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2009 CRLEA Boating Related Carbon Monoxide Poisoning

2009 CRLEA Boating Related Carbon Monoxide Poisoning. Robert Baron, MD ED Co-Director, Phoenix Banner Good Samaritan RMC Medical Advisor, Glen Canyon National Recreation Area. We only see what we look for, and we only look for what we know.

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2009 CRLEA Boating Related Carbon Monoxide Poisoning

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  1. 2009 CRLEABoating Related Carbon Monoxide Poisoning Robert Baron, MD ED Co-Director, Phoenix Banner Good Samaritan RMC Medical Advisor, Glen Canyon National Recreation Area

  2. We only see what we look for, and we only look for what we know Baron & McCammon Nov 2008

  3. For a copy of this presentation go to: • http://www.doubleangel.org

  4. CO Overview How big of a problem is this? What are the high risk areas on a boat? What needs to be done? Baron & McCammon Nov 2008

  5. CO % in Blood Carboxyhemoglobin Hemoglobin At 50 -60% Coma and Death At 20-30% Loss of conscious-ness (LOC), disorientation CO CO CO CO At about 10% Headache, nausea, confusion Baron & McCammon Nov 2008

  6. After exposure ends, how long does CO remain in the blood?* CO CO CO CO • In room air, after exposure ends, COHb will decrease by half every 2 - 6 hours. • Oxygen therapy reduces that time to 1 - 2 hours. • Hyperbaric oxygen therapy reduces it to 20 minutes *Half-life varies widely by individual and activity level

  7. How Many Boat-Related CO Poisonings? 810 poisonings in 37 states (95% occurred 1990 – 2008) 149 people died Remember: Lake Powell data collection is the most extensive. 1 1 14 16 7 7 7 23 6 8 5 1 3 2 19 30 24* 1 1 5 1 6 44 60 37 15 44 Lake Powell 202 (25%) 24 6 2 2 29* 12 12 Location unspecified 92 20 1 *Excludes Lake Powell cases 18 2 July 2008

  8. But How Many Poisonings? Is it 810? Lack of Recognition Lack of Reporting Baron & McCammon Nov 2008

  9. Drowning and CO at Lake Powell: 1994 - 2004 12 (48%) of the 25 boat-related drownings were CO poisonings first Baron & McCammon Nov 2008

  10. National Estimate ? 1997 – 2005: Drownings off of boats = 4676* *Based on US Coast Guard Boating Accident Report Database If 48% of those were CO-related ….. 250 per year nationwide. Baron & McCammon Nov 2008

  11. Outdoor Fatal Poisonings Why wasn’t the extent of the problem recognized earlier? Because it’s unbelievable. Baron & McCammon Nov 2008

  12. A sunny day on Chesapeake Bay What’s wrong with this picture? Baron & McCammon Nov 2008

  13. CO: 1 typical boat engine = ??? cars 188 Calculations by Paul Roberts, Sonoma Technology Inc.

  14. Circumstances of Poisonings - Houseboats 27 CO-related deaths 282 nonfatal poisonings* *National Case Listing Baron & McCammon Nov 2008

  15. Dixey Boys Arizona Republic Newspaper August 4, 2000 Divers Find Bodies of Brothers in Lake “Divers recovered the bodies of two brothers who drowned while swimming at Lake Powell. The brothers, 10 and 7, from Parker, Colorado were swimming at the rear of a houseboat Wednesday night … when they disappeared.” COHb: 59 and 52% after a brief exposure in the “Death Zone”

  16. Inside the “Death Zone”

  17. Inside the “Death Zone” Children playfully enter the area. Resulting COHb : 26 – 72 %within minutes of exposure WHY? Adults enter to clear fouled propellers or to do maintenance.

  18. Inside the “Death Zone” CO : Generator operating 30,000ppm (maximum) Oxygen Deficient – as low as 10% CO : Propulsion engines operating 60,000 ppm (maximum)

  19. Outside the “Death Zone” Why? 200 ppm CO 10’ away 7,000 – 10,000 ppm on the swim platform 85,000 ppm CO measured where generator exhaust leaves the boat

  20. Pleasurecraft (ski boats, cabin cruisers, etc.) 91 CO-related deaths 259 nonfatal poisonings

  21. Death Comes Quickly: Boats Underway COHb: Duration of Exposure 57%: 5 minutes 50%: 2 minutes 48%: “in minutes” 61%: 20-25 minutes 56%: 10-15 minutes 64%, 62%, 53%, 41%, etc..... 32 people poisoned on platforms of moving boats 22 died or lost consciousness

  22. Death Comes Quickly Poisonings Resulting in Death/Drowning COHb: Minutes Exposed 57% 1 56% <1 56% 5 50% 1 - 2 48% 10-15 41% <1 67, 64, 64, 41, 39% in “minutes” Why? 26,700 ppm CO –boat moving 10,000 ppm CO –boat stopped

  23. It’s not just teak surfing! Example: Lake Kaweah, CA In June, 2007 a boat operator stated that he started the vessel and then went up to bow of the 23’ Malibu I/B boat to untie from neighboring boat. At this time, the victim was in the water holding onto the swim platform. The operator and witnesses stated that the engine was only running for approximately two minutes. During those two minutes, the operator was alerted from others at rear of vessel that something was wrong and to shut off the engine. The victim began to go underwater when someone pulled her up and then onto the vessel. Lake patrol was flagged down, an ambulance was summoned and the victim was transported to the hospital. Nat’l Case Listing

