Inflammatory Breast Cancer–Any Change Could be Serious

Inflammatory Breast Cancer is a deadly diagnostic challenge as it is harder to spot but no less lethal.

A Personal Story by Rebecca Martin

If you google Inflammatory Breast Cancer you will undoubtedly run across this information from the American Cancer Society.

“Inflammatory breast cancer (IBC) is rare and accounts for only 1-5% of all breast cancers. Although it is often a type of invasive ductal carcinoma, it differs from other types of breast cancer in its symptoms, outlook, and treatment. IBC has symptoms of inflammation like swelling and redness, but infection or injury do not cause IBC or the symptoms. IBC symptoms are caused by cancer cells blocking lymph vessels in the skin causing the breast to look inflamed.”

Perhaps you have been one of the few who have seen the PSAs describing symptoms and warning that any changes to the breasts are to be taken seriously. One such warning stuck with me and maybe saved my life. It is a disease few know about and disturbingly many of those unfamiliar with it are doctors and others in the medical profession. This is disturbing in that, although IBC accounts for 1-5% of all breast cancer, it accounts for 10% of all breast cancer deaths.

Inflammatory Breast Cancer Recognition

It is recognized through several different symptoms. It is not detectable by presence of a lump. Instead it may present as a bruise, swelling, tenderness, redness or rash, a change in the skin often described as an orange peel look, dimpling, an inverted nipple, itching, a difference in breast size and/or tenderness in the lymph nodes under the armpit or collarbone.

Inflammatory Breast Cancer is one of many variants of breast cancer. Tumors can take many shapes, as shown above.

Statistically, you are more likely to be at risk for IBC if you are obese, African-American, or a young female. Aside from being female, I am none of those things. But in 2016 I was diagnosed with stage IIIb Inflammatory Breast Cancer.

My journey began with a increasing level of fatigue. I often said to friends that I just didn’t feel like myself. My active lifestyle was becoming more burdensome. And when I noticed a small bruise on my left breast, I thought nothing of it. Weeks went by and the swelling and hardness increased and when I saw a dimple appear, I knew what it was because that particular symptom was included in the media I had seen.

At this point many women go to their family doctor complaining of redness and swelling. Due to the rarity of the disease they are more than likely to be diagnosed with mastitis, prescribed antibiotics and sent home. But IBC has only two stages III and IV. By the time it can be detected it has sometimes already spread to other parts of the body. The delay in proper diagnoses can be deadly as IBC is an aggressive cancer which can spread in weeks or even days.  Many women seek out several opinions before receiving an accurate diagnosis. And unfortunately it is too late for some.

One in three cases have already metastasized by diagnosis. By diagnoses the cancer has already grown into the skin and is considered locally advanced. IBC cannot be detected by a mammogram like typical breast cancer. The delay in proper diagnosis is one reason more education is needed for the public and medical professionals. This does not only affect women; it affects men too. Approximately 2000 men get breast cancer annually and 1-5% of those cases are IBC.

Quick Medical Action Saved Me

I was fortunate. My primary care physician was familiar with IBC and took one look at me and rushed me off to the oncologist the same day. I knew, he knew, but now it was time for conclusive tests. That part of cancer diagnosis becomes such a blur if you are going through it. The same day I was given a mammogram, a sonogram and biopsies were taken. Then you wait for the cancer to be identified and staged. Before I knew it, I was scheduled for surgery to install a chemo port.

This is the next stage that a doctor unfamiliar with IBC can err; treatment plans. Normally a person diagnosed with breast cancer would be planning for surgery. But the international protocols for treatment of IBC are different and call for chemotherapy first. This is done to decrease the cancer as much as possible because surgery at this point could increase the risk of it spreading through the lymphatic system and is unlikely to contain and remove all the cancer cells. The protocol for IBC is chemotherapy, surgery and then radiation.

Standards for Treatment of Inflammatory Breast Cancer

The standards for the treatment of IBC were established by an international expert panel on inflammatory breast cancer originally in 2008. It was felt that a consensus of all experts in the field was needed to form a standardized model for the diagnosis, treatment and followup care of IBC for the medical community. IBC had an extremely poor prognosis at that time. The expert panel identified that there was also a serious lack of clinical trials aimed at IBC and research, and part of the goal was to target a strategy to further our understanding of the disease.

I prepared myself for chemotherapy in probably a very typical way. I googled information. At that time, the pre-2011 statistics were still prioritized on google and the official survival rate for Stage III IBC was 40% at five years, while the median life expectancy for Stage IV was at just under two years. That is like getting hit by a truck. Only much later would I learn that a new drug introduced in 2011, Herceptin, along with proper protocols, would raise my chance of a five year survival to 70%.

Preparing for chemotherapy is a difficult thing to do. I was looking at what was referred to as “some hard core chemo” administered every three weeks to give me a chance to recover in between. The weeks before I ate more. Every movie shows some haggard actor reduced to skin and bones by cancer. I scheduled that hair appointment for a short haircut, confident that I would be the one to not lose my hair. I talked to family and friends. I loved everything I saw, or smelled, or tasted and said goodbyes a million times to things I thought I might be experiencing for the last time. And I avoided asking my oncologist about my prognosis. The grim demeanors of everyone involved in my treatment plan made that question seem impossible to ask.

My first chemotherapy and every one to follow started early in the morning with bloodwork. And then the dreaded insertion of the needle into my port. My chemo port was surgically implanted in my chest and consisted of a target disc and a tube sewn into a pulmonary artery It’s hard to deal with a needle aimed at your chest and I admit, I was a terrible coward about it, even after dowsing the area with numbing agent an hour before my appointments.  An hour or so would pass waiting for the lab work and drugs to be prepared and finally chemo would begin. It was always preceded by drugs to help lessen the effects of chemo and then hour after hour of nothing to do but watch what felt more like poison than a cure some days drip down the tubes.

The first chemo appointment I left feeling triumphant. That was nothing, I had conquered it in champion fashion. I went home with a timed Neulasta injection set to go off 24 hours later to help boost my immune system. But I was feeling great. Before the second appointment I had already shaved my head when my hair began to hurt and fall out and was finding out that the worst day is not the first day, it’s the days that follow. It is like having the worst flu you can remember every day. You eat little, but the steroids before chemo guarantee no weight loss.  And just about the time you are feeling better and can eat and be somewhat normal…it is time for the next round of chemo. You learn to use those good days.

During this time every ache or pain or complaint is taken very seriously and scans are frequent. Because of Herceptin, heart echoes are done as well to check for heart damage. It gets very real, very fast. I am focusing on the chemotherapy because many women I have spoken with who have gone through breast cancer have had a choice of whether to do chemotherapy. For IBC, there is no choice. After my third chemo when it is time to evaluate the progress I asked my doctor what would happen if I quit. By then I was very miserable and really thinking I couldn’t face much more. She said that I would probably be gone before the holidays and not in the most pleasant way. But the good news was, chemo was working and suddenly my prognosis was very much better.

Once I completed chemotherapy I was not done with infusions. I would receive Herceptin infusions for the next year. I was HER2 positive which means my cells had more receptors and Herceptin is a receptor inhibitor. Herceptin would shut down the spread of cancer throughout my body permanently.

Then it was time for surgery. This also differs for IBC patients in a few different ways. First, because it is not a typical breast cancer and most likely to recur in other areas of your body, it is not necessary to remove both breasts as it is highly unlikely it would recur in a remaining breast. But it is necessary to do a non-skin sparing modified radical mastectomy. Reconstruction is not done at this time and it is recommended to wait at least a year after treatment ends to consider reconstructive surgery unlike other breast cancer. And ideally to forego surgery. However it is recommended that all lymph nodes adjoining be removed and personally I had just a few removed. My doctor decided that the threat of lymphedema outweighed the extra lymph node removal. This was due to my good response to chemo. Every case differs. This was not discussed; pros and cons. Something that continues to cause concern. I did have mild lymphedema which was quite unpleasant. But a qualified oncology physical therapist was prescribed and I was fortunate to avert that issue. However, for the rest of my life I can have neither blood pressure taken or needles in my left arm for risk of triggering lymphedema. Lymphedema is an incurable condition. Lymphedema causes swelling in the arm on the side of lymph removal as the nodes which carry away fluids have been removed.

It is after surgery that I received the news that there was no evidence of disease. Surgery was the easiest phase and once healed I began making the everyday trip to radiation. By that point you are not feeling entirely human anymore. Treatment can be a very dehumanizing process which strips away dignity.  First thing every morning I headed for radiation and after thirty plus sessions, I was beyond fatigued. But the first funny bristles of hair were reappearing. Taste buds began to recover and life was looking a lot better. And the months of infusions ahead just seemed to be leading to a finish line which was now in sight.

