Lab Error Almost Causes Panic at Gibraltar

Editor’s Note: This article has been updated to include a statement from Door County Medical Center regarding the lab error.

A lab error at Door County Medical Center almost caused a panic among the Gibraltar school community on Sept 12.

Gibraltar High School Principal Gereon Methner said he was informed near the end of the school day that students and staff in some classrooms near where construction is being carried out at the school were complaining of an exhaust-like smell.

Methner tracked down the construction manager, who took air-quality readings that detected carbon monoxide in some of the classrooms.

“We moved the students in the general area out,” Methner said. The school then contacted emergency services and the Door County Sheriff’s Department.

At the same time, the superintendent of the construction site had identified the cause of the exhaust smell: a subcontractor had placed a generator on the roof near a fresh-air intake.

“Luckily it was an exhaust smell that was recognizable because carbon monoxide does not have an odor,” Methner said. In fact, because it is colorless, tasteless and odorless, carbon monoxide has been dubbed the “silent killer.”

“Once we noted the source of the problem – the generator – it was immediately removed from the area,” Methner said.

EMS personnel checked with the evacuated students to see whether they were experiencing any symptoms of carbon monoxide exposure.

“One student elected to see the EMS, as well as two staff members,” Methner said.

Meanwhile, fire department personnel took air-quality readings and found very low levels of carbon monoxide.

“We did a flush of the building, with windows and doors open,” Methner said.

As principal, he was thinking of the evening use of the building for sporting events, but air-quality readings taken throughout the building after the flush revealed zero levels of carbon monoxide.

“We were feeling pretty good at that point. That was about 5:30,” Methner said. “We felt we had caught a problem before it turned into a real disaster, frankly.”

But now the story takes a bizarre twist. Methner was not on duty that night, but Assistant Principal Tim Mulrain was.

“About 8:30, I get a phone call from Tim saying, ‘You need to come back to school right now. We have a major issue,’” Methner said. “We learned at that point that there was a Gibraltar student in the hospital who had significant blood levels of carbon monoxide. We were talking about levels that would require immediate air transport. Very, very grave readings. Immediate, hyperbaric chambers necessary to maintain life. That put us into a very, very difficult situation. We needed to make sure we got word to parents immediately.”

They let parents know there had been a carbon monoxide issue, and they should seek immediate medical attention if their children were experiencing any symptoms, such as headache, dizziness, nausea or fatigue.

It was the fact that the school sent word out so late after the original incident that got some parents talking about a cover-up by the school.

“Then,” Methner said, “maybe a half hour or 45 minutes into this, we get a phone call from the hospital that the reading that was so concerning was a routine lab error. You can just imagine the relief we were all feeling.”

Door County Medical Center acknowledged the error but disputed the characterization of it as routine, releasing the following statement Tuesday:

“An error in the laboratory is anything but routine. Tens of thousands of lab results are reported out monthly and an error is extremely rare, with a less than .1% error rate. Multiple safe guards are in place to avoid errors and the laboratory is extremely diligent in producing high quality results and meeting all national standards of quality. The laboratory did identify and correct the error in a timely manner and took appropriate action when they discovered the error. Door County Medical Center continues to be dedicated to providing the utmost quality and professional care possible and consistently ranks among the top health care organizations in Wisconsin and the nation.”

Although he regrets causing so much parental concern because of an inaccurate lab result, ultimately, Methner said, the school handled the incident properly.

However, he added, the incident will lead to new protocols in communications with parents and will cause the Policy Committee to come up with a policy for subcontractors to avoid any future possibility of exhaust poisoning.