Boat-Related Carbon Monoxide Poisoning Boat-Related Carbon Monoxide Poisoning

Jane McCammon Robert Baron, MDTechnical Advisor ED Co-Director, Phoenix Banner Good Samaritan RMCDouble Angel Foundation Medical Advisor, Glen Canyon National Recreation Area

Jane McCammon Robert Baron, MDTechnical Advisor ED Co-Director, Phoenix Banner Good Samaritan RMCDouble Angel Foundation Medical Advisor, Glen Canyon National Recreation Area

2009 Marine Advisory Committee MeetingLewiston ID

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

McCammon & Baron Nov 2009

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?

McCammon & Baron Nov 2009

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?879 poisonings in 39 states (96% occurred 1990 – 2009)879 poisonings in 39 states (96% occurred 1990 – 2009)

160 people died160 people died

*Excludes Lake Powell cases

14

8

62

8

3137*

31*

16

20

24

6

21

5

1

12 14

56

77

44

28

3815

231

20

6

3

Location unspecified

92

Lake Powell 24% of the total

1

Nov 2009

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

1

8

2 6 3

2

1

7

4 9

Idaho Poisonings: Lake Pend Orielle

Idaho Poisonings: Lake Pend Orielle

June 2001: A 61-year-old man was poisoned as he fished from the back of a slowly moving 2000 Bayliner Sierra Sun Cruiser 2855 cutty cabin boat. He was standing on

the back open deck of the boat as it moved slowly through the water, when he lost consciousness as a result of CO poisoning. His COHb was 22% when

measured at the hospital. (Source: Augusta Chronicle newspaper article; interview of victim; Boating

Accident Report)

June 2001: A 61-year-old man was poisoned as he fished from the back of a slowly moving 2000 Bayliner Sierra Sun Cruiser 2855 cutty cabin boat. He was standing on

the back open deck of the boat as it moved slowly through the water, when he lost consciousness as a result of CO poisoning. His COHb was 22% when

measured at the hospital. (Source: Augusta Chronicle newspaper article; interview of victim; Boating

Accident Report)

8

Idaho Poisonings: Lake C'Oeur D'Alene

Idaho Poisonings: Lake C'Oeur D'Alene

July 2005: A 42-year-old woman survived CO poisoning aboard a 1989 Sea Ray cabin cruiser boat. The boat had been underway at about 15 miles per hour for approximately 30 to 45 minutes when the operator noticed a problem with his children. One was napping on the mother's lap on the driver's bench and the other was sitting next to the mother. The child on the bench started getting tired and laid on the bench. About 1-1/2 miles further the child napping on the mother's lap cried in her sleep three times and then had a seizure. They attempted to wake the daughter by shaking her but she was unresponsive. The mother removed the daughter's PFD and gave her mouth-to-mouth resuscitation. They checked on the son and he was also unresponsive. They carried both children to the front of the boat and continued trying to wake them while also summoning aid. The children and their mother were transported to a local medical center, and then later to a distant hospital with a hyperbaric medicine department. Deputies were informed by the duty nurse that they all had high levels of CO in their blood. Based on evidence on hand, it was believed that the slow speeds, angle of the hull when not on plane, excessive exhaust, and an enclosing canopy all contributed to this case of Carbon Monoxide poisoning. An inspection was done on the boat, where a CO detector installed into the main power grid of the boat was found. The CO detector appeared to be in working order and had power; the door to the living compartment was open but the detector never sounded. (Source: US Coast Guard BARD)

July 2005: A 42-year-old woman survived CO poisoning aboard a 1989 Sea Ray cabin cruiser boat. The boat had been underway at about 15 miles per hour for approximately 30 to 45 minutes when the operator noticed a problem with his children. One was napping on the mother's lap on the driver's bench and the other was sitting next to the mother. The child on the bench started getting tired and laid on the bench. About 1-1/2 miles further the child napping on the mother's lap cried in her sleep three times and then had a seizure. They attempted to wake the daughter by shaking her but she was unresponsive. The mother removed the daughter's PFD and gave her mouth-to-mouth resuscitation. They checked on the son and he was also unresponsive. They carried both children to the front of the boat and continued trying to wake them while also summoning aid. The children and their mother were transported to a local medical center, and then later to a distant hospital with a hyperbaric medicine department. Deputies were informed by the duty nurse that they all had high levels of CO in their blood. Based on evidence on hand, it was believed that the slow speeds, angle of the hull when not on plane, excessive exhaust, and an enclosing canopy all contributed to this case of Carbon Monoxide poisoning. An inspection was done on the boat, where a CO detector installed into the main power grid of the boat was found. The CO detector appeared to be in working order and had power; the door to the living compartment was open but the detector never sounded. (Source: US Coast Guard BARD)