You never return to the you who began the journey. It’s a hard battle for the human body to go through and many fight their way back to a new way of life with many ups and downs. After treatment I was set to begin five years of aromatase inhibitors, drugs which shut down all hormone production in the body. At that point I raised the white flag and left treatment. The wear and tear was already enough. We all make the best decisions we can for us.

The Phases of Recovery

There are so many psychological phases survivors go through. You may have lost what you believed to be close friends and embraced those who unexpectedly gave their support. Your body has changed and the stages of grief are a real battle back to self-acceptance. And there is fear of recurrence which is extremely difficult once you are past the intense care you received during treatment. Support groups offer comfort and there are many programs available through the hospital, online and even at your local YMCA.

Today I am still ‘no evidence of disease’ and my five year survival anniversary is approaching. There is neuropathy and the frustration that comes with it. I can taste things but they are subtly different than my memories of them. My hair is absolutely straight where it once had waves, and thinner than it was. My eyebrows are almost nonexistent. I forget that I have one breast sometimes. But that is a scar I am proud of, at last. It was a journey to get there filled with some tears. I am easily fatigued and a lot weaker. But I am here to tell you, there is life on the other side of IBC. You will not go through it unscathed. But you won’t be unchanged either. Life is different after cancer. Perhaps the hardest thing is going through treatment and realizing that once it is all done you are not being restored the exact person you were before.

If I could say one thing to all people about IBC: take any change in your breasts seriously. Get second opinions and be your own best advocate.  Seek out others who have experience with IBC and remember chemo, surgery, radiation.

Inflammatory Breast Cancer is 1-5% of all Breast Cancers

1-5% of all breast cancers are IBC. The statistics said it was almost unthought of that I should be diagnosed with it. But I was. It can touch anyone. It is not genetic. It is not environmental. No one knows exactly what causes it yet. Studies are being done which lean towards some type of viral component. Hopefully new advances are on the horizon. Prior to the introduction of Herceptin, my prognosis was not as bright as it is today. New advances with Herceptin have also increased survival rates.

It is important to note that women in the black community have 70% more incidents of IBC than white women.  And this is an important issue when we factor in racial disparities such as access to early diagnosis and treatment and long term follow up care. It is imperative that we keep in place those facilities who provide cancer screening for all. And educate the medical professionals involved in screening. Any delay in diagnosis of IBC can spell the difference between life and death.

This also brings up the problem of high risk insurance pools for IBC patients.  Being located to the cancer pool is virtually a death sentence for IBC patients. High risk pools are known for delays in treatment and one thing IBC patients don’t have is time.

IBC is no longer the poor prognosis it once was and so much progress has been made in the treatment and understanding of the disease. I hope you will not dwell on the numbers you might find on google and be reassured by the survival stories. Make sure women…and men in your life are aware. This disease can strike at a very early age as well. IBC is the most aggressive and deadliest form of breast cancer. But there are more than just statistics, there are real people behind those numbers. I am just one of them. Survivors today are living twice as long as those in the 70s.

For those who might find themselves, like me, facing that journey, or finishing that journey, don’t let it consume you.  Be educated. Don’t be immersed. It is going to be with you, it’s not you. Although the threat of this disease can be very present, we are so much more than cancer patients and survivors. There will be good days and bad days, but every day is a day that we are still here to experience.

For more information on Inflammatory Breast Cancer, go to the IBC Network Foundation

This story was written by Rebecca Martin who has been the primary author of our blog content at https://carbonmonoxide.com/news since last summer. Rebecca and I have been writing content about brain damage and health since our seminal web pages in 1996 and 1997 http://tbilaw.com and http://waiting.com  For our Holiday Wishlist published all of those years ago, go to https://tbilaw.com/brain-injury-christmas-list.html

Becca and I hope to be providing you important and interesting content for another generation.

Gordon

Pets Carbon Monoxide Poisoning is a Thing

Pets carbon monoxide poisoning is an actual thing. Stories of dogs awakening their owners during a fire or gas leak make feel good news stories. However, many people believe that a dog can also detect carbon monoxide and thus act as an alarm system. But just as we humans cannot smell or detect carbon monoxide, dogs and other pets are also unable to detect carbon monoxide. Carbon monoxide is odorless and simply cannot be not detected by any of our pets.

However, that doesn’t mean that pets can’t warn people about carbon monoxide because they can smell things that we can’t, even if it isn’t CO they are smelling. Carbon monoxide forms in a fuel burning appliance because the carbon fuel (natural gas) isn’t completely combusted or burned. This is called incomplete combustion. While pets can’t smell CO, they can smell the other products of incomplete combustion. Another term for the products of incomplete combustion is SMOKE. The pets are smelling smoke, but in quantities too small for human nose to detect to it.

In our experience testing countless furnaces, the human nose will begin to detect smoke when the CO in the exhaust of a furnace gets to levels above 6,000 ppm. A dog can likely smell it when it is a fraction of that level.

Pets Carbon Monoxide Poisoning – An Imperfect Warning

In addition, our pets may act as warning systems due to the fact that they are smaller and have faster respiratory rates than we do. Because of this they may exhibit the symptoms of carbon monoxide poisoning before we do. Some of the symptoms they may exhibit are similar to the symptoms humans display, but there are some symptoms which can point to lethal levels of carbon monoxide in the home.

Pets Carbon Monoxide Poisoning

Pets Carbon Monoxide Poisoning is an actual thing, not a myth. Pets may smell smoke before humans and they are likely to be sick at lower levels.

 

When we consider size as a factor, smaller animals will react faster and they may perish suddenly with little warning. There are countless stories of the sudden deaths of pet birds alerting families to the presence of carbon monoxide.

Pets Carbon Monoxide Poisoning – A Recurring Story

One such story occurred in Illinois in 2000 right after Christmas. The children were playing while their pet parakeets sang happily nearby.  The family suddenly noticed one bird had died and the other one was struggling and succumbed shortly after. The heartbroken kids were burying their pets when a neighbor suggested that the symptoms sounded very much like carbon monoxide poisoning. The mother called 911 and it was discovered that a slow leak had developed near their furnace blower in the basement and  carbon monoxide has entered the air ducts and filled the dining room near where the children were playing and the birds were located.

In this instance there were carbon monoxide detectors installed in the home which did not alarm. And this suggested that placement of the alarms was an issue in this incident. The mother said that she has since learned that it is a good idea to move alarms around in your home to test carbon monoxide levels in different areas and to also replace older detectors with those with more precise monitors.

Ill Pets Should not be Ignored

The key fact in this case is that multiple healthy pets suddenly perished without explanation. This is common with smaller pets who succumb to carbon monoxide poisoning.

The cliché about the canary in the coal mine meaning the early warning of something, has its origins is that canaries were used in coal mines to warn humans of toxic gases.

Birds have a very unique respiratory system and are highly sensitive to carbon monoxide. Rodents, such as mice, can tolerate twice that amount. Rabbits react very similarly to dogs and cats, sometimes becoming very manic and uncoordinated in the early stages of carbon monoxide poisoning. Reptiles have a very efficient respiratory system, slow metabolic rates and can potentially tolerate periods of time without oxygen. Many exotic pets like spiders have variable needs for oxygen depending on when they ate and their metabolic rate.

What Airs is Your Pet Breathing?

Because carbon monoxide tends to disperse in a room, the location of the pet is not a big factor. The bird hanging in a cage is equally as susceptible as a pet at floor level.

Dogs also can be indicators that there is carbon monoxide present. They may suddenly exhibit anxiety or aggression. They may refuse to enter the house after being outside. They may vomit and appear uncoordinated or become less responsive and appear to have difficulty breathing. Dogs may also have seizures. But a much more alarming symptom is if your dog appears to have bright red lips, gums, ears or skin. This is a sign that your dog is not getting enough oxygen and considered an emergency. This can lead to coma, arrhythmia, dyspnea, acute lung damage and death. Permanent deafness and blindness may occur. The symptoms are very similar in cats. The appearance of a cherry red color in the mucous membranes of dogs and cats should always indicate that there is a lack of oxygen and carbon monoxide needs to be ruled out.

Cats Sleep in Dangerous Places

Cat owners will understand when I say that cats are never happy if they begin to feel ill. And they can be quite vocal about it. In 2019, a cat named Bella saved the lives of a Florida couple who accidentally  forgot to turn off their car after pulling into the attached garage. Bella’s cries from under the bed alerted the couple, who by that point were almost too weak to dial 911 and close to collapse. The husband was close to death by the time firefighters arrived. Bella and her family survived the incident, though all suffered neurological damage. This time, the cat’s unusual behavior is what sounded the alarm.

