Boat-Related Carbon Monoxide Poisoning

1
Boat-Related Carbon Monoxide Poisoning
2009 Marine Advisory Committee Meeting Lewiston ID

• Jane McCammon
  Robert Baron, MD
• Technical Advisor
  ED Co-Director, Phoenix Banner Good
  Samaritan RMC
• Double Angel Foundation
  Medical Advisor, Glen Canyon National Recreation
  Area

2

• We only see what we look for,
• and
• we only look for what we know

McCammon Baron Nov 2009
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?

McCammon Baron Nov 2009
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
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?
879 poisonings in 39 states (96 occurred 1990
2009)
160 people died
Remember Lake Powell data collection is the
most extensive.
14
1
8
16
7
8
7
23
6
8
7
1
4
3
9
2
20
31
37
8
1
5
1
6
44
62
38
15
56
24
Lake Powell 24 of the total
6
3
2
31
12
14
Location unspecified 92
20
1
Excludes Lake Powell cases
21
2
Nov 2009
8
Idaho Poisonings Lake Pend Orielle
8

• 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)

9
Idaho Poisonings Lake C'Oeur D'Alene
8

• 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)

10
Idaho Poisonings Dworshak Reservoir
8

• 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

11
Idaho Poisonings
8 1

• Sometime in 2009 Another poisoning identified
  (Idaho Data)

12
But How Many Poisonings?
Is it 879?
Lack of Recognition
Lack of Reporting
McCammon Baron Nov 2009
13
Drowning and CO at Lake Powell 1994 - 2004
12 (48) of the 25 boat-related drownings were
CO poisonings first
McCammon Baron Nov 2009
14
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.
McCammon Baron Nov 2009
15
Outdoor Fatal Poisonings

• Why wasnt the extent of the problem recognized
  earlier?
• Because its unbelievable.

McCammon Baron Nov 2009
16
A sunny day on Chesapeake Bay
Whats wrong with this picture?
17
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
18
Circumstances of Poisonings - Houseboats
McCammon Baron Nov 2009
19
Inside the Death Zone

20
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.

21
CO 1 typical boat engine ??? cars
188
Calculations by Paul Roberts, Sonoma Technology
Inc.
22
Inside the Death Zone
CO Generator operating 30,000 ppm (maximum)

Oxygen Deficient as low as 10
CO Propulsion engines operating 60,000 ppm
(maximum)
23
Outside the Death Zone
Why?

200 ppm CO 10 feet away
7,000 10,000 ppm CO on the swim platform
85,000 ppm CO where generator exhaust leaves the
boat
24
Pleasurecraft (ski boats, cabin cruisers, etc.)
25
(No Transcript)
26
32 people poisoned on platforms of moving boats
22 died or lost consciousness
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.....
27
Death Comes Quickly
Poisonings Resulting in Death/Drowning COHb
Minutes Exposed 57
1 56 lt1 56
5 50 1 - 2 48
10-15 41 lt1 67, 64,
64, 41, 39 in minutes
Why?
26,700 ppm CO boat moving
10,000 ppm CO boat stopped
28
Its not just teak surfing!
Example Saguaro 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
29
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.
McCammon Baron Nov 2009
30
Cabin Cruisers
Deaths and poisonings occur both inside and
outside the cabin. By far, most cabin cruiser
associated deaths occur inside the cabin.
McCammon Baron Nov 2009
31
Cabin Cruisers
Deaths and poisonings outside the cabin - Why?
41,600 ppm CO measured at the generator
exhaust terminus
570 ppm CO 10 feet away
32
Comparison of Swim Platform CO Concentration
Windy day
No wind
33
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.
34
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.
35
(No Transcript)
36
So what needs to be done at the scene?

• 1. Recognition
• If a victim was anywhere on or near a boat with
  an engine, think CO.
• If a victim has a headache, nausea, vomiting or
  loss of consciousness, think CO.
• Pitfalls delay in COHb and/or normal pulse
  oximetry false negatives

37
(No Transcript)
38
So what needs to be done at the scene?

• 2. Treatment
• a. Extrication / scene safety
• b. 100 oxygen

Baron McCammon Nov 2008
39
Transport patients for further evaluation and
treatment, including consideration of hyperbaric
therapy, if they experienced

• LOC or
• 1st COHb gt25 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

40
So - What do we need to do?

• 3. Report it
• This is the key to prevention,
• because if it doesnt get counted, it didnt
  happen.
• Notify the appropriate agency
• (Sheriff, Boating Law Administrator, State Parks,
  State Fish and Game, etc.)

41
It is time to redirect efforts from collecting
examples of poisonings to prevention of
poisonings.
42
Prevent it !

• Engineering controls
• Education Legislation/
• Regulation

43
Vertical Stacks Moving Generator Exhaust to a
Safer Location
44
Control at the Source - Generators
45
Control at the Source Inboard Engines
 Its the right thing to do, .
46
Prevent it !

• Engineering controls now exist,
• THEY NEED TO BE IMPLEMENTED TO SAVE LIVES
• Education Legislation/
• Regulation

47
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."
Legislation
48
Prevention through Public Awareness
One example of many
49

• We only see what we look for,
• and
• we only look for what we know
• Now lets prevent it!

McCammon Baron Nov 2009