On May 18, 1980, Mount St Helens, Washington State's most active volcano, erupted violently. Volcanic eruptions in recent geologic history have demonstrated tremendous environmental impact and caused significant loss of human life. Volcanic ash expelled during the eruption was deposited on much of eastern Washington and had a profound effect on local air quality. Although ash is relatively inert, analysis revealed a small but significant amount of free crystalline silica, the causative agent of silicosis. The fine particles of ash were of respirable size, and there was a remarkable increase in the volume of respiratory cases seen in emergency departments during the period of high airborne particulate levels. Numerous cases of injury indirectly related to the fall of ash were also seen. The long-term effect of exposure to this volcanic ash is unknown. A prompt, coordinated community medical response is necessary to protect the general population from the potential hazard of exposure to volcanic ash.