and his 17 year old son became ill shortly after entering the room. p. 71 930111OCN0667 attachment #1 Photo 13: this photo shows the markings on the bottom of the 5 oz. spray can which states "292." ... #- teacmng Briet - MedPage Loday Page 1 o f2 m e d page Visit us online at www.MedPageToday.com W aterproofing Sprays Booted Off Market Over Illness By M ichael Sm ith, M edPage T oday S ta ff W riter R e v ie w e d b y R o b e rt J a s m e r, MD; A s s is ta n t P ro fe s so r o f M ed icin e, U n ive rsity o f C a lifo rn ia , S a n F ra n cisco May 08, 2006 S ou rce N ew s A rticle: ABC N ew s, C hicago Tribune, MSNBC M edPage Today A ction Points Ask patients with respiratory illness - coughing and shortness of breath - w hether they have recently used w aterproofing sprays or tile grout sealer. Note that this study suggests that even when used as directed such sprays can cause illness. R e v ie w DETROIT, M ay 8 -- Two w aterproofing sprays for boots have m ade m ore than 170 people ill with respiratory problem s, researchers have reported. "You basically Teflon your lungs," according to Susan Sm olinske, Pharm .D., of the poison control center at the C h ildren's Hospital of M ichigan here. Both sp ra ys -- Jobsite H eavy Duty Bootm ate and Rocky Boot W eather and Stain Protector - have been pulled from store shelves. Dr. Sm olinske said, although the recall has not com pletely elim inated 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. Sm olinske. Dr. S m o lin ske and colleagues in five states have identified 172 cases o f respiratory illness related to the two w a te rp ro o fin g sp ra y s p lus 19 anim al cases, they reported in the M ay 5 issue of th e C D C 's Morbidity and M ortality Weekly Report. No deaths were reported among the hum an patients, but three pet cats died from exposure to the sprays. Physicians should be aware of the risks of such sprays. Dr. Sm olinske said. When treating patients with respiratory illness, she said, "they should ask the question: 'W ere you using an aerosol w aterproofing spray?'" For consum ers, she said, there are four guidelines: Hold your breath when using waterproofing sprays. Do the w ork outside. Lim it other people's exposure Keep pets away. The two sprays were m eant 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% w hen using the products as directed. Som e people w ere exposed when sprayed boots were brought indoors before the product had com pletely dried. The two w aterproofing sprays contain fluoropolym er particles, which com bine with a hydrocarbon carrier, heptane. In the lungs, the com bination prevents gas exchange, "and you asphyxiate," Dr. S m olinske said. W hile there were no hum an deaths, the researchers found, 10% of the sym ptom atic patients were adm itted to a h o sp ita l and one m an w as h osp ita lize d for 19 da ys on a ve n tila to r. "W e had no deaths," sh e said, "but we did have one near-death." ' Dr. Sm olinske said there's little doubt that the waterproofing sprays caused the illness, which was characterized by coughing and shortness o f breath. "It's a pretty high case rate," she said. "It's at least 1%, http://www.medpagetoday.com/tbprint.cfm?tbid=3244 5/9/2006 Teaching Brief - MedPage Today p.73 Page 2 of 2 because they didn't m ake that m any cans." W h a fs more, she said, som e people who becam e ill later used the substance again - and got sick aqain One guy even did it a th ird tim e," Dr. Sm olinske said. W. f re k n Wn t0 h ave been e v a lu a ted in h o sp ita ls o r h osp ita l e m e rg e n cy d e p a rtm e n ts Pulse oxim etry o f patients evaluated in hospitals ranged from 61% to 100% (w ith a m edian o f 94.9% ). Cnesc radiograph s w ere taken for 47 patients; 13 w ere positive for infiltrates. Eight patients m et the case definition for chem ical pneum onitis. They had bilateral infiltrates suggestive of chem ical pneum onitis and pulse oxim etry ofJe ss than 95% on room air. Dr. Sm olinske added: the problem is not going away" now that sum m er is com ing. Sim itar risks are associated with sprays used to w aterproof tents and other outdoor gear, as w ell as with the tile qrout sealers used in hom e renovations. Also, she said new products using nano-scale particles - less than 10 m icrons in diam eter - are com ing on the m arket and we re keeping en eye out for sim ilar problem