  24. Showers in a Toxic Environment 4 YO on the swim platform playing with the shower stopped breathing after less than 15 minutes. (COHb 2.2 % - 4 half-lives later) 4 children in various locations on a canopy-enclosed cabin cruiser. All found unconscious 45 minutes after last being seen; 1 died (COHb = 47%) “Preheat your wetsuit, warm up after a cool swim or wash sand and dirt from your feet and decks.” To use it, you have to be on the swim platform while the engines are running. Baron & McCammon Nov 2008

  25. Cabin Cruisers Deaths and poisonings occur both inside and outside the cabin. By far, most cabin cruiser associated deaths occur inside the cabin. Baron & McCammon Nov 2008

  26. Cabin Cruisers Deaths and poisonings also occur outside the cabin. Why? 41,600 ppm CO measured at the generator exhaust terminus Most recent drowning: 8 year old girl Lake Powell July 2007 570 ppm CO 10 feet away Baron & McCammon Nov 2008

  27. Comparison of Swim Platform CO Concentration Windy day No wind

  28. Congested Boat Traffic – Lake Havasu On Memorial Day, Independence Day, or Labor Day, there may be as many as 700 boats in the Bridgewater Channel at any given time. If each boat has only one engine, and only a third of the boats are operating, exhaust is roughly equivalent to that of 40,000 automobiles.

  29. Congested Boat Traffic – Lake Havasu NIOSH found that over half of Lake Havasu City public safety workers in the Bridgewater Channel were overexposed to CO during 2003 Memorial Day weekend….. …And, more than half of the public safety workers in the Bridgewater Channel reported post-shift symptoms consistent with CO poisoning (headache, fatigue, weakness, visual disturbances, dizziness) on days with highest CO exposures.

  30. So… what do we need to do? 1. Recognition • If your patient was anywhere on or near a boat with an engine, think CO. • If your patient has a headache, nausea, vomiting or loss of consciousness, think CO. • Pitfalls: delay in COHb and/or normal pulse oximetry – false negatives Baron & McCammon Nov 2008

  31. So - What do we need to do? 2. Treatment 100% oxygen Baron & McCammon Nov 2008

  32. Transport patients for further evaluation and treatment, including consideration of hyperbaric therapy, if they experienced: • LOC or • 1st COHb >25% or • Persistent abnormal mental status or • Abnormal cerebellar function at time of exam or • Cardiovascular disfunction (chest pain, arrhythmias, hypotension) associated with the poisoning or • If the patient is pregnant Baron & McCammon Nov 2008

  33. So - What do we need to do? 3. Report it This is the key to prevention, because if it doesn’t get counted it didn’t happen. Notify the appropriate agency (Sheriff, Boating Law Administrator, State Parks, State Fish and Game, etc.) Baron & McCammon Nov 2008

  34. It is time to redirect efforts from collecting examples of poisonings to prevention of poisonings

  35. Engineering controls Education Legislation/ Regulation Prevent it ! Baron & McCammon Nov 2008

  36. Vertical Stacks: Moving Generator Exhaust to a Safer Location

  37. Control at the Source - Generators Baron & McCammon Nov 2008

  38. Control at the Source – Inboard Engines “It’s the right thing to do,” ….

  39. Engineering controls now exist, THEY NEED TO BE IMPLEMENTED TO SAVE LIVES Education Legislation/ Regulation Prevent it ! Baron & McCammon Nov 2007

  40. Prevention at Lake Havasu Reduced number of hours of exposure for public safety officers (through shift and assignment rotation) On six occasions during the first summer of monitoring, the Channel was closed to incoming traffic after prolonged “Unhealthy” conditions, CO levels in the “Hazardous” range.

  41. Dangerous 'teak surfing' prohibited in Nevada, CaliforniaJeff MunsonSeptember 29, 2004SOUTH LAKE TAHOE - A dangerous boat activity called teak surfing will be banned by the Nevada Department of Wildlife and made illegal in the state of California.The Nevada ban and California law, to take effect next year, are intended to save lives after a series of accidents and fatalities over the past decade, officials said Tuesday.On May 28, 2003, an 11-year-old El Dorado Hills boy died behind the boat his father was driving at Folsom Lake. An autopsy revealed Anthony Farr had 63 percent of his bloodstream filled with carbon monoxide, which was emitted from the boat's engine into the boys lungs as he surfed hanging onto the step at the back of the boat."Had I known this was dangerous, had I heard of the dangers of doing this, I would never have put my son or myself at risk," said Mike Farr, Anthony's father, who convinced Sacramento lawmakers to support the legislation. The Nevada ban on teak surfing was agreed to Sept. 12 by the Board of Wildlife commissioners, the body that regulates boating safety in the Silver State. "We are extremely pleased the Wildlife Commission has stepped up to address this very serious issues," said Fred Messmann, the boating law administrator for Nevada. "We have had a hard time quantifying the exact number of deaths each year because of this activity, but the specific examples show how dangerous teak surfing can be." Legislation

  42. One example of many: Prevention through Public Awareness

  43. We only see what we look for, and we only look for what we know Now let’s prevent it! Baron & McCammon Nov 2008

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