One point to make about cats as well, is their tendency to curl up next to anything that is warm–putting them in the immediate vicinity of fuel burning devices such as heaters or fireplaces.

Treating Pets with Carbon Monoxide Poisoning

Dogs and cats who have been exposed to carbon monoxide require the same follow up as humans because neurological problems can present later on. Sometimes the prognosis for these delayed neurologic defects results in a very poor prognosis.

It is of primary importance to remove your pet and family away from the suspected source of carbon monoxide and not return until professionals have investigated. Treatment for dogs and cats is very similar to that of humans entering an emergency room. The vet will do a blood count to determine the levels in the blood and additional tests of bodily fluids to determine the impact on other organs.  An ECG may be administered to check heart function. It is highly recommended that dogs recovering from carbon monoxide exposure stay on limited activity for at least six weeks with short walks and limited playtime. Cats should also follow a limited activity regimen. Neurological symptoms can surface many weeks after the initial exposure so follow ups are a part of post exposure protocols.

Several studies have been done to follow up the long term effects of carbon monoxide exposure in pets. Seizures, sometimes fatal, can be the ultimate result of carbon monoxide poisoning. Seizures occurred after pets showed immediate initial improvement so it it vital to observe a pet who has been successfully treated and report changes to their vet.

In one such study, three chihuahuas who initially survived a house fire, recovered well initially and later succumbed to seizures, were examined. Lesions were found on necropsy compatible with carbon monoxide poisoning.

A survey by an energy company for carbon monoxide awareness month asked 2000 dog and cat owners if they owned a carbon monoxide detector. A third of those polled said that they didn’t. One in ten didn’t know carbon monoxide was dangerous. And a quarter believed that you could see, smell or taste a leak.  Yet a third of dog and cat owners believe their pets have alerted them to dangers in the home and one in ten credits their pet with saving their lives. I count myself in the last  group as a family dog alerted my family to a chimney fire when I was young. This may be true in the case of house fires or gas leaks, but our pets do not have the special ability to detect carbon monoxide–only the smoke of incomplete combustion gets to what is likely a toxic level of CO. Only carbon monoxide detectors are sensitive enough to alarm before and warn at the same time. And they help keep family pets safe as well.

In fact, a certain scenario comes to mind when discussing pets and the placement of detectors. Many working families crate or limit the access of family dogs while they are away for the day. This is often for the safety and wellbeing of the pet in addition to protecting property. Just be aware of where the pet is spending those hours. It is not uncommon for the utility room to be the area chosen and that is an area that should also be checked for carbon monoxide levels and fitted with a detector. There are not just a few people who leave the dog in the garage. Starting the car remotely or not having adequate venting for any appliances located in the garage could be deadly for your pet. Think about the areas your pets are in while you are gone and remember that they are even more susceptible to poisoning than you are.

We still have to wonder about pets carbon monoxide poisoning when we see news stories of heroics by family pets. Take, for instance, the 2008 story about the Graziani’s who were awakened at 2 am by their husky mix, Molly. Once awakened they realized something was very wrong and they were all in danger of collapse. They had removed the batteries from their carbon monoxide detector earlier because it kept alarming while they were cooking. Once awakened they replaced the batteries and it immediately sounded, so they knew it was carbon monoxide. When firefighters arrived, the carbon monoxide levels in the home were so high the firefighters had to wear self-contained breathing equipment and the carbon monoxide levels were 30 times the limit. Although neurological problems ensued, there were no fatalities.

How did Molly know something was wrong? Was Molly merely in distress because she was feeling the effects of carbon monoxide poisoning, or was it that intangible sixth sense pet owners swear by? We may ponder that question in the face of the science behind it, but there is no doubt that carbon monoxide detectors that are properly positioned and maintained save lives. Including the lives of our pets.

If carbon monoxide is suspected, vacate the home immediately. Wait for firefighters to arrive rather than returning to the home to search for pets. Carbon monoxide can act quickly to incapacitate you and ultimately become fatal. You are more likely to save your pet by being conscious when help arrives with the proper equipment.

It is also important to be aware of wildfire dangers for animals. When air quality is compromised and/or haze is present,  pets should be kept indoors with windows closed, outside activities kept to a minimum and they should be monitored carefully for signs of distress. This is especially important for animals with respiratory conditions.

The Merck Veterinary Manual also warns that facilities heated by combustion sources be tested for carbon monoxide levels with carbon monoxide monitors and/or testing the air with a Drager Tube.  This includes barns, stables, facilities for poultry or any area heated in the winter where animals are housed. Larger animals may not exhibit the severity of symptoms as a human might upon entering that environment.

For horse owners, care should be taken when sleeping inside the sleeping quarters of a horse trailer during horse shows. In 2007, two children and their grandparents were killed while sleeping in a horse trailer during the World Clydesdale show in Madison, Wisconsin. Their trailer was not manufacturer equipped with a heater so they were using a propane heater to warm the sleeping quarters. While an open roof vent was observed at the scene, this was not enough to prevent a build-up of carbon monoxide.

Remember that air even if air can escape through vents in upper levels that lack of oxygen flowing to the flame can lead to the build up of carbon monoxide in lower levels of a structure. Carbon monoxide happens when the fire doesn’t have enough oxygen, even if there is a path for the smoke or exhaust. Click here for more. 

In 2015, another couple attending the Midwest Horse fair in Madison, Wisconsin were successfully saved when a first responder attending the Fair noticed they had not shown up to feed their horse. They were found unconscious due to carbon monoxide poisoning, but alive due to the first responder’s actions.

It should be noted that heating systems included in horse trailers need to be inspected and maintained according to manufacturer specifications.

Don’t let pets carbon monoxide poisoning impact your family. While pets may not be super heroes in carbon monoxide detection, they can be indicators of the presence of carbon monoxide. They may also present unique challenges for carbon monoxide safety which we must be mindful of due to their unique responses to exposure and our exposure when indulging in pet hobbies. As always, education is a key element to insure the safety of human and pets.

Rebecca Martin authored this blog.

Negative Air Pressure Equals Carbon Monoxide

Negative air pressure can cause carbon monoxide poisoning because it interrupts the flow of oxygen to a flame, causing incomplete combustion. A fire without enough oxygen creates CO, not the harmless CO2.

Negative air pressure is a crucial component in understanding how carbon monoxide can accumulate.  In carbon monoxide news this week, seventeen-year-old Jenna Fish succumbed to what is believed to have been an incidence of negative air flow. For her story, click here. This negative air low was believed to be a result of a fire dying out in a wood burning fireplace causing the radiator heat to kick on. Jenna had gone to the basement to sleep after messaging her boyfriend that the family’s snoring dog was disturbing her sleep. When her family, sleeping upstairs, woke up to suspected carbon monoxide poisoning, they discovered Jenna lifeless in the basement. The carbon monoxide had accumulated more densely in that area. The family said they had four functioning smoke and carbon monoxide detectors in the home, but none sounded the alarm.

What Causes Negative Air Pressure?

There are several reasons negative air pressure can occur. Negative air pressure occurs when the pressure inside your home is less than the air pressure outside your home. One of the main structural reasons is that our homes are more airtight. Since the seventies we have built homes to be more fuel efficient, tightening them up to reduce heating costs. This can decrease the air flow in our homes resulting in insufficient air/oxygen to allow for the proper combustion or venting of appliances and heating devices.

For more on negative pressure, click here.

Normally air moving out of our homes is replaced by air moving into our homes. But modern homes have reduced the amount of air coming in without necessarily increasing the amount going out.  This occurs because the movement of warmer air upwards, the use of exhaust fans and just humans using air to breathe.

Modern Homes Require Dedicated Fresh Air

In theory, a modern home has a high efficiency furnace which gets its combustion air from outside, while also exhausting air out the side wall of the house, as shown in the below picture. But when a house with a natural draft furnace (not high efficiency) gets tightened up, negative pressure problems can become more severe.

Negative air pressure may be avoided in tight modern homes with high efficiency furnaces which get combustion air directly from outside air. Outside air comes into this house directly from the down facing pipe here.

The average home creates a natural vacuum as warm air rises to the ceiling. But add in the many other ways we remove air from our homes, we can see the problems created. Bathroom fans, central vacuums, clothes dryers, and numerous other appliances remove air at a faster rate than it can be replaced.  Restricting the replacement air can cause a rise in carbon monoxide from furnaces, hot water heaters, wood stoves and fireplaces.

One might conclude that if your home is drafty then it is not at risk. But drafty homes are often signaling us that there is a greater flow of air out of the house and not that the airflow in has increased. The same effect is created. Consequently, equalizing the pressure in the house through proper air intake could actually reduce drafts.