s," she said. N ano-particles are ea sily able to get deep Into the alveoli and interfere with gas exchange, she said. Prim ary source: M orbidity and M ortality W eekly Report Source reference: Centers for Disease Control and Prevention. "Respiratory Illness Associated w ith Boot Sealant Products Five States, 2005-2006." - MMWR 2006;55:488-490. D isclaim er The information presented in this activity is that o f the authors and does not necessarily represent th e views of the University of Pennsylvania School of Medicine, MedPage Today, and the commercial supporter. Specific medicines discussed in this activity m ay not yet be approved by the PDA for the use as indicated by the writer or reviewer. Before prescribing a n y medication, we advise you to review the com plete prescribing information, including indications, contraindications, warnings, precautions, and adverse effects. Specific patient care decisions are the responsibility of the healthcare professional caring for the patient. Please review our Terms of Use. 2 0 0 4 -2 0 0 6 MedPage Today, LLC. All Rights Reserved. http://w w w .medpagetoday.com/tbprint.c fm?tbid=3 244 5/9/2006 Leather protectant makes dozens sick Page I of 1 Posted on Thu, Feb. 09, 2006 Leather p ro tectan t m akes dozens sick P oiso n c o n tro l ce n te rs in M id w e st s a y 165 ill By Jonathan O. Rockoff Baltim ore Sun W A S H I N G T O N - A w ater repellent spray for leather products has sent dozens o f people to hospitals in the M idwest with severe respiratory problem s, and it appears to be made of a sim ilar m ix of chem icals that prom pted a recall 14 years ago, poison control officials say. Since October, poison control centers in Indiana, Kentucky, Michigan, Ohio and Pennsylvania have received 16S reports o f illness after exposure to the spray, which is sold under the name ' ' Jobsite H eavy Duty Bootm ate" o r ' ' Rocky Boot W eather and Stain Protector." Last week, a Maryland man became ill after using the substance, according to th e National Capital Poison Center. The poison control cen ter in Syracuse, N.Y., has also had four reports, a to xico lo gist there said. The Consum er Product Safety Com mission is investigating but has yet to take action. Neither M anakey Group of Grand Rapids, Mich., the distributor of the leather sprays, nor Assured Packaging o f Ontario, Canada, the m anufacturer, returned calls seeking comment. On Jan. 3, Manakey Group agreed to recall the product from store shelves, said Susan Sm olinske, managing director of the poison control center in Detroit. Two days later, the Michigan Health D epartm ent issued a warning to consum ers. But poison control officials don't know whether the company performed the recall, and some are frustrated because they say the com pany refuses to identify the states where the product is distributed and its chem ical makeup, saying that is a trade secret. Officials w orry that people who have bought the product m ay not know of the serious health problems. If they've been using a waterproofing product and developed sym ptom s -- difficulty breathing, chest pain -- they should not shrug it off. They should seek medical attention im m ediately," said Rose Ann Soloway, a clinical toxicologist at the National Capital Poison Center. The pain feels like an asthm a attack, and some doctors have misdiagnosed it as pneum onia, said Sm olinske. There have been no deaths reported. The sym ptom s m irror ones that sickened at least 157 users of ' ' W ilson's Leather Protector," prom pting a recall in 1992. The m anufacturer, Vangard Chem ical of St. Louis, recalled the product. No one died. 2006 D eacon Journal and w ire service sources A ll R icJils R eserved liup'.'V w w w nliu* com http://www.ohio.eom/mld/ohio/news/nation/l 3827780.htm?template^contentModules/print... 4/6/2006 WNDU-TV: Danger in a Can Story: Jobsite Heavy Duty Boot Mate - February 02, 2006 Page l of4 W NDU CENTER SUIIIH jj:ND lf.CIA.NA C0V.