Not long ago, the only definitive way for us to know if patients (or potential patients) had carbon monoxide (CO) poisoning was to take them to an emergency department (ED), where blood could be drawn and analyzed, a process that not only delayed diagnosis but also patient care.
As a result, many patients were either misdiagnosed as having minor CO exposure or flu-like symptoms. Worse yet, many simply went undetected and untreated. At the scene of major exposures to CO and other products of combustion, we used to “hand pick” exposed building occupants, firefighters and other obvious patients. We didn’t have the benefit of advanced technology and fingertip sensors to assess, triage and treat people with CO exposure early and definitively.
Case in point: In 1983, one of my department’s crews was dispatched on a “man down” call. Within seconds of their arrival on scene, the crew reported multiple patients down from CO poisoning and requested a full fire-rescue response and five additional ambulances.
When I arrived on scene, six patients were sprawled on the front lawn; three were unconscious—including a small child. I learned a 67-year-old man, paralyzed from the waist down as a result of an automobile crash years earlier, came home drunk, drove his specially equipped vehicle into the garage, closed the garage door and fell asleep at the wheel of his car with it still running. His son, daughter-in-law and three grandchildren were asleep in the house.
The six-year-old daughter woke her parents, vomiting and complaining of a headache and upset stomach. While on the way to bathroom with the six-year old, the mother found her three-year-old daughter unconscious in the hallway. The father took this child outside to the front lawn and returned to evacuate his seven-year-old son from his bedroom. He found the son unconscious and also carried him outside. His wife called 9-1-1.
When the father returned to investigate the cause, he heard the car running in the garage and found his disabled father unconscious in the front seat. Unable to extricate his father by himself, he shut off the car, opened the garage door and waited in the garage for the firefighters to arrive. He then collapsed due to his extended CO exposure.
The initial fire crews extricated the driver and his adult son from the garage, and two rescue teams entered the house to search for other potential patients. The initial EMS crews began to triage and treat the patients on the front lawn. But because three were unconscious and three others experienced significant respiratory distress, there was no easy way to determine in what order the three conscious patients should be transported. So all six were tagged as Priority 1 patients.
No safety officer was designated at the scene, and the crews didn’t “mask up” because “there was no visible smoke or odor present.” (Remember: This incident happened in the early ’80s when air packs weren’t used often during building searches and overhaul, safety officers weren’t frequently deployed and rehabilitation wasn’t a standard practice.)
The next day, several of our personnel complained of nagging headaches and lethargy. Two of them, while at an ED the next morning following an EMS call, ran into our medical director and told him their symptoms and involvement at a CO incident. He ordered tests that showed both had significantly high CO levels. They were kept at the hospital on oxygen for most of the day. He then called and advised our EMS crews to assess all personnel involved in the CO incident, “flush” them with oxygen and transport them to the ED if their symptoms persisted.
That incident presented a wake-up call for my department about the hidden dangers of CO exposure, the need for vigilant use of air packs at suspicious scenes, use of a safety officer and the need to establish rehab and assess our personnel at incident scenes.
This supplement illustrates these lessons—and more. It also outlines how CO-oximetry can improve your assessment, triage/screening, and treatment of actual and potential patients, as well as emergency personnel exposed to CO—the silent killer that can sneak up on them at many scenes.
This article originally appeared in an editorial supplement to the October 2010 JEMS as “‘Sensing’ the Effects of CO Exposure: Carbon monoxide exposure can present a significant hazard to patients and rescuers.”