Carbon Monoxide Diagnosis Requires Epidemiological Thinking

More must be done to improve carbon monoxide diagnosis at hotels and emergency rooms. CO Poisoning must always be considered when multiple people are getting sick contemporaneously.

By Rebecca Martin

The deaths of three tourists ostensibly due to carbon monoxide poisoning in a Sandals Resort in the Bahamas raised another question no less important than the question of causality. This is the question as to why two separate couples purportedly housed in the same building at the resort, had both visited the emergency room the night prior to the incident, reporting similar symptoms and had been consequently released back to the location which ultimately took three lives and had severe impact on a fourth.

carbon monoxide diagnosis procedures

More must be done to improve carbon monoxide diagnosis at hotels and emergency rooms. CO Poisoning must always be considered when multiple people are getting sick contemporaneously.

Admittedly that question arises partly as the result of a lack of public information on the details surrounding the incident, but it is a valid question when examining the carbon monoxide diagnosis either at the scene, prior or during the arrival of emergency services, and in the emergency room.

Research into Best Practice for Carbon Monoxide Diagnosis

The CO Research Trust, a UK registered charity, was set up in 2005 to look establishing guidelines and aids for carbon monoxide diagnosis, with a goal towards improving public safety as well as accuracy in reporting such incidents. One of the areas of focus in that research is the establishment of more accurate protocols for diagnosis of carbon monoxide poisoning in the medical setting.

 “A study funded by the CO Research Trust has revealed that the most important factor in diagnosing carbon monoxide (CO) poisoning is a high level of suspicion by the healthcare professional who treats them once they arrive in an Emergency Department (ED).” https://www.coresearchtrust.org/media-information/study-highlights-the-challenges-for-emergency-departments-in-diagnosing-carbon-monoxide-poisoning

The study was conducted using patients who arrived in the Emergency Department with symptoms that could be potentially linked to carbon monoxide exposure; chest pain, headache or seizure, for example.  The patients confirmed to have been exposed to carbon monoxide through a health questionnaire and testing their COHb levels had a registered gas engineer sent to their residences to investigate.

The items explored in a health questionnaire were guided by the acronym COMA:

  • C for Co-habitees and co-occupants – is anyone else in the house affected (including pets)?
  • O for Outdoors – do your symptoms improve when out of the house?
  • M for Maintenance – are heating and cooking appliances properly maintained?
  • A for Alarm – do you have a carbon monoxide alarm?

Memo to Health Detectives – Consider Carbon Monoxide Poisoning

These are all questions which should have been asked at any emergency room servicing a tourist area, even internationally. From what we know from news outlets in regard to the incident at the Sandals Resort, we do have some idea of what the answer was to some of those questions. We know that more than one person was impacted at the scene prior to the fatal exposure that occurred during the night as four individuals reported the same complaints the night before. We can assume that they might have experienced some relief from those symptoms upon leaving the original location in which the symptoms appeared, though that information was not released. We know that there were no carbon monoxide detectors at that original location. What we don’t know is the source of the exposure or what would have caused the source to malfunction.

This raises the question as to whether bloodwork was done to test the levels of carbon monoxide via a test for elevated COHb levels at the emergency room? And if so, were those levels such that a diagnosis of possible food poisoning was made? All we do know is that both couples returned to their original lodging and three of them died prior to be discovered the following day.

They Can’t All Have the Flu – At Once

One of the potential diagnoses which can be ruled out in the medical environment when dealing with the broad range of carbon monoxide symptoms is the flu. Flu-like symptoms are generally consistent with the symptoms of carbon monoxide exposure except in one area; carbon monoxide poisoning does not result in a fever.[1]Although the flu and carbon monoxide can present with headache, dizziness, fatigue, nausea, etc., an elevated temperature is not a symptom of carbon monoxide poisoning. Once flu is ruled out ,the ambiguous symptoms of carbon monoxide poisoning can be addressed by questioning the patient and through the administration of a test to determine if there has been exposure to carbon monoxide.

 “Measurement of elevated COHb levels in blood should serve as a confirmation of diagnosis due to suspected exposure” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5363978/

Prolonged Carbon Monoxide Exposure can Still Cause Brain Damage

The symptoms of prolonged exposure to carbon monoxide at low levels generally presents with decreased cognitive function and neurological issues:

 “These criteria are not strict; caution should be given to not eliminating cases of potential chronic lower-level CO poisoning” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5363978/

Testing for carbon monoxide levels in the event that there is any suspicion of carbon monoxide exposure is really the only tried and true response on the part of the emergency team, or in this case, the emergency department.

