Fatality Assessment and Control Evaluation (FACE) Program
Young Adult Female Waitress Died From an Asthma Attack While Working in a Bar
On May 1, 2004, a 19-year-old African-American female waitress working at a bar died from an asthma attack. The bar was divided into two separate areas, the bar area with limited seating and a room with a disc jockey (DJ) booth (See Figure 1). When the victim arrived at work at 9:45 p.m., she talked with the DJ who was setting up in the adjacent room, then walked about 25 feet to an open section of the bar. The bar owner stated she was not experiencing any difficulty breathing at this time. There were approximately 30 people in the bar area. No individuals were in the room with the DJ. According to the owner, the bar was not “overly smoky”. Shortly after the victim went behind the bar, she grabbed the bar manager, saying she needed to get to the hospital and that she needed fresh air. The victim said she wished she had her inhaler with her. As the two walked out from behind the bar and toward the back door, the victim collapsed onto the dance floor. The bar patrons were asked if anyone had an inhaler. Someone did, and the victim attempted to use the inhaler, but was unable to do so. According to the bar manager, the inhaler mist came back into her face. Emergency Medical Service (EMS) was called and she was transported to a local hospital where she was declared dead 30 minutes from the time of the call to EMS.
On May 1, 2004, a 19-year-old African-American female waitress working at a bar died from an asthma attack. MIFACE investigators were informed of this incident by a referral from an asthma study. On September 27, 2005, the MIFACE researcher talked with the owner of the bar where the victim worked and visited the incident scene. The bar owner permitted the MIFACE researcher to take pictures of the establishment. During the writing of this report, the death certificate and medical examiner death scene investigation report were obtained.
The bar has been in business for approximately three years and employs approximately 11 people. There were five employees on site at the time of the incident. The victim worked as a waitress and as a door monitor. She checked for age identification and took cover charges to enter the establishment. The bar served primarily alcohol and food snacks. The victim worked part-time, on an on-call basis to staff the 10:00 p.m. – 2:00 a.m. shift. The victim had been employed at this establishment for approximately three months. She also worked another part-time job at a fast food establishment. The employer did not have an emergency action plan.
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The bar had two separate areas, the bar area with limited seating and another room with a DJ booth that also sat patrons. The bar area was approximately 18 feet wide and 80 feet long. The front door was very near the area where the victim first began to have breathing problems. (See Figure 1). Walking toward the back door, there was a pool table adjacent to the bar, then a small dance floor. The bar seating accommodated 11 patrons, and had seven tables near the wall, each with four chairs. The room with the DJ booth had a small dance floor, and could be accessed by a standard size door from the bar area. The access door was across from the pool table.
The owner described the ventilation in the bar area as having a “smoke eater”, which drew air from the patron seating area into a 2- to 3-foot high plenum above the drop ceiling (See Figure 2). This drawn air was then discharged above the back door to the outside of the building. There were six rectangular exhaust fans laid on top of the vent panels, presumably to assist in the air discharge to the ceiling plenum (See Figure 3). The “smoke eater” ventilation was working, but the exhaust fans were not turned on at the time of the incident.
According to the medical examiner’s report, the victim’s father had seen her at 9:30 p.m. and stated she was having breathing problems at that time.
The victim arrived at work at approximately 9:45 p.m. and greeted her coworkers. She walked into the room with the DJ booth and talked with the DJ for approximately 15 minutes while he was setting up for the evening. After talking with the DJ, she walked through the door to the bar area, walked along the bar to the open area of the bar (See Figure 1). The owner stated that the DJ and the bar manager indicated that she was not experiencing difficulty breathing at this time. There were approximately 30 people in the bar area, and there were no individuals in the room with the DJ. According to the owner, the bar was not “overly smoky”. Shortly after the victim went behind the bar, she grabbed the bar manager, saying she needed to get to the hospital and that she needed fresh air. The victim said she wished she had her inhaler with her. The manager and the victim walked out from behind the bar and toward the back door. The victim collapsed onto the dance floor. The bar patrons were asked if anyone had an inhaler. Someone did, and the victim attempted to use the inhaler, but was unable to do so. According to the owner, the inhaler mist came back into her face.
After her collapse, the bar manager called the owner, who told the bar manager to call for an ambulance. The call was recorded by 911 at 10:06 p.m. The ambulance arrived in five minutes. EMS found her unresponsive, without a pulse and having agonal respirations. Approximately five minutes after EMS arrival, the victim stopped breathing, and EMS started CPR. EMS tried to assist breathing with a mask and bag, but according to the medical examiner report, the EMS personnel could not get air into her lungs. She was transported via ambulance to a local hospital. When she arrived at the hospital, she was unresponsive and the heart monitor showed no heartbeat. She was declared dead at the hospital at 10:36 p.m.
According to the owner, she had not previously had an asthma attack at work. She did not carry her inhaler to work on the day of the incident.
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Cause of Death
The cause of death as stated on the death certificate was status asthmaticus. A medical examiner report and toxicology results were not obtained.
To protect the health of employees, private business owners, including bar and restaurant owners should consider prohibiting smoking within their establishments.
Ventilation systems, including the most commonly utilized ventilation system – general dilution ventilation – can reduce odor, but fail to guard against environmental tobacco smoke (ETS or secondhand smoke) health dangers. Secondhand smoke is a known asthma trigger. The American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE)1, in their position document on Environmental Tobacco Smoke (June 30, 2005) conclude that:
The full text of the ASHRAE position document on Environmental Tobacco Smoke may be found at: http://www.ashrae.org/content/ASHRAE/ASHRAE/ArticleAltFormat/20058211239_347.pdf
There is no safe level of exposure to secondhand smoke. Occupational, environmental and public health agencies have recognized that substantial subpopulations with disease states such as asthma or heart disease have their conditions exacerbated by ETS exposure. Air monitoring studies in bars, restaurants and other venues that permit smoking in Massachusetts, Virginia, Minnesota, Delaware and other international locales have shown that the levels of respirable particulate air pollution concentrations inside of these establishments are magnitudes above the respirable particulate air pollution levels found in the outdoor environment; these pollutants are regulated by the Environmental Protection Agency under the National Ambient Air Quality Standard (NAAQS).
According to the American Lung Association State of Tobacco Control: 2005 report:2 “For adult nonsmokers, the workplace is the primary source of secondhand smoke exposure. Levels of secondhand smoke in restaurants and bars are approximately 1.6 times greater and 7.6 times greater, respectively, than in office workplaces. Food service workers have a 50 percent greater risk of dying from lung cancer than the general population”. The American Lung Association Report may be found on the Internet at: http://lungaction.org/reports/tobacco-control05.html
The State of Michigan does not at the time of this report, have a state smoke-free workplace law in place. Private businesses and bars do not have any smoking restrictions; restaurants do have smoking restrictions (i.e. allow smoking in restricted areas). Working in an establishment that permits smoking provides an unhealthy work environment for employees. MIFACE recommends that all private business owners, including owners of bars and restaurants, provide a smoke-free work environment to reduce the risk of their workers developing secondhand smoke-related disease and the exacerbation of existing health conditions.
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