<AC; YOU CA.?, COUfH' 0,N S e a r c h WNDU Site Map Advanced Search Autos, H ouses, Rentals and M erchandise. Rod or sen them in our Classifieds Home > News > > Danaer in a Can > Jobsite Heavy Duty Boot Mate Posted: 02/02X006 06:00 pm Last Updated: 02/03/2006 08:17 am TOP Jobsite H Boot Mat< f A rchive 1 Mishawaka, IN - Watch broadband video It's the kind of product most of us have used at one time or another, a shoe protecting spray. Make W f ho INFORMATION About WNOU Advertise on WNDU Contact Us FCC Children's Shows Contests HDTV Jobs at WNDU Meet the WNDU Team Public Service The More You Know Press Releases TV Schedule Sites Mentioned onj v reso u r ces 16 Health Resource Ask the Experts Classifieds Daily Email Headlines Subscribe | Unsub. Gas Price Update JobsMichiana .com Holiday Events Festival Guide Local Events Lottery Links Movie Times Unique Eats WNDU Extra Michele Cripe and Bob Sherry love their little dog Elvis; he's lull of energy, but right before Christmas, that wasn't the case RSS room. However, there's one particular brand that poisoned one Mishawaka woman and her dog, making them very sick. They are not alone. Hundreds in the Midwest have been poisoned as well, even sending some to the emergency In a special Contact 16 report, we warn you about this potential "Danger In a Can." Unknown toxin Michele Cripe and Bob Sherry love their little dog Elvis. He's full of energy, but right before Christmas, that wasn't the case. "| notjced the dog hadn't been acting right, he threw up," says Michele. "His breathing got really bad, real rapid and shallow and his whole body felt cold, it was like his whole body was going into shock." Concerned Elvis maybe ate something he shouldn't have. Bob took him to the vet. "By the time he left, I just started having these horrible, horrible, shivering, uncontrollable chills and shivers and my breathing got a lot worse," says Michele. Not sure what made her and little Elvis 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. The spray is called Jobsite Heavy Duty Boot Mate. http://www.wndu.com/news/dangerinacan/022006/dangerinacan_47719.php 4/7/2006 WNDU-TV: Danger in a Can Story: Jobsite Heavy Duty Boot Mate - February 02, 2006 Page 2 of 4 ITEEg USEFUL LINKS Do Nol Call Lists Sex Offender Sparrh Unclaimed Property Safety Alerte Michele bought the spray at Pells Shoe Store inside a local Meijer store to waterproof a pair of suede clogs. Michele says, "It said use in a well ventilated area and I had sprayed in here; it's a large room, I had the front door open for some fresher air." 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. I n p i ? ne interview with Dr. James B Mowry, of the Indiana Poison Center, he said, " h a t'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 clue 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 fluoropolymer 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 Pennsylvania had a combined 162 poisoning cases; the product made 145 people sick and 17 animals sick Doctor Mowry says that fluoropolymer irritates the membranes of the throat and lung airways, causing inflammation. 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. 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 sprayed product back into the home until its completely dried." http://www.wndu.com/news/dangerinacan/022006/dangerinacan_477I9.php 4/7/2006 WNDU-TV: Danger in a Can Story: Jobsite Heavy Duty Boot Mate - February 02, 2006 Page 3 of 4 poisoning cases, we questioned why this product was making hundreds side; since there is only one ingredent listed on the can. which is called heptane M ic h e le , saVs Situation COUld have been a lot worse. Someone with small children would of have had a much more 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 Pells 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. Contact 16 left several messages and emails for Manakey. They have yet to respond. Michele bought the spray at Pells Shoe Store inside a local Meijer store; they tell Contact 16 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 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 | F&umr&n4itushropepingRcoenwter Centered ire u n d you.