 “Your symptoms will often indicate whether you have carbon monoxide poisoning, but a blood test will confirm the amount of carboxyhaemoglobin in your blood.” https://www.nhs.uk/conditions/carbon-monoxide-poisoning/

This is particularly important when attempting a differential diagnosis between food poisoning and carbon monoxide exposure in that many of the symptoms are common to both instances.

Carbon monoxide diagnosis is a rule out diagnosis, which is simple if it is put in the differential. Test the environment for CO. Test the blood for COHb. The problem is that it is too often left out of the differential.

Emergency responders may not initially find elevated levels of carbon monoxide at the scene. This can be because levels of carbon monoxide can dissipate merely by ventilating the area during the rescue process. Doors are opened, windows are opened, fans can be employed, or fuel-burning devices may be turned off.[2]Often it is only through a continuing investigation of the premises that a source for carbon monoxide can be discovered.

Again, this is an easy rule out diagnosis. Most of the time when it is missed at the scene, it is because the emergency responders didn’t think to check.

We are certainly awaiting more information as to why these two couples were returned to the same environment after making separate appearances at medical facilities and how such an environment proved to be fatally toxic.

Hotel Carbon Monoxide Events Keep Happening

What is equally disturbing is the number of incidents when potential carbon monoxide dangers are reported to hotel staff and disregarded. Such was the case of a Days Inn in Budd Lake, NJ this past January. Several guests had reported to the police that numerous carbon monoxide alarms had gone off over the course of several hours and had been advised by management that the batteries were being changed and to disregard the warnings. The fire department found elevated levels of carbon monoxide at the scene and the hotel manager was arrested and charged with reckless endangerment. One guest was transported to the hospital for evaluation. https://www.tapinto.net/towns/roxbury/sections/police-and-fire/articles/police-budd-lake-hotel-placed-guests-in-carbon-monoxide-danger

Another such incident occurred at a Comfort Suites in Freeport, Maine last year. A maintenance worker was on the scene when a carbon monoxide alarm sounded in the proximity of water heaters in the hotel. Rather than calling 911, he left a message of the fire department’s voice mail. As a result, emergency responders were not on the scene until the following day. They discovered levels of carbon monoxide in the hallway at 675ppm and in the lobby at 175ppm though some news sources report higher levels had been found. Guests in the adjacent room, two adults and a child, were transported to the hospital. The decision to not call 911 when the alarm sounded was reportedly due to the fact that a previous call to report a “malfunctioning” carbon monoxide detector had been made a day or so earlier.

 “If you have a (carbon monoxide) emergency, that needs to be a 911 call.” https://www.pressherald.com/2021/06/29/emergency-crews-respond-to-carbon-monoxide-leak-at-freeport-motel/

A mortifying account by two former guests of the Waldorf Astoria in Chicago describes their experiences in 2020. Hours after checking into their room, they began to experience symptoms, dizziness and increasing lightheadedness. At 3:30 AM they were awakened by a carbon monoxide alarm.  They immediately reported it to the front desk who sent a building engineer to their room to take a look at the gas fireplace. What he said next stunned them.

“It happens every night. I mean it just happens. It’s carbon monoxide buildup. So they say just leave your door cracked open.” https://www.nbcchicago.com/news/local/mysterious-deaths-and-injuries-in-hotels-and-motels-nationwide/2222836/

These stories raise a serious question – is it enough to require hotels to install carbon monoxide detectors or is more needed? What exactly does it take for the hospitality industry to take the dangers posed by carbon monoxide seriously and to prioritize the safety of guests?

[1] When multiple people contemporaneously have flu-like symptoms, consider the epidemiology. Flu doesn’t strike like that. An environmental exposure does.

[2] The emergency responders should all be wearing personal protective CO meters. If these are not registering, but the windows and doors are opened, then the responders should be asking, why did you open the windows and doors? In a recent case that the Brain Injury Law Group settled for millions of dollars, the readings were lower than expected based on the high levels in the blood, because the utility company dispatcher had told them to open windows and doors.

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