More Draft Isn’t Always the Solution

However holes in the upper portion of the home, especially in the upper portion of the home, can create the same problems. Warm air rises and escapes through leaks in the upper portion of the house, creating more of a draw of cold air in the basement. If this airflow is less than the loss of air in the upper portions of the home it ultimately depressurizes the house and increases the risk of downdrafts which can raise the level of carbon monoxide.

Fireplaces function because warm air rises. Again that air must be replaced by incoming air. Certain weather conditions such as high winds can cause the chimney to malfunction, creating a downdraft.

Debris can also cause problems with proper ventilation. In the case of Jenna Fish, when the fire went out, the heating system itself created a depressurized state that allowed carbon monoxide to build up in the basement. Exhaust fans in bathrooms and kitchens can have the same effect.

Most of these instances of negative airflow are also called backdrafting or downdrafting. They can be detected by strips called Backdraft Indicators. Qualified heating contractors can use these strips to monitor the potential for negative air flow in the home. Unlike carbon monoxide detectors, these are not alarms. They are indicators to a professional of the patterns of air flow in the home and reveal areas of concern.

Never try to solve these negative air pressure issues yourself. Adding more exhaust pipes for heating may not be helpful as these tend to be highly affected by weather. Fan powered combustion kits are more effective but should only be installed by a professional as fixing one source may actually create problems at other sources. An overall look at the home’s air flow needs to be understood and considered.

Other Solutions for Negative Air Pressure

There are other measures which can be taken to decrease the possibility of depressurization in the home. Some of the ways one can reduce the risk are sealing up leaks and holes in the upper portions of the home and increasing air leakage in the lower portions through the use of combustion air and make-up air openings. Turning off exhaust fans can reduce depressurization. Sealing return ducts in the basement and closing return registers in the basement can reduce backdrafts. Opening supply vents to the basement. And simply, keeping doors open to rooms can reduce the risk of negative air flow.

One can look at a home as made up of general areas of pressure levels with the mid-range level likely being the most neutral pressure zone. The lower level or basement is generally the area where the air pressure falls below the air pressure outside. While the higher levels of the house would have higher pressure than outside as warm air is pressing against the ceiling. This is why your basement is the most likely place for problems. Furnaces, hot water heaters, and fireplaces located in the lower portion of the house are working harder against the negative pressure. So a fireplace in the basement is more likely to cause problems than one located above the neutral zone at a higher level.

It is important to note, however, that the neutral zone is a house is also impacted by other factors. If the basement is better sealed than the upper levels the neutral zone rises. If the basement is the leakiest place in the house the neutral zone drops. This is called the stacking effect and it determines the air flow and potential for problems due to depressurization.

We see this stacking effect also with chimneys, as in the Jenna Fish case. A fireplace installation below the neutral plane, in this case lowered by the heating system itself creates negative air flow if the flue has cooled. When a fireplace is not being used the flue is cold. However when the fire has died, the flue also cools down and the air in the flue begins to match the outdoor temperature. At this point even the most minor venting issues in the home, such as the heat kicking on, can cause negative air flow and the fireplace will backdraft into the home spilling carbon monoxide.

Why did it affect Jenna in the basement and only mildly affect her family? Several factors could explain this, including the location of the heat burning appliance. Most often CO levels will be highest closest to the appliance. Another factor may be that the rest of her family was sleeping in the upstairs bedrooms above the neutral zone where the air pressure was greater than atmospheric pressure while Jenna was sleeping in the basement below the neutral zone where the air pressure was below the atmospheric pressure. The backdraft bringing carbon monoxide into the area in levels high enough to have contributed to her death.

It is important to note that small damages to the heating venting and its connections can lead to the same type of dynamics in that carbon monoxide can be produced when the air going out exceeds the air coming in and combustion is compromised.  It is exacerbated if it occurs in combination with a home which is prone to negative backdrafts in addition.

What spoke to me about this particular news article is that the family had carbon monoxide detectors installed and they did not alarm to the danger. Not only to prevent the death of Jenna, but also to warn the family that they had been exposed to carbon monoxide. Though they did not suffer a lethal dose, one must question how the actual physics of air flow might affect the performance of detectors placed in the wrong location. We see combination smoke and carbon monoxide detectors placed in hallways outside upstairs bedrooms, typically on the ceiling. However that is not the only area they should be placed. Upstairs bedrooms are important because we presume that is where people are sleeping. Ironically, it may be the one place in the home where the atmospheric pressure is greater than the pressure outside.

We begin to understand why this might not be the only location they are needed. It seems a foregone conclusion that based on the stacking affect that precautions should be in place for the lowest areas of the home most at risk for negative air pressure.

Generally, CO alarms should be on every level and certainly on every level where there is a fuel burning appliance and of course on any level there is a fireplace. While rarely the cause of CO poisonings in the United States, they can be the cause, or as in this case, contribute to the cause.

I hope that Jenna’s death brings some awareness to the issue and perhaps that we see better information in the future about home safety. Our homes continue to become more efficient due to rising costs so understanding the dynamics of air flow is of utmost importance in the future.

Take aways:

Landlords Must Have Professional HVAC Maintenance

As important as all of these issues are in a residential single family home, landlords have these problems magnified. Almost all large apartment complexes try to do their own maintenance, with clearly unqualified people doing the work that should be done by licensed professionals. That is a recipe for a disaster, especially when apartments get to be older than the 20 year life expectancy of furnaces and other fuel burning appliances. Demand your landlords use professionals. Your life may be at stake.

This blog was written by Rebecca Martin.

Evidence Based Politics to Beat COVID

Only evidence based politics can save our democracy. In this replay of the Cold War between communism and the American idea of freedom, China won. China won because despite early mistakes, they tackled the greatest challenge of the 21st Century with evidence based medicine not politics. Today’s article in the New York Times delves into the how deep our COVID crisis still is:

There are a thousands stories to illustrate how long our COVID ordeal has been. The New York Times chose to tell the story of an ICU nurse from Oklahoma City, Lizanne Jennings. In the Spring, Oklahoma braced for a New York size onslaught, it didn’t come. In the summer, she went off to Texas to help.

In March, Ms. Jennings remembered sitting after work one day with her husband, Dennis Davis, a machinist and former bodybuilder.

“I need you to pay attention,” Ms. Jennings, 53, recalled telling him. “Look at me: People we know, people we love — our family, our friends — people are going to get this virus. And people we know are going to die.”

She returned to Oklahoma this fall, with many of her friends, in the deep red Oklahoma still not believing the virus was real. Last Friday, her mother, Linda Jennings, who had been infected with the coronavirus, died.

“I’m weary and I’m miserable,” she recalled her mother, who was 78, saying as she lay in a hospital bed. “I can’t do this anymore.”

Then on Monday, Ms. Jennings sat beside her husband, eight and a half months after warning him of the dangers of this frightening new virus. He was lying on his stomach in a hospital bed, hooked up to a machine that helps with breathing. He had been admitted 11 days earlier, she said, with a Covid-19 diagnosis.

“I love you so much,” Ms. Jennings remembered saying as she held his hand in the last hours before he died. “I said, ‘You’re going to go, OK? I’m letting you go. You’re going to be at peace.’”

I was angered by the needless march of this disease, touched by Ms. Jennings story. I live in a small Wisconsin town and her description of the denial of the public health threat is as true here as there.

I make my living challenging medical professionals, especially those who work for insurance companies who try to evade evidence based medicine, to claim that carbon monoxide does not cause permanent brain damage. Epidemiology is core to proving a carbon monoxide case. Thus, when COVID struck, I followed the science closely, from the safety of my conclave in rural Wisconsin. I have not spent a night away from home, or eaten in a restaurant since March 11, 2020. But most people don’t have the ability to work at home like I do. Most are forced to give up strict social distancing to survive.

Here is the comment I wrote to today’s New York Times story:

The epidemiological curve of this virus has been crystal clear since April, despite the White House Task Force misdirection. In March, there was an article in Lancet from Wuhan that said the virus could only be controlled with 85% mask compliance. It waxes and wanes, depending how scared people get, but there was no chance to defeat it without comprehensive tracing, which was never really attempted.

It could have been worse, the number could be two to four million. It still could get to be a New York level in South Florida, although, when fear kicks in, the numbers drop.

It has been said countless times, but history must record it. Had the Trump administration acted in February, the death toll could have been low five figures. If Trump had modeled a mask, it would not have ever gotten to the 50,000 he promised in April would be good news.

This has been political genocide. All these deaths because of one man’s ego, one man’s calculation as to how to save a failed presidency.

This is his biggest crime. Yet, I am not even sure he was held accountable for it at the polls. He got more than 70 million votes. I think his mask stance may have helped him.