* News | Weather | Sports | Contests | Local Events | Contact Us | WslDUExtra.com Questions or comments about this website? C ontact the webmaster. http://www.wndu.com/news/dangerinacan/022006/dangerinacan_47719.php 4/7/2006 WNDU-TV: Danger in a Can Story: Jobsite Heavy Duty Boot Mate - February 02, 2006 Page 4 of 4 Copyright 1999-2006 Michiana Telecasting Corp. All rights reserved. Unauthorized, use, reproduction, or redistribution of the content of this page is strictly prohibited. WNDU-TV South Bend. Indiana 46634 Privacy Policy I EEO Public Fite Report http://wmv.wndu.com/news/dangerinacan/022006/dangerinacan_47719.php 4/7/200.6 Cincinnati Healthcare News D e n g a te said: "It is an endangering factor. Nobody can be sure a t this stage how big a th re a t it poses, but w e're treating it very, very seriously." D engate said the departm ent had begun tre a tm e n t on the infected trees and was hopeful that the disease could be cured. D espite th e th re a t, the species is not at risk of extinction because thousands of the trees have been g row n in plantations from the wild stand and som e w ent on sale to the public in October. Dengate exonerated anyone officially involved with the wild trees. "W e've been scrupulous w ith our staff to m ake sure they don't carry anything in," he said. Experts are asking people to please "stay away." 1 /2 9 /2 0 0 6 3:05:40 PM (GMT Standard Tim e, UTC<-00:001 Trackback SATURDAY, JANUARY 28, 2006 Leather Protector Leads to illness and Death Boot leather protectors and aerosol sealant products have b e e n identified as the cause o f 11 reported respiratory illness cases and one cat's death. According to Cadillac News: https://www.cincinnati.md/bIog/default.aspx p. 79 Page 4 of 26 4/6/2006 Cincinnati Healthcare News "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 we're 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," Trustrail said. "I'm guessing we'll 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 people's shoes, they'll also waterproof people's lungs," Trustrail said. 1/28/2006 3 :11:25 PM (GMT Standard Tme, UTC.00:00) https://\vww.cmc innati.md/blog/default.aspx p. 80 Page 5 o f26 4/6/2006 Boot-waterproofing products causing respiratory problems p. 81 Page 1of2 post-gazetfsglim Health, Science & Environment Health & Science Previous Articles Health Medicare Science Environment H ealth Boot-waterproofing products causing respiratory problems Friday, December 23, 2005 By Byron Spice, Pittsburgh Post-Gazette An unusual number o f people developed respiratory problems this fall after using aerosol products to waterproof their leather boots and shoes, Takecontrol of Pittsburgh Poison Center officials said yesterday. yourhealth. Eight people have called the center with breathing problems in just the past week, said center director Edward P. Krenzelok, and a review of the center's records shows 21 such poisonings since October. Checks with poison centers in other states showed Travel ; this phenomenon is widespread this season The Pittsburgh Poison C1-e8n0t0e-r2c2a2n- 1b2e2r2e. ached at Getaways Dr. Krenzelok said he can only speculate as to the reason for the ^__ click here ' poisonings. It could be that cold weather has caused people to apply the post-flazettfl.com Headlines products in confined spaces, rather than outdoors or in well-ventilated areas as directed by the product labels. by E-m ail In most cases, people complain about coughing, shortness o f breath or difficulty breathing after using the products; usually, they feel better within an hour after breathing fresh air. But some cases have required 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 o f 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 wprhoabtleamgesn. t or combination o f agents is responsible for the breathing Tuesda http://www.post-gazette.com/pg/05357/626879.stm 4/11/2006 Boot-waterproofing products causing respiratory problems p. 82 Page 2 of 2 About 10 years ago, a number of respiratory problems were reported in connection with leather conditioning products, he recalled, but "that sorta disappeared." Last week, however, one o f the staff members o f the Pittsburgh center, Rita Mrvos, noted that the center had handled eight cases o f 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 o f the house. Four family members suffered respiratory problems and one was hospitalized. The Pittsburgh center handles calls from throughout western and central Pennsylvania. All o f the incidents occurred outside of Pittsburgh, in such communities as Windber, Clearfield, Northeast and State College. (Post-Gazette org azette.com science editor Byron 4 12-263-1578.) Spice can be reach ed at b s p ic e @ p o s t - PAlBADVeTfSlbf Sp.yware Rempyer_Ppwnlpad Free Scan, awarded Spyware and Adware killer - 5 Stars Rated. Spyware Remove] Guaranteed Virus &. Spyware Removal, EarthUnk Access Not Required. 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