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. 1 14 8 16 7 8 7 23 6 8 7 1 4 9 3 2 20 31 37* 8 1 5 1 6 44 62 38 15 56 Lake Powell 24% of the total 24 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 wasn’t the extent of the problem recognized earlier? Because it’s unbelievable. McCammon & Baron Nov 2009

16. A sunny day on Chesapeake Bay What’s 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 30,000ppm (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.)

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% <1 56% 5 50% 1 - 2 48% 10-15 41% <1 67, 64, 64, 41, 39% in “minutes” Why? 26,700 ppm CO –boat moving 10,000 ppm CO –boat stopped

28. It’s 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.

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

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 >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

40. 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.)

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

42. Engineering controls Education Legislation/ Regulation Prevent it !

43. Vertical Stacks: Moving Generator Exhaust to a Safer Location

44. Control at the Source - Generators

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

46. Engineering controls now exist, THEY NEED TO BE IMPLEMENTED TO SAVE LIVES Education Legislation/ Regulation Prevent it !

47. Dangerous 'teak surfing' prohibited in Nevada, CaliforniaJeff MunsonSeptember 29, 2004SOUTH 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. One example of many: Prevention through Public Awareness

49. We only see what we look for, and we only look for what we know Now let’s prevent it! McCammon & Baron Nov 2009