We hope to inform the Hispanic population regionally and nationally, with respect to the treatment of Carbon Monoxide (CO) poisoning.
Project status: This project is on hold pending funding.
We will produce a Spanish-language video aimed at the Hispanic population explaining CO poisoning and its Hyperbaric Oxygen (HBO) treatment procedure, with its accompanying advantages and risks. In this collaboration with the Duke University Center for Hyperbaric Medicine and Environmental Physiology, the treatment safety clinical films will be accessible throughout the world on the Research Repository Project, and specifically targeting the members of the Undersea and Hyperbaric Medical Society (UHMS), an international, non-profit association of scientists and health professionals who work in the field of diving and hyperbaric medicine, for use in training patients who require this emergency treatment.
On December 4, 2002, a winter storm struck the Carolinas. Heavy snow began falling along the Interstate 85 corridor from Spartanburg, SC to Raleigh, NC in the late morning and early afternoon of that day, and during the night of December 4-5, snow changed to sleet and freezing rain and ice began to accumulate. By the early morning hours of December 5, one quarter of an inch to one inch of ice had accumulated; innumerable tree limbs and power lines fell, leaving more than one million households without power in the Carolinas. Temperatures dropped on the night of December 5 and remained cold until December 8. Most of the population did not have power restored for several days: on Monday, December 9, 10% of the population remained without electricity. Even homes with natural gas furnaces were without heat because furnace blower motors failed to function in the power outage.
The cold temperatures and lack of power forced the population to turn to alternative, and often improper, methods of heating and cooking. The first cases of carbon monoxide (CO) poisoning began to present to Emergency Departments (ED) in the area beginning in the morning of December 5 and continuing though the duration of the power outage. Carbon monoxide exposure causes the body to become starved for oxygen. This type of systemic hypoxia (lack of oxygen) can lead to headaches, nausea, vomiting, and even death; emergency treatment in a Hyperbaric Chamber is the only definitive therapy for these symptoms.
Duke University Medical Center serves as the primary referral center for Hyperbaric Services in the Piedmont area of North Carolina. Treatment in a Hyperbaric Chamber involves exposure of the patient to greater than normal atmospheric pressures in order to provide oxygen at higher levels in the blood than those available at normal atmospheric pressures. This process is often referred to as a “dive” because it is similar to the changes in pressure experienced by SCUBA divers in water. The elevated oxygen levels help to “push out” the CO molecules attached to the red blood cells, or hemoglobin. Exposure to hyperbaric oxygen (HBO) can speed the reduction of the Carboxyhemoglobin (the measure of CO attached to red blood cells) by as much as ten times faster than exposure to oxygen under normal atmospheric pressure.
During the period of December 5 through December 12, the Hyperbaric Center treated a total of 29 patients for CO poisoning. Three patients (10%) received multiple treatments. During this time, the Emergency Department at Duke University Medical Center evaluated approximately 220 patients for carbon monoxide exposures. A summary of the treated patients by date and ethnicity is shown in Figure 1.
The median age of the patients was 23 (range 5-58). Of those patients, 65% were Hispanic, 31% were African-American, and only 1 (4%) was Caucasian. The treated population was equally split by gender (14 male, 15 female), but Hispanic patients were more likely to be female than were non- Hispanic patients (68% vs. 20%, Chi2 p=0.013). None of the Hispanic patients treated had a working knowledge of English. Eighty-seven percent of patients had loss of consciousness, and two (6.9%) were comatose upon arrival at the Emergency Department. Carboxyhemoglobin levels were measured in 27 patients: The mean was 19.3% (+-8.1%), with a range of 6.0 to 33.1%. Symptoms did not correlate with carboxyhemoglobin levels.
All of the patients were exposed to CO from either a charcoal burner (72%) or a gasoline powered generator (27%). All of the Hispanic patients were exposed to a charcoal burner, versus 10% of the non-Hispanic patients (Fisher’s Exact Test p<0.0001). All of the seriously ill patients and all of the patients who required multiple treatments with HBO were exposed to a gasoline generator (Fisher’s Exact Test for multiple treatments, p=0.015).
As in previous CO poisoning outbreaks, Hispanic patients were over represented in our patient population. Approximately 10% of Piedmont residents are Hispanic. Interviews with patients after the crisis revealed that the use of charcoal burners for heat is common in the areas of Central America where many of the Hispanic patients originated. Cold days were few, and dwellings had high ceilings and were well ventilated. These practices caused life-threatening complications in the apartment dwellings where most of the patients live. Most were unaware of the potential danger, but a few engaged in the practice despite the advice (sometimes of family members) that it was dangerous. The large influx of Hispanic immigrants into the area in the past ten years, infrequent cold weather, and slow restoration of power contributed to this problem.
Other storms since our initial data collection following the 2002 ice storms have also resulted in numerous patient treatments for CO poisoning. In 2004, data collected by the Center for Disease Control (CDC) and the Undersea and Hyperbaric Medical Society (UHMS) concluded that 40% of the patients presenting after the Florida hurricanes were treated using Hyperbaric therapy. On August 29, 2005, Hurricane Katrina struck the Gulf Coast of the United States. A total of 51 cases of CO poisoning were reported in Alabama, Louisiana, and Mississippi from August 29th to September 24th. 46 of the cases resulted in non-fatal CO treatments and five fatal cases (24 Alabama, 16 Louisiana, and 6 Mississippi). The CDC and American Association of Poison Control Centers (AAPCC) have tracked CO exposures since March 15, 2003. The AAPCC reports 58 calls from the August 29th to September 24th period following Katrina (21 Alabama, 29 Louisiana, and 8 Mississippi). It is unknown at this time how many of these patients were Spanish speaking.
An important consideration in the response to incidents following a winter storm or hurricane and the accompanying power loss is the treatment process during, and after exposure to this colorless and odorless gas. The primary areas we have identified for making an impact are:
* A short video which explains what a hyperbaric chamber is, including footage of an actual treatment “dive” to ease the anxiety usually associated with the procedure; and
* A video explaining middle ear pressure equalization techniques associated with exposure to greater than normal atmospheric conditions.
The introduction of the World Wide Web has allowed for great advances in education and communication around the globe. The audio and video media produced during this project will be housed in our Research Repository Project and accessible to anyone in the world via the internet. Clinicians who utilize Palm-type devices for the display of video images will be able to download compatible media to allow playback at the bedside in the absence of an internet-capable computer. Other types of media such as digital video and VHS tape, compact disk (CD), and digital video disk (DVD) will be available by request. Every effort will be made by the Rubicon Foundation and the Duke Center for Hyperbaric Medicine and Environmental Physiology to contact the news media and other hyperbaric treatment facilities to ensure that the resource is utilized locally as well as internationally. This should effectively promote better understanding of the risks associated with CO poisoning treatment as well as provide better care to the individuals experiencing this very dangerous problem.
Special thanks to Dr. Ward Reed for his data collection, writing and statistics used in this summary.