8

Idaho Poisonings: Dworshak Reservoir

Idaho Poisonings: Dworshak Reservoir

May 2006: Four people were found dead as a result of CO poisoning aboard a Thunderjet fishing boat. Carbon monoxide built up in the motorboat, killing all four

occupants after they pulled a cover over the boat to shield themselves from a storm. The occupants apparently lost consciousness as the motorboat was underway, as the

boat was found aground on the shoreline. (Source: News clippings on the internet) Propulsion engine exhaust

May 2006: Four people were found dead as a result of CO poisoning aboard a Thunderjet fishing boat. Carbon monoxide built up in the motorboat, killing all four

occupants after they pulled a cover over the boat to shield themselves from a storm. The occupants apparently lost consciousness as the motorboat was underway, as the

boat was found aground on the shoreline. (Source: News clippings on the internet) Propulsion engine exhaust

8

Idaho PoisoningsIdaho Poisonings

Sometime in 2009: Another poisoning identified (Idaho Data)

Sometime in 2009: Another poisoning identified (Idaho Data)

8 + 1

Lack of Recognition

Lack of Reporting

But How Many Poisonings? But How Many Poisonings?

Is it 879?

McCammon & Baron Nov 2009

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

McCammon & Baron Nov 2009

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.

McCammon & Baron Nov 2009

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.

McCammon & Baron Nov 2009

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

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”

Circumstances of Poisonings - HouseboatsCircumstances of Poisonings - Houseboats

McCammon & Baron Nov 2009

Inside the “Death Zone” Inside 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: 1 typical boat engine = ??? carsCO: 1 typical boat engine = ??? cars

188

Calculations by Paul Roberts, Sonoma Technology Inc.

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

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 where generator exhaust leaves the boat

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

200 ppm CO

10 feet away

Why?

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

Saguaro Lake , AZ 2008Saguaro Lake , AZ 2008

22 year old male was sitting on the back deck of boat while the motor was at idle. Witnesses state he lost consciousness and fell into water. Bystanders pulled him from the water, at which point he was unresponsive. After they performed chest compressions for 2 minutes, he regained consciousness, sat up, spoke a few words and then again lost consciousness. His carbon monoxide reading was 45% upon transport. O2 saturation was 92%.

Incident Information - Medical Transport Record

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%)

McCammon & Baron Nov 2009

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

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

McCammon & Baron Nov 2009

Cabin CruisersCabin CruisersDeaths and poisonings outside the cabin -

Why?

41,600 ppm CO measured at the

generator exhaust terminus

570 ppm CO 10 feet away

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 HavasuNIOSH 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 needs to be done at the scene?So… what needs to be done at the scene? So… what needs to be done at the scene?So… what needs to be done at the scene?

1. Recognition 1. Recognition

• If a victim was anywhere on or near If a victim was anywhere on or near a boat with an engine, think CO.a boat with an engine, think CO.

• If a victim has a headache, nausea, If a victim has a headache, nausea, vomiting or loss of consciousness, vomiting or loss of consciousness,

think CO. 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 a victim was anywhere on or near If a victim was anywhere on or near a boat with an engine, think CO.a boat with an engine, think CO.

• If a victim has a headache, nausea, If a victim has a headache, nausea, vomiting or loss of consciousness, vomiting or loss of consciousness,

think CO. think CO.

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

negativesnegatives

2. Treatment2. Treatment

a. Extrication / scene safetya. Extrication / scene safety

b. 100% oxygen b. 100% oxygen

2. Treatment2. Treatment

a. Extrication / scene safetya. Extrication / scene safety

b. 100% oxygen b. 100% oxygen

Baron & McCammon Nov 2008

So… what needs to be done at the scene?So… what needs to be done at the scene? So… what needs to be done at the scene?So… what needs to be done at the scene?

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 Legislation/Education Legislation/Regulation Regulation

Engineering controlsEngineering controls

Education Legislation/Education Legislation/Regulation Regulation

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

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

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!

McCammon & Baron Nov 2009