Somehow, to save our society, our great democracy, we must find a way to get real news, real facts to that other 48% who don’t read newspapers.

Thank you New York Times.

Only evidence based politics can save us. My first degree was in journalism and there was a time where the writing for the New York Times might have been the pinnacle achievement for me. The newspapers of our country may be the only thing that stands between us and a failed country. Unfortunately, a large segment of our country, far larger than I would have believed until Election Day, doesn’t get news as part of its daily information intake. In Journalism school at Northwestern University, objectivity was our creed. Only in newspapers does that continue to be the standard.

My comment references a March paper in Lancet that mandate that an 85% Mask compliance was necessary to defeat the virus.

What is Required to Prevent a Second Major Outbreak of the Novel Coronavirus COVID-19 Upon Lifting the Metropolitan-Wide Quarantine of Wuhan City, China: A Mathematical Modelling Study. https://papers.ssrn.com/sol3/cf_dev/AbsByAuth.cfm?per_id=3257337

Here is what that paper, published on March 3o said:

Early quarantine lifting on 21st March is viable only if Wuhan residents sustain a high facial mask usage of ≥85% and a pre-quarantine level public contact rate. Delaying city resumption to mid/late April would relax the requirement of facial mask usage to ≥75% at the same contact rate.

Instead, the White House COVID Taskforce was talking about reopening by Easter and no one was wearing a mask. Much of April, Trump was bragging about keeping the fatalities as low as 50,000 instead of 250,000. I was so angry at the time I started to keep my own daily tally.

My April Warning

Here is what I posted on April 30, 2020:

As trial lawyers, our natural instinct is to distrust everything that comes out of the administrations mouth, even the hostage medical experts, Fauci and Birx. Our instincts appear to be substantiated by high quality medical research. As someone who has been watching what has happened in the NYC metro area from the safety of my wooded environment in central Wisconsin, I do apologize for any lack of empathy my take on the future might imply. I do not get what you guys are going through; I only know that it is coming here too.

A few of the facts that I have been focusing on.
The Curve: The curve is not flattening nationally. Despite a major drop in NYC area deaths, there were 2,612 reported deaths yesterday. With the exception of two days when NYC reported a bunch of deaths that were outside of hospitals, this is one of our worst days yet.
The curve so to speak, is a matter of the density of the populated places it gets inside of the fastest (not necessarily the hardest.) It is easy to say if you live in west Texas or central Wisconsin that this is a big city problem and as long as you can avoid density, it may avoid you. But even in small town American, we have dense places like meat processing plants, prison, and yes schools. And yes, we have nursing homes too. We have a nursing home in Berlin, Wisconsin and a pretty good small hospital. Once COVID gets inside that nursing home, it will overwhelm that hospital in days. But why would we worry. We aren’t a big city, how would it get its start here? Two cases in our County so far, wait now it is two. Yet Brown County, Wisconsin is small town America, too, except they have meat processing plants, which is why they call them the Green Bay Packers. Now a 1,000 cases from the meat processing plants.

Mortality. Fauci moved the goal posts again this week, before the last two days of 2,000 plus deaths to 80,000. For the first time I heard him say that the issue might not be a second wave in the fall, but that the virus will have never left. On Tuesday:  “In my mind, it’s inevitable that we will have a return of the virus, or maybe even that it never went away.” Keep in mind that Sunday’s reported deaths were 1,378 and Saturdays 1,126. Below is a chart which shows the daily deaths reported by Johns Hopkins.

Evidence based politics must look at hard science rather than political considerations in managing epidemics, climate, hunger.

The modeling out of the University of Washington where these numbers the Trump folks are relying on come from has almost nothing to do with medical science but would more accurately be categorized as “analytics,” ala the sports analogy. https://jamanetwork.com/journals/jama/fullarticle/2764824?
What is the true case fatality rate (“CFR”)? All of the projections have been based on the Wuhan data. Yet, the CFR in Europe is far higher. While the deaths per positive case number ratio is clearly too high to predict a CFR, by how much is it really too high? (On one hand not everyone who had the disease died, on the other hand not everyone who died has been counted.) When an epidemic is as mature as it is in Italy and Spain, it may a meaningful relationship. Currently Spain has 24,543 deaths out of 239,000 infections. Italy has 27,682 out of 203,000 cases. France and the UK are even worse. In contrast, China, where all the projections are coming from had 4,637 out of 84,000 cases (if you trust the Chinese reporting.) I have been looking and I haven’t seen anything that has revised the CFR against the European mortality figures.
Treatment. While progress for treatment and a vaccine are the only hopes, these two articles from Lancet should provide some perspective.
Morbidity – Brain Damage. Another thing that is missing is in this reopen the economy is calculus of the disability that may occur in those who survive this. Brain damage is a real possibility. Hypoxia of this level can kill brain cells, but perhaps more dangerous is the inflammatory/immunological response, like you might get in a carbon monoxide poisoning or other hypoxic event. It may be years before we figure that out and young people don’t appear to be immune from catastrophic events like strokes.
The Facts and the Science Matter. What is my point? The facts matter as we look towards the next few months. Stay home, maintain every possible social distancing measure you can. It may be a long time before we can safely impanel a jury.
I wasn’t prescient. I was wrong about some things. The death rate, the CFR, has been less than I anticipated. The slower but methodical pace of the spread to all 50 states has not yet created the need to triage cases where some who couldn’t get treatment might have lived. We have gotten better at treating the sickest, which might change if our hospitals get overwhelmed. But I wasn’t wrong about the threat, and I wasn’t wrong about the cost. Next year the studies on brain damage will start to surface.
The April 2020 White House projections were flawed because they relied on confirmation bias, not epidemiology.  From the JAMA article referenced above:
For instance, the predictions assumed similar effects from social distancing as were observed elsewhere in the world (particularly in Hubei, China), which is likely optimistic.
Those words were published on April 16, 2020. Armed protestors invaded the Michigan State Capitol, demanding an end COVID precautions on May 1, 2020. https://www.bbc.com/news/world-us-canada-52496514  Trump tweeted his approval.
Trump never modeled a mask. Until the COVID scare was staring my neighbors in the face, they didn’t either. Yes, there will be a vaccine. Jury trials will some day resume. We may not get to 1,000,000 deaths in the U.S. before that. But the difference between the deaths here and in China has a been a political genocide, all for one man’s ego.
If we don’t insist on evidence based politics–use our collective creative capacity to penetrate the sphere of Trumpism with facts–it won’t just be a COVID genocide, the cost will be the United States of America. The only way to Make America Great Again, is to insist on facts and evidence in our marketplace of ideas.

Attorney Gordon Johnson, BS-Journalism, Northwestern University-1975.

Long-term Problems Not Tied to the Dose of Carbon Monoxide

The dose of carbon monoxide in the blood, does not predict long term outcome once CO gets to a level where symptoms occur – 15% COHb. In the context of medicine/toxicology, the issue of how much of a toxin the body ingests, is often thought key to outcome. We often hear the term, severe carbon monoxide poisoning, used to classify those at the most risk for permanent damage from carbon monoxide exposure. However studies indicate that there is little difference in the possibility of permanent damage and ultimately deficits in the classic definitions of mild versus severe carbon monoxide poisoning. In fact, a COHb level of 15% is sufficient to result in permanent damage and deficits caused by triggering the immunological and inflammatory processes of the body. This can lead to permanent damage of the brain, heart or organs. The sequelae of carbon monoxide poisoning can typically arise two to 21 days after exposure, and up to five or six weeks after exposure. In some cases long term problems will not be recognized until a significant change is observed in functioning. Though we can, with certainty, predict the significant potential for long term problems due to carbon monoxide poisoning and that those deficits may be permanent regardless of the amount of exposure.

Carbon monoxide exposure can absolutely become lethal, but let us examine the symptomatology of carbon monoxide poisoning as experienced at the scene, during emergency treatment and post-exposure.

Dose of Carbon Monoxide ­- Symptoms Imperfect Correlation

One of the very first symptoms of carbon monoxide poisoning is a headache resembling a tension headache. Other initial symptoms are often difficult to differentiate from the flu. In the instance where more than one person is affected, food poisoning is often mistakenly suspected. Even though carbon monoxide poisoning can present with flu-like symptoms such as headache, muscle ache, stomach pain, nausea, vomiting, dizziness, shortness of breath, fatigue and confusion, there is a major difference between the flu and carbon monoxide poisoning: Carbon monoxide poisoning is not accompanied by a fever.

