Abstract

Background and Purpose: This case report describes an incident of chlorine gas poisoning in an aquatic exercise class of senior adults in which 24 participants, facility employees, and first responders required emergency medical attention with some requiring hospitalization. The cause of the chlorine gas release, the health effects on participants, and the facility's subsequent response are described. The purpose of this case is to inform physical therapists and exercise professionals working in aquatic exercise pools about chlorine gas poisoning prevention and mitigation efforts. Case Description: The cause of this incident was a series of breakdowns in safety procedures leading to the release of chlorine gas while a class was in session. Because of limited exit points, physical debilitation of some participants, and a lack of proper safety equipment, the evacuation effort was delayed, overwhelming participants, facility employees, and first responders with toxic gas. Twenty-four people were transported to the emergency department with 7 hospitalized. At least 3 are known to suffer long-term health effects. Outcomes: The facility concluded that normal operating procedures and safety protocols were not followed. Following the review, the facility took measures to ensure adherence to proper procedures, revised its emergency action plan, and acquired the appropriate safety equipment. Discussion: The accidental release of chlorine gas in an exercise pool is a rare but potentially catastrophic event. Facilities operating exercise and aquatic therapy pools must follow strict protocols for the safe handling of pool chemicals and be prepared to respond immediately if a chlorine gas accident occurs. This case report serves as an example of risk management for the prevention of and response to a catastrophic release of chlorine gas during a group exercise or aquatic therapy session.

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