2009 crlea boating related carbon monoxide poisoning

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

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, We only see what we look for,

andand

we only look for what we knowwe only look for what we know

We only see what we look for, We only see what we look for,

andand

we only look for what we knowwe only look for what we know

Baron & McCammon Nov 2008

• For a copy of this presentation go to:

• http://www.doubleangel.org

• For a copy of this presentation go to:

• http://www.doubleangel.org

CO OverviewCO Overview

How big of a problem is this?How big of a problem is this?

What are the high risk areas on a boat?What are the high risk areas on a boat?

What needs to be done?What needs to be done?

How big of a problem is this?How big of a problem is this?

What are the high risk areas on a boat?What are the high risk areas on a boat?

What needs to be done?What needs to be done?


CO % in Blood

At about 10%

Headache, nausea,

confusion

At 20-30%

Loss of conscious-ness (LOC),

disorientation

At 50 -60%Comaand

Death

COCO

COCO

HemoglobinCarboxyhemoglobin


After exposure ends, how long does CO remain in the blood?* After exposure ends, how long does CO remain in the blood?*

• 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

• 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*Half-life varies widely by individual and activity level

COCO

COCO

How Many Boat-Related CO Poisonings?How Many Boat-Related CO Poisonings?810 poisonings in 37 states (95% occurred 1990 – 2008)810 poisonings in 37 states (95% occurred 1990 – 2008)

149 people died149 people died

*Excludes Lake Powell cases

14

7

60

8

3024*

29*

16

20

24

6

18

5

1

12 12

44

57

44

21

3715

231

19

6

3

Location unspecified

92

Lake Powell

202 (25%)

1

July 2008

Remember: Lake Powell data collection is the most extensive.Remember: Lake Powell data collection is the most extensive.

1

1

2 6 2

2

1

7

Lack of Recognition

Lack of Reporting

But How Many Poisonings? But How Many Poisonings?

Is it 810?


Drowning and CO at Lake Powell: 1994 - 2004

Drowning and CO at Lake Powell: 1994 - 2004

12 (48%) of the 25 boat-related drownings 12 (48%) of the 25 boat-related drownings were CO poisonings firstwere CO poisonings first


National Estimate ?National Estimate ?

1997 – 2005: 1997 – 2005: Drownings off of boats = 4676*Drownings off of boats = 4676*

*Based on US Coast Guard Boating Accident Report Database

1997 – 2005: 1997 – 2005: Drownings off of boats = 4676*Drownings off of boats = 4676*

*Based on US Coast Guard Boating Accident Report Database

If 48% of those were CO-related ….. If 48% of those were CO-related ….. 250 per year nationwide.250 per year nationwide.


Outdoor Fatal PoisoningsOutdoor Fatal Poisonings

Why wasn’t the extent of the problem Why wasn’t the extent of the problem recognized earlier?recognized earlier?

Because it’s unbelievable.Because it’s unbelievable.

Why wasn’t the extent of the problem Why wasn’t the extent of the problem recognized earlier?recognized earlier?

Because it’s unbelievable.Because it’s unbelievable.


A sunny day on Chesapeake BayA sunny day on Chesapeake BayWhat’s wrong with this picture?What’s wrong with this picture?


CO: 1 typical boat engine = ??? carsCO: 1 typical boat engine = ??? cars

188

Calculations by Paul Roberts, Sonoma Technology Inc.

Circumstances of Poisonings - HouseboatsCircumstances of Poisonings - Houseboats


27 CO-related 27 CO-related deaths deaths

282 nonfatal 282 nonfatal poisonings*poisonings*

*National Case Listing

Dixey BoysDixey BoysArizona Republic NewspaperAugust 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.”

Arizona Republic NewspaperAugust 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”

Inside the “Death Zone” Inside the “Death Zone”


Children playfully enter the area.

Adults enter to clear fouled propellers or to do maintenance.

Resulting COHb :26 – 72 % within minutes

of exposure

WHY?


CO :

Propulsion engines operating

60,000 ppm (maximum)

Guidelines – CO in Air(parts of CO per million parts

of air – ppm)

87WHO limit for a 15-minute exposure

1200

Immediately Dangerous to Life and Health (IDLH)

Oxygen Deficient –

as low as 10%

CO :

Generator operating

30,000 ppm (maximum)

Outside the “Death Zone”Outside the “Death Zone”

85,000 ppm CO measured where generator exhaust leaves the boat

7,000 – 10,000 ppm on the swim platform

200 ppm CO 10’ away

Why?

Pleasurecraft (ski boats, cabin cruisers, etc.)Pleasurecraft (ski boats, cabin cruisers, etc.)

91 CO-related deaths

259 nonfatal poisonings

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.....

26,700 ppm CO –boat moving26,700 ppm CO –boat moving

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?

10,000 ppm CO –boat stopped10,000 ppm CO –boat stopped

Death Comes QuicklyDeath Comes Quickly

It’s not just teak surfing!It’s not just teak surfing!

Example:Example:Lake Kaweah, CALake 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

Showers in a Toxic EnvironmentShowers in a Toxic Environment

“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.

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%)


Cabin CruisersCabin CruisersDeaths and poisonings occur both inside and outside the cabin.