In the event these initial symptoms are mistaken to be due to flu or food poisoning and the affected person or persons remain in the contaminated environment, symptoms can quickly escalate and lead to more serious issues. The person might enter a mental state and show personality changes similar to intoxication. Dizziness will escalate to vertigo and the feeling the room is spinning. There can be ataxia, a disconnect between the brain and nervous system. Breathlessness and an accelerated heartbeat, tachycardia, may occur and even lead to angina or a heart attack. One might experience seizures as the brain experiences bursts of electrical activity. Ultimately unconsciousness and death may occur.

The onset of symptoms may be gradual or rapid. And because carbon monoxide poisoning can affect judgment, the escalation of symptoms may make it extremely difficult for the victim to assess the danger or seek help.

Other neurological symptoms might include loss of vision, or hearing, speech and language problems and memory/attention problems as well as a general slowdown of mental functioning and increasing confusion and disorientation.

How do we know we are experiencing the initial symptoms of carbon monoxide poisoning? First and foremost, if you suspect that carbon monoxide poisoning could possibly be the cause of symptoms, evacuating the area is the most important way to verify concerns. Don’t do the common sense thing of airing out a place you suspect of having carbon monoxide leak. Get out. The flu and food poisoning will not lessen when evacuating the area. In the time it takes you to air out the premises, you may pass out. You don’t know how much CO is in the air. It could be deadly levels. Do not reenter until emergency services have told you it is safe. Call 911. Do not try to self-diagnose. Leaving the environment is not the only treatment that may be needed and blood work will be needed to determine the levels of carbon monoxide and whether oxygen treatment is indicated.

There are other clues to whether or not the symptoms you are experiencing are from carbon monoxide exposure. If other people in the area are also experiencing similar symptoms that is the red flag that carbon monoxide is the culprit. Pets can be affected as well so pets may also be experiencing the same symptoms. In fact, pets are more susceptible and the smaller the pet, the more susceptible it is. A healthy pet’s sudden unexpected death can be a huge warning sign.

In our experience of the most deadly of CO cases, the pets are the canary in the coal mine. It is not just that they get sick quicker, because of smaller body weight and faster respiration rates. It is when CO levels (as opposed to dose of carbon monoxide[1]) get to the highest levels, they are often accompanied by unburned hydrocarbons, which a dog may in fact smell. If you are feeling ill and your dog is highly agitated, get out.

Winter is Worst Carbon Monoxide Season

Time of year is an issue as well as the majority of home carbon monoxide poisonings occur in the winter, especially when furnaces are first turned on. And there may be physical clues as well such as pilot lights which frequently blow out or yellow instead of blue flames coming from gas appliances. The message is, if you suspect that it might be an issue, take action to rule it out before it becomes lethal. And the first step is evacuation.

Pulse CO-oximeter by Masimo

While Dose of carbon monoxide doesn’t predict long term symptoms, determining that poisoning occurred is important. One under used but useful tool to do so is this, Rad 57 finger tip carboxyhemoglobin saturation monitor with pulse c0-oximetry. This pulse CO-oximeter is manufactured by Masimo. Photo ©James Heilman, MD.  https://commons.wikimedia.org/w/index.php?curid=8838592 

It is extremely important to seek out medical care if exposure is suspected. A blood test is the most accurate way to determine the level of carbon monoxide in the blood, but finger probes, called pulse co-oximeters, are also diagnostic. These are similar to the pulse oximeters that are used to measure oxygen in the blood. The pulse co-oximeters also measures CO.

Even in cases where it is suspected that a low level of carbon monoxide may be present, exposure over time can still cause permanent health issues and at the very least one should consult a doctor for further testing. Keep in mind that even what emergency personnel deem to be mild exposure can have permanent consequences. In this case, the home or workplace must still be inspected to determine whether it is safe to return or if there is an ongoing problem.

There is also the issue of the accuracy of blood testing. By the time you reach emergency care, the levels may have fallen and testing becomes inaccurate. This is why sometimes the pulse co-oximeters provide the most diagnostic COHb measurement. This is especially true of children. Children breathe faster than adults and their levels may drop quickly even though initial damage has occurred. And there may also be delays as children are not as cooperative with the blood testing procedure which creates further delays in discerning the level of carbon monoxide which may have been present.

In cases of CO exposure one might experience many of the symptoms of carbon monoxide poisoning which can combine to produce brain impairment, cardiac conditions, or organ damage or a combination of all of these and result in long term problems. These include neuropsychiatric issues which may result in a long term inability to concentrate or function at a pre-exposure level. In children, the full extent of these neuropsychiatric issues may not be determined because of the developmental level at time of exposure. These issues may not surface until future developmental milestones in brain development are reached, such as puberty. As the dose of carbon monoxide is far less predictive of brain damage than most medical personnel think, the underdiagnosis of permanent problems in those whose testing shows COHb levels around 10% or below, is legion.

A family may not see the patterns of neuropsychiatric  malfunctions until a child returns to school where their performance may show negative changes. A teacher may complain of the child’s inability to concentrate or a drop in grades. An adult may not be aware until returning to work and finding that focus, concentration or memory become not only impaired but also find that routine tasks are resulting in frustration and fatigue which can become debilitating. All of these ongoing symptoms can lead to other psychiatric issues as well as school or job performances spiral lower. Depression and anxiety may result.

Scientists have recently determined that not only is the ability of the blood to carry oxygen impaired during carbon monoxide poisonings but also the cells of the organs the blood is being delivered too. This can result in changes in the heart, brain or organs which makes their cells less receptive to receiving and utilizing oxygen in an efficient way. This can create a cycle of functioning that is virtually defeating the body’s ability to heal and return to normal functioning. This inability to absorb oxygen becomes a permanent dysfunction which can in turn cause other issues.

One of these issues is inflammation which occurs as a result of continuing damage caused by cells which are no longer functioning at a pre-exposure level. The body attempts to correct the damage by throwing more oxygen at the damaged areas. However the human body requires a mix of gases to function and break down the oxygen it is receiving. It does this by using carbon dioxide to help break down the oxygen for use. The body malfunctions and creates inflammation which ultimately causes more damage. The body then attempts to correct his and the result is a loop of damage which may arise weeks after the exposure.

We know that carbon monoxide attaches to the hemoglobin more readily than oxygen. But we are now learning that the components of hemoglobin itself react in different ways and ongoing studies are determining what impact each of the components of hemoglobin may be impacting the cells they come in contact with.

One of the possible outcomes of carbon monoxide is the development of Parkinsonism. This is a clinical syndrome which is characterized by tremors, rigidity, postural instability and slowness of movement or bradykinesia. A 2015 study, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4602584/ showed a significant connection between carbon monoxide poisoning and Parkinsonism. Additional studies have found correlations between the onset of dementia and former carbon monoxide poisonings.

As we continue to delve into the functions of the human body we are finding long term health issues that may persist beyond weeks and into years after the exposure. particularly as relates to the functioning of the brain and nervous system. And just as our exploration into the long term effects of brain injury, we see more and more connections between compromised brain function and carbon monoxide poisoning.

Disability in those Who Survive

Carbon monoxide may be invisible but it impacts the human body in ways that we are constantly discovering as new scientific research is done.

We are entering another winter season when carbon monoxide injuries and fatalities tend to rise. We also looking at another possible Covid 19 lockdown and spending more time at home or in enclosed spaces.  This is a time for absolute awareness that carbon monoxide is deadly and at best can result in other health issues. And it is preventable on every level. Whether it be that vacation hotel trip, or a hunting weekend at a cabin, or just time spent at home with family–awareness to the danger of carbon monoxide poisoning and a familiarity with potential symptoms could save countless lives. Know the symptoms and be cautious when discounting symptoms as just the flu, or just a bout of food poisoning. Better safe than sorry were words written to particularly suit carbon monoxide awareness. If in doubt, evacuate immediately, seek care, and do not return until the area has been inspected for safety.

Make sure you have a functioning carbon monoxide alarm, everywhere that you are indoors. Having an outdated alarm on the ceiling or one that doesn’t have batteries that work, won’t help. Our advice: get a new combination smoke/CO alarm, one with a sealed, ten year batteries.

Becca Martin authored this blog

[1] When we are talking about dose of carbon monoxide we are talking about the concentration in the blood, not in the ambient air. How high the dose of carbon monoxide becomes will be dependent on how high the ambient air level is, how much of the CO a person (or pet) breaths. The faster the mammal breaths, the faster the dose of carbon monoxide will climb.

Preexisting Conditions Protections- More than an Election Catch Phrase

Finally in 2014, preexisting condition protections came into effect in the Affordable Care Act (ACA) by prohibiting the insurance market from denial of coverage or benefits based on a patient’s previous health history. This move has been a major issue within the current administration and a contested issue in the 2020 election.

