Lessons for a Broader Perspective

1
Lessons for a Broader Perspective
Carbon Monoxide Poisoning and Boats

• Jane McCammon
  Robert Baron, MD
• Double Angel Foundation
  ED Co-Director, Phoenix Banner
  Good Samaritan
• jmccammon_at_earthlink.net
  Medical Advisor, Glen Canyon National
  Recreation Area
• [phone]

CSTE June 2007
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Overview

• CO poisonings in places you least expect it.
• A call to improve recognition and reporting of CO
  poisonings
• AND
• To respond to poisonings in the most effective
  way possible

RESEARCH AND PREVENTION INFORMATION
http//safetynet.smis.doi.gov/COhouseboats.htm
McCammon / Baron CSTE 2007
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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
McCammon / Baron CSTE 2007
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CO 1 typical boat engine ??? cars
188
Calculations by Paul Roberts, Sonoma Technology
Inc.
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Lake Powell
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Lake Powell - August 18, 1994
Cause of death drowning Exposure duration -
around 30 minutes COHb - 80 first analysis
repeat analysis 61
This was the 30th boat-related CO poisoning Lake
Powell since 1990.
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Elsewhere..
1995
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1998 19 poisonings at Lake Powell 4 in
August on houseboats

• August 10 Witness statement regarding
  13-year-old niece that had gone to the back of
  the houseboat to wash sand from her red bathing
  suit
• "I walked out to the back of the houseboat and
  noticed 2 brightly colored items at the bottom of
  the lake. More of our party came out and
  identified it as my nieces bathing suit. Her
  brother came to the back and saw a figure and
  yelled "is that her?" Her dad dove down and
  brought her to the surface. I checked for
  carotid pulse and breathing, both negative.
• COHb 30, she survived

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Two Lake Powell drownings too close

• August 18, 1998 56 year old dove to retrieve a
  lost oil cap he went into the death zone a
  couple of times to get air. He never surfaced.
  (COHb 55)

• August 30, 1998
• 37 year old entered the death zone to clear a
  rope from the prop. Within 5 to 10 minutes, he
  sank and drowned.
• (COHb 49)

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Elsewhere..

• 1998 Mary Jumbelic
• (ME, Onendaga County NY)
• published the first case report of a CO-related
  drowning associated with boat engine exhaust.
• Exposure Duration 10 minutes
• COHb 62

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Dixey BoysAugust 4, 2000
COHb 59 and 52

• Arizona Republic Newspaper
• 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.

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Lake Powell Boat-Related CO Poisonings Dec 2000
MMWR
111 cases (1990-2000) 64/74 HB poisonings
attributed to marine generator exhaust

• Sources of Information
• NPS dispatch, EMS, investigative, and Death Book
  records
• Hospital COHb laboratory records
• State-based hospital discharge data
• and anything else we could find

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How Many Boat-Related CO Poisonings?
750 recognized poisonings in 34 states (95 from
1990 2004)
141 people died/182 lost consciousness
Remember Lake Powell data collection is the
most extensive.
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1
1
16
7
7
14
6
8
5
1
3
2
15
30
23
1
5
1
6
44
52
32
15
44
24
Lake Powell 179 (24)
6
2
2
29
10
12
Location unspecified 92
20
1
Excludes Lake Powell cases
18
2
April 2007
McCammon / Baron CSTE 2007
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48 of Lake Powell boat-related drownings
(1994-2004) were CO poisonings first

• Approximately 520 boat-related drownings are
  reported to the US Coast Guard annually
• Based on US Coast Guard Boating Accident Report
  Database 1997-2005

If 48 of those were unrecognized CO poisonings
.. 250 annually
McCammon / Baron CSTE 2007
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How Does that Relate to the 750 Known
Boat-Related Poisonings?
49 of the 750 people drowned
Thats 2 CO-related drownings from boats per year
248 unrecognized and unreported???
McCammon / Baron CSTE 2007
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What We Know Nationwide Inside the Death Zone
27 people poisoned 13 died / drowned (Most
recent drowning July 14, 2006) Adults
clearing ropes from or doing maintenance on
props Children playing in the space COHb 26
72 within minutes of exposure WHY?
CO Generator operating 30,000 ppm (maximum)

Oxygen Deficient as low as 10
CO Propulsion engines operating 60,000 ppm
(maximum)
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Houseboat Recall

• February 28, 2001
• US Coast Guard issues media advisory re
  Recalls of houseboats with death zone design
  accepts side exhaust as an engineering control

McCammon / Baron CSTE 2007
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What We Know Nationwide Outside the Death
Zone
57 people poisoned 11 died

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
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2001 Chad Ethington Drowns at Lake Powell
Duration of Exposure 5 minutes COHb 56
20
Ski Boats / Other Motorboats
Nationwide 61 people poisoned on the swim
platform 21 died - 28 others lost
consciousness 34 on moving boats 23 on
boats not moving (4 unknown)
Most recent drowning June 2, 2006 (Utah
Lake, UT) COHb 51
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Death Comes Quickly
Poisonings Resulting in Death/Drowning COHb
Minutes Exposed 57
1 56 5 50 1 - 2 48
10-15 41 64, 41, 39 in minutes
Why?
26,700 ppm CO boat moving
10,000 ppm CO boat stopped
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Cabin Cruiser Poisonings, Lake Powell 2002
About 30 minutes later, the second girl was
found on the bottom of the lake. Her COHb
(autopsy) - 39
Two 9 year old girls were near the generator
exhaust for 10 minutes. The first girl had
difficulty responding to parents when called in
for lunch. Her COHb (measured after 71 minutes
of oxygen therapy) 15
41,600 ppm CO measured at the generator exhaust
terminus
570 ppm CO 10 feet away
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Congested Boat Traffic Lake Havasu
14 people poisoned since 1997 4 deaths / 6 LOC
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.
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• Recognition the Key to Prevention

If investigators dont ask about CO risk factors
And clinicians/coroners dont request a COHb
CO poisonings go unrecognized
Example An Olympic swim coach drowns beneath
the rear deck of a houseboat. We know He said
he was going trick the fisherman at the rear
deck He donned a swim mask and went underwater
beneath the rear of the boat 10 minutes later,
someone noticed that he was missing The
on-board generator was operating and exhausted
into the Death Zone. What we dont know his
COHb.
McCammon / Baron CSTE 2007
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Reporting - its the same for all CO poisonings!

• Problems
• Limited reporting systems
• Limited sharing of case-based data between state
  and federal agencies.
• Limited ability to target source-based prevention
  programs.

McCammon / Baron CSTE 2007
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Prevention - its the same for all CO poisonings!

• Engineering controls first
• Education Legislation/
• Regulation

McCammon / Baron CSTE 2007
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Engineering Controls Marine Generator Exhaust
Moving it to a safer location
Even better Controlling it at the source
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Engineering Controls - Inboard Engines
 Its the right thing to do, .
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LEGISLATION / REGULATION
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Education