By far, most cabin cruiser associated deaths occur inside the cabin.


Cabin CruisersCabin CruisersDeaths and poisonings also occur outside the cabin.

Why?

41,600 ppm CO measured at the

generator exhaust terminus

570 ppm CO 10 feet away

Most recent drowning:8 year old girl Lake Powell

July 2007Baron & McCammon Nov 2008

Comparison of Swim Platform CO Concentration Comparison of Swim Platform CO Concentration

Windy day No wind

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.

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.

So… what do we need to do?So… what do we need to do? So… what do we need to do?So… what do we need to do?

1. Recognition 1. Recognition

• If your patient was anywhere on or If your patient was anywhere on or near a boat with an engine, think near a boat with an engine, think

CO.CO.

• If your patient has a headache, If your patient has a headache, nausea, vomiting or loss of nausea, vomiting or loss of consciousness, think CO. consciousness, think CO.

• Pitfalls: delay in COHb and/or Pitfalls: delay in COHb and/or normal pulse oximetry – false normal pulse oximetry – false

negativesnegatives

1. Recognition 1. Recognition

• If your patient was anywhere on or If your patient was anywhere on or near a boat with an engine, think near a boat with an engine, think

CO.CO.

• If your patient has a headache, If your patient has a headache, nausea, vomiting or loss of nausea, vomiting or loss of consciousness, think CO. consciousness, think CO.

• Pitfalls: delay in COHb and/or Pitfalls: delay in COHb and/or normal pulse oximetry – false normal pulse oximetry – false

negativesnegatives


So - What do we So - What do we need to do?need to do? So - What do we So - What do we need to do?need to do?

2. Treatment2. Treatment

100% oxygen 100% oxygen

2. Treatment2. Treatment

100% oxygen 100% oxygen


Transport patients for further evaluation and treatment, including consideration of hyperbaric therapy, if they

experienced:

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

• 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


So - What do we need to do? So - What do we need to do?

3. Report it3. Report it

This is the key to prevention, This is the key to prevention, because if it doesn’t get counted it didn’t happen.because if it doesn’t get counted it didn’t happen.

Notify the appropriate agency Notify the appropriate agency (Sheriff, Boating Law Administrator, State Parks, State (Sheriff, Boating Law Administrator, State Parks, State

Fish and Game, etc.)Fish and Game, etc.)

3. Report it3. Report it

This is the key to prevention, This is the key to prevention, because if it doesn’t get counted it didn’t happen.because if it doesn’t get counted it didn’t happen.

Notify the appropriate agency Notify the appropriate agency (Sheriff, Boating Law Administrator, State Parks, State (Sheriff, Boating Law Administrator, State Parks, State

Fish and Game, etc.)Fish and Game, etc.)


It is time to redirect efforts from collecting examples of

poisonings to prevention of poisonings

It is time to redirect efforts from collecting examples of

poisonings to prevention of poisonings

Prevent it ! Prevent it !

Engineering controlsEngineering controls

Education Education Legislation/Legislation/

Regulation Regulation

Engineering controlsEngineering controls

Education Education Legislation/Legislation/

Regulation Regulation Baron & McCammon Nov 2008

Vertical Stacks:Vertical Stacks:

Moving Generator Exhaust to a Safer LocationMoving Generator Exhaust to a Safer Location

Control at the Source - GeneratorsControl at the Source - Generators


Control at the Source – Inboard EnginesControl at the Source – Inboard Engines

“It’s the right thing to do,” ….

Prevent it !Prevent it ! Engineering controls now exist,

THEY NEED TO BE IMPLEMENTED TO SAVE LIVES

Education Legislation/Regulation

Engineering controls now exist,THEY NEED TO BE IMPLEMENTED TO SAVE

LIVES

Education Legislation/Regulation


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.

Prevention at Lake Havasu

Reduced number of hours of exposure for public safety officers (through shift and assignment rotation)

Dangerous 'teak surfing' prohibited in Nevada, CaliforniaJeff MunsonSeptember 29, 2004 SOUTH 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."

KATU 2 News - Portland, Oregonwww.katu.com

Come 2006, teak surfing will be illegal in Oregon

- SALEM, Ore. - A summertime water sport popular with teens and young adults will become illegal in Oregon beginning in 2006. Teak surfing, also known as platform dragging, is when a person hangs onto the rear of the boat to be pulled through the water until the boat's wake builds enough to allow body surfing. Senate Bill 56, which Gov. Ted Kulongoski is expected to sign, would make teak surfing illegal. There are a number of dangers associated with teak surfing. An obvious danger is the swimmer's proximity to the boat propeller. Another not so obvious danger is carbon monoxide poisoning. In addition to these dangers, teak surfing is usually done without a life jacket because it inhibits body surfing. (Copyright 2005 by The Associated Press. All Rights Reserved.)

Legislation

http://www.nevadaappeal.com/apps/pbcs.dll/frontpage

Prevention through Public

Awareness

One example of many:

We only see what we look for,

and

we only look for what we know

Now let’s prevent it!

We only see what we look for,

and

we only look for what we know

Now let’s prevent it!


2009 crlea boating related carbon monoxide poisoning

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