The ACA is commonly referred to as Obamacare, even though Obama didn’t take an active role in drafting it. Most of the what is in it (and potential pitfalls) are the result of an intense process of political compromise that took up much of Obama’s first two years in office.

Preexisting Conditions Protections is one big issue as we look towards the next presidential term

Preserving Preexisting Conditions Protections is one of the most critical issues at stake in 2020 election. Obama Care was on the ballot.

According to the Kaiser Family Foundation, it is estimated that at least 53.8 million adults under the age of 65 have a preexisting condition that would make them uninsurable. That is 27% of non-elderly adults who need reexisting condition protections.  Other studies have found those numbers to be much higher with roughly half of those numbers not enrolled in public assistance. The Department of Health and Human Services puts the number at 51%, around 133 million people.

Preexisting Condition Protections is Core to Obamacare

Prior to the ACA ruling, insurance companies could deny coverage to the part of the population. They could charge higher rates depending on the preexisting condition. This would be similar to charging higher auto insurance rates to those with a history of tickets or auto wrecks. Insurance companies are essentially gambling that they won’t have to pay. The gamble only pays off if what is paid in claims, is less than what is collected. But rather than insuring everyone and charging a fair premium for that, insurance companies historically only insured the healthiest, or those who were in group plans. Prior to Obama Care, insurance companies could write coverage which excluded at risk health conditions for an individual or even body parts from coverage. The ACA required that patients with preexisting conditions would receive the same access to health care and insurance with adequate and affordable premiums. In order to accommodate this new coverage, certain portions of public health care were increased via subsidies for the middle class, including Medicaid expansion for lower income individuals and families in order to extend coverage for health care under the new act.

This law also provided a cap for out of pocket expenses and banned annual and lifetime caps for treatment, as well as providing for basic health care for other policy owners such as annual check-ups, etc. A treatment cap is a provision that provides that when the lifetime cap is reached (say $1 million) then the insurance company doesn’t have to pay any more for that individual or family. Of course, any family that has reached its lifetime cap with one insurance company wouldn’t be able to get insurance coverage with any other insurance company.

This has traditionally only been an issue in the private insurance industry and never part of Medicaid or Medicare which are defined by their commitment to adults with preexisting conditions except when supplemental policies are in place which specific caps to annual or lifetime coverage. Both Medicare and Medicaid expanded in order to meet the needs of those specifically in need of long term care such as renal patients in need of dialysis or breast cancer patients who typically have longer terms of care.

Medicare is the federal medical insurance program for those over 65 who have worked. Medicaid is the federal income program for those people with insufficient resources, regardless of age.

By placing a ban on insurance companies in regards to preexisting conditions people with preexisting conditions were able to experience health care coverage which was not motivated by insurance companies competitively attracting only the healthiest in order to reduce their costs. In a highly suspect PR campaign, insurance companies brag about lowering rates without the ACA. But they are only lowering quoting insurance policies where based on them being able to take on only the healthiest in the population and offer them the cheapest rates. These rates are driven by competition between insurance companies for these low risk clientele which indeed leads to lower insurance rates, but only amongst the lowest risk Americans.

By providing government subsidies and incentives to insurance companies we are able to do what regulations have not done which is to even out the price of policies if at a higher rate than would be seen prior to the ACA ruling. In essence, only the healthiest are paying more than they might have, while those with any health concerns are paying a fairer rate.

This does not end with just health status. Insurance companies were also able to examine many other aspects of the lives of those they were considering for insurance. They could look at age, gender, occupation, and lifestyle in order to limit their clientele to only the lowest risk categories. This also allowed for insurance companies to sign on new customers with rates quoted at one level but with renewals which could bring rate increases and screening to make sure medical histories were indicative of low risk clients. For customers this put them at risk of denial of renewal due to health issues which would move them closer to or into the column of preexisting conditions. Acceptance for insurance would be a year to year commitment based on age, gender, health, occupation and lifestyle as well as other demographics. These demographics could expand into environmental and geographical concerns and something that was not even considered at the time: issues arising from Covid 19.

What we have seen in the past is that certain chronic health conditions, such as allergies or depression could also be considered as exclusions or reasons for denial in an industry vying for the healthiest among us. Any type of ongoing health condition would be a black-mark for acceptance or continuing coverage. This translates to a catch 22 in which, aside from basic medical care such as annual exams, almost any reason one might visit a doctor regularly would eventually disqualify you from coverage. This presents a dilemma to the consumer in which actually relying on your insurance coverage makes it more likely to lose coverage.

In the past this created huge uncertainty because conditions which arose while under insurance coverage could be examined and be denied coverage. They could ultimately deny coverage of common conditions such as maternity care or mental health issues. And refuse coverage of long term prescriptions.

Current Election Impacts Preexisting Condition Protections

The current election is a big decider in where we go from here. The Democrats propose expanding public coverage programs and perhaps going to a single payer program or other buy-in options to subsidize a standard of care for those with preexisting conditions.

Americans repeatedly have leaned in the direction of preserving protections for preexisting conditions and President Trump has falsely claimed to be for preserving these protections. But the GOP has introduced several proposals which would eliminate these protections for Americans and ultimately leave elderly Americans with higher insurance rates without the needed subsidies to cover an escalation of costs year to year.

It is wise to consider the ramifications of changes in the existing protections because they do not impact individuals in particular. For example, the concern is not limited to the breast cancer patient who is denied coverage and forced to seek a high risk policy as a result. The concern is that insurance companies will institute a general cap on what they will pay for anyone who might get breast cancer in the future amongst all their clients, literally guaranteeing that regardless of the fact that you believe you are insured for that possibility, you may be very disappointed to discover that a current insurance policy has no intention of paying if you become ill. This has been a practice in the past. It then becomes almost a case of one paying premiums for general health checkups in order to determine if you are healthy enough to be worth insuring and not to determine if you might have a health issue. That is not what we think of when paying an insurance bill.

Lifetime Caps another Trap

Lifetime caps for coverage are also a very emotional and heated topic. A child born with a heart defect requiring future surgeries might reach the cap for coverage before ever leaving the hospital. This forces otherwise self-sufficient and productive families to virtually change their financial status to qualify for assistance. The same holds true for cancer patients who often require years of followup and in particular those who may require ongoing maintenance chemotherapy or drug therapy even in the presence of high risk policies.

Accessibility to adequate care also brings up the question of what is adequate care? Is it access to only traditional and basic modes of treatment or does it include access to new and costly drugs or treatment? For example, this issue arose in several countries with the introduction of the drug, Herceptin, which is prescribed for HER2+ breast cancer patients to inhibit overactive cell receptors and prevent the spread of cancer cells. When it was introduced to the public, it was immediately touted as highly successful in raising survival rates. But with a global price tag of around $70,000 for a course of treatment, it set off lawsuits against insurers who declined coverage. This extended in the public health systems in countries like Canada who were basically forced to cover the costs of the drug. However, those countries with public health care were able to, in some cases, negotiate slightly lower costs as it was in the best interests to do so. The argument that public health care must provide accessibility is an undeniable legal argument which is a hard one to make when accessibility is not guaranteed in the private sector.

And while we examine the aspects of medical care itself there are other issues which are impacted by removal of protections for preexisting conditions. Employment is a huge concern when employers are providing health care coverage options. In order to participate in group options and employer might look at policies which limit certain types of coverage in order to reduce their costs. As a result they might reconsider hiring in the face of certain health conditions. For example when faced with a choice between an HIV positive individual or a healthy one they might choose against the HIV positive person. So far the language in proposed revisions do not provide enough specific explanation of how the limitations placed on individual coverage might impact all of those covered in a group plan. That limit place on an HIV positive individual might be construed to also apply to a cancer patient or other types of health issues.

We have also seen an entirely new scenario with Covid-19 in that 30 million Americans reported coverage gaps in their insurance due to job loss due to the initial stages of lockdown. Proposed alternatives to the existing system would not protect those temporarily losing coverage and would create obstacles to them finding alternative coverage when returning to work.

The GOP talks about preexisting condition protections but thinks  high-risk pools to subsidize those with preexisting conditions is the answer. But that is a situation we have never seen work effectively in this country as it has been chronically underfunded and inadequate.

At stake on this Election Day for almost half of Americans and their accessibility to adequate and affordable health care. We can see from the mildest examples such as allergies to life threatening conditions, the impact is indeterminable in its magnitude and ramifications. It affects so many aspects of American life from quality of life, to employment to individual and family pride in being part of a strong and productive workforce. This is a battle being fought in courts currently and continuously as the GOP attempts to dismantle what progress has been made in addressing the health concerns of those currently affected by preexisting conditions and those  who may be summarily shifted to that label in the future without recourse.

