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

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Presentation on theme: "2009 CRLEA Boating Related Carbon Monoxide Poisoning Robert Baron, MD ED Co-Director, Phoenix Banner Good Samaritan RMC Medical Advisor, Glen Canyon National."— Presentation transcript:

1 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

2 We only see what we look for, and we only look for what we know 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 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? 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 At about 10% H eadache, nausea, confusion At 20-30% Loss of conscious- ness (LOC), disorientation At 50 -60% Coma and Death CO Hemoglobin Carboxyhemoglobin Baron & McCammon Nov 2008

6 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 CO

7 How Many Boat-Related CO Poisonings? 810 poisonings in 37 states (95% occurred 1990 – 2008) 149 people died * Excludes Lake Powell cases 14 7 60 8 30 24 * 29 * 16 20 24 6 18 5 1 12 44 5 7 2 1 37 15 23 1 19 6 3 Location unspecified 92 Lake Powell 202 (25%) 1 July 2008 Remember: Lake Powell data collection is the most extensive. 1 1 2 62 2 1 7

8 Lack of Recognition Lack of Reporting But How Many Poisonings? Is it 810? 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 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. 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 Baron & McCammon Nov 2008 27 CO-related deaths 282 nonfatal poisonings* * National Case Listing

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

18 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) 87 WHO 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)

19 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?

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

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22 Death Comes Quickly:Boats Underway COHb: Duration of Exposure57%: 5 minutes50%: 2 minutes48%: “in minutes”61%: 20-25 minutes56%: 10-15 minutes64%, 62%, 53%, 41%, etc.....Death Comes Quickly:Boats Underway COHb: Duration of Exposure57%: 5 minutes50%: 2 minutes48%: “in minutes”61%: 20-25 minutes56%: 10-15 minutes64%, 62%, 53%, 41%, etc..... 32 people poisoned on platforms of moving boats 22 died or lost consciousness32 people poisoned on platforms of moving boats 22 died or lost consciousness

23 26,700 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 stopped Death Comes Quickly

24 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

25 Showers 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%) Baron & McCammon Nov 2008

26 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

27 Cabin Cruisers Deaths 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 2007 Baron & McCammon Nov 2008

28 Comparison of Swim Platform CO Concentration Windy day No wind

29 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.

30 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.

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

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

35 Transport patients for further evaluation and treatment, including consideration of hyperbaric therapy, if they experienced: LOC or 1 st 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 1 st 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

36 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.) 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

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

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

39 Vertical Stacks: Moving Generator Exhaust to a Safer Location

40 Control at the Source - Generators Baron & McCammon Nov 2008

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

42 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 Baron & McCammon Nov 2007

43 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)

44 Dangerous 'teak surfing' prohibited in Nevada, California Jeff Munson September 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, Oregon www.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

45 Prevention through Public Awareness One example of many:

46 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! Baron & McCammon Nov 2008


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