Why are we addressing the issue preexisting condition protections on a page about carbon monoxide poisoning? Because we are in the business of representing disabled people, primarily those with brain damage. It is hard enough to get care for the brain injured, but if preexisting conditions are another bar, the life disruption from brain damage will be that much worse.

This blog was written by Rebecca Martin

The Season for Chicago Carbon Monoxide

Chicago carbon monoxide poisonings increase in frequency as the cold is upon us. Daylight savings time is over, the nights are longer and colder. Thanksgiving is rapidly approaching. If you had not already done it, last week’s cold spell probably had you turning on your to heat. For many, winter will bring both an increased risk of carbon monoxide poisoning. Yet, the late fall is in many ways more risky than the dead of winter, because this is the time the heat systems are fired up for the first time. Further, people living in poverty have often had power turned off and they seek alternative methods of heat, all which come with more risk of CO poisoning. Power outages which accompany winter snowstorms, and the greater risk that venting sources might be blocked by snow.

Chicago carbon monoxide risks

Winter and Chicago carbon monoxide poisoning risks are correlated because furnaces run more, storms increase stress to exhaust systems and people use substandard methods for heat. 

Chicago Carbon Monoxide Risks linked to Snowstorms

A study by researchers from Hartford Hospital in Hartford Connecticut (American Journal of Preventative Medicine) found that cases of carbon monoxide poisonings rose following power outages and snowstorms. They also were able to determine that the number of cases of carbon monoxide poisoning during snowstorms were more prevalent within the first 24 hours of a snowstorm while those due to power loss rose the second or third day of the outage. This allowed the hospital to determine that different staffing and call schedules could be put in place depending not only on the outages expected, but the nature of the outage itself. This type of preparation saves lives.

During a snowstorm there is a greater risk of exposure Chicago carbon monoxide poisonings inside of vehicles. As a precaution one should always check the exhaust to make sure it is free of snow. If it is blocked it is not safe to sit in your car while it is running even if you have all the windows down. If you find yourself off the road in a snowdrift waiting for help to arrive…it is imperative to check the exhaust to make sure it is clear and is not backing up into the vehicle. Maybe you like to run out and start your car on snow days to get a head start on scraping the ice. Take a minute to make sure the exhaust is clear as well because 10 minutes later you don’t want to be jumping into a car that has been filling with backed up fumes. Many people assume that rolling the window down a bit is all that is needed and that can be a deadly assumption if the exhaust is not clear. It is also very important to address exhaust warnings in vehicles. The winter brings more opportunities to damage exhaust systems directly or indirectly, leading to more Chicago carbon monoxide poisonings.

The same principle holds true for home heating exhaust. A major snowstorm can create blockages of home furnace venting systems and be just as deadly as using an improperly vented generator in the home. Snowstorms often make for a more closed in environment in your home so checking vents is a good habit in the winter. Our homes have become more and more airtight historically which creates its own problem.

Chicago Carbon Monoxide Poisonings from Generators

Another factor is home generator poisonings which is common globally and increasing in the United States. Generator poisonings are often making the news, but those news events tend to track hurricanes, where large areas of power is knocked out by high winds. One isn’t well understood is that portable electric generators are also deadly when used to replace the electricity when the utility company has turned off the electricity.  You may be under the impression that it is illegal for utility companies to shut off utilities at those times when people are most at risk; during extreme heat or extreme cold, but the laws vary from state to state.

We have blogged on the risk factors of portable electric generators repeatedly. See https://carbonmonoxide.com/2017/06/generator-carbon-monoxide-events.html

Although the majority of states have some sort of law in place during the coldest months of the year, some require some sort of contract specifying a payment plan or have these options only open to certain groups of people, the elderly, disabled and low income families. These laws cover longer spans in the north and shorter spans in the south. Some require documents from a treating doctor, some require a percentage of the bill be paid. There just is not a federal standard in place as our President had insisted at the beginning of the pandemic.  In fact, during the pandemic,  many states implemented bans on the shut off of utilities especially due to the heat waves this summer but those restrictions are now being lifted as the weather begins to get cold again and most ended in September. House Democrats passed a relief bill in May that was not included in the Senate GOP proposal.

Portable Electric Generators Can be Hazards in Winter

The issue of Chicago carbon monoxide poisonings hit the news last week with two people severely poisoned on the South Side. The two adults who were the victims of carbon monoxide poisoning in their home this past week. The home was being powered by a generator to supply electricity.  A family pet was also found deceased on the scene. Though Illinois had voted to extend Covid relief in regards to utility shut offs until the state was reopened or until September 1, whichever came first, this doesn’t necessarily mean it is possible for families in need to get necessary help when the temperatures plunge again. I find this highly wishy washy on the entire governments’ part as on one hand, at risk individuals are still living in a continuing lock down state, others are proceeding back to work and activities and essentially emergency provisions are being forgotten, and the news is turning to regional upsurges in Covid cases as a result of reopening. A highly vulnerable place for the elderly and disabled to be in to make ends meet. And those in charge assuming that one can’t get their utilities turned off if it might be dangerous for their health.

Utility Disconnections Can Cause Poisonings

The United States CPSC has been worried about this very issue of utility disconnection related poisonings since it began the rule making process to regulate the amount of carbon monoxide emissions from portable electric generators. Prior to the beginning of the Trump administration, that Rule was poised to go into effect, but it was sidetracked by a shift in politics. Generators are one of the single most deadly products manufactured in the United States, accounting for nearly a 1,000 deaths in a ten-year period.

Attorney Gordon Johnson testified at one of the hearings for this Proposed Rule in 2017. At the time, it was thought this regulation would soon be implemented. It didn’t happen. I warned at that time that it wasn’t just the number of deaths from these poisonings but all of the survivors who were left with brain damage. The economic cost to our country of tens of thousands of survivors with brain damage is staggering.

We have witnessed surges in carbon monoxide poisonings after storms like Hurricane Laura where half the deaths in Calcasieu Parish were due to carbon monoxide poisoning and not from the storm itself. The deaths in question were caused by a generator placed in an attached garage with the door to the home left partially open. Generators are not the only cause of poisoning in storm related deaths. Kerosene lanterns, propane powered devices and grilling indoors have also proved lethal under the right circumstances.

But how do we address the danger to people when they have no alternative for life saving heat? That basically puts us into the same position as many third world countries where the burning of various fuels has been one of the leading causes death n and certainly the leading cause of poisoning. Research done by the charity National Energy Action (NEA) in the UK showed a definitive link between poverty and CO poisoning with  33% of the homes they monitored  showing levels greater than 10ppm, enough to create health concerns. One of the causes was just the general state of any fuel burning devices as those with less money were unable to perform necessary maintenance and repairs or replacement. Another reason was that some homes were using the stove to heat the house, which as I mentioned earlier can lead to a buildup beyond the specifications the stove was intended for.

We have to focus some blame on those housing developments in poorer areas which do not meet a proper level of maintenance and repair. HUD does not require carbon monoxide detectors. And so we see incidents like that in Columbia, SC in 2019 where two people died and inspectors found high levels of carbon monoxide inside all 26 buildings in the development as well as numerous other health infractions. There have been 11 deaths from carbon monoxide poisoning in HUD housing since 2003. HUD recommends that detectors be used but there are no requirements for them to be in place for those running these developments. Some states are stepping up, such as Maryland, to require detectors in all new construction in 2007 and in 2018 voted to require detectors in all rental properties. But federal carbon monoxide standards are lowest for public housing. Standards are somewhat stricter for properties subsidized by HUD as a 2016 housing law was passed by Congress to require that detectors “where required” be operational. But this language is vague as it does not specify where the detectors are required.

CO Poisonings from Ovens

In the average home with a gas range, studies found that 51% of kitchen ranges raised CO levels in the home above the EPA standard. This is especially problematic if gas ranges are left on to give a source of heat. Thus, continued use inside an isolated home can quickly send that number to unacceptable levels. Whenever we introduce any fuel burning device into our homes we have to remember that that innocent looking range has certain capabilities to impact our health and it is regulated. Whatever we introduce haphazardly into that environment is something to be treated with the utmost respect for its ability to turn into a lethal device and sometimes too quickly for us to react to what is happening. We hear about periodic preventative maintenance on our furnaces. The need to replace filters and clean burners. When was the last time you had your oven serviced?

Perfect Storm for CO is Coming

We have really entered a somewhat unique situation as we approach winter 2020-2021. We have a pandemic which is impacting the economy and we have a government which has left many decisions regarding the most vulnerable up to the individual states. And we have seen some weather extremes over the summer with record breaking heat. What will winter hold for us? Whether we face carbon monoxide hazards through storms and power outages or whether we face unexpected financial hardships in the midst of extreme temperatures…will we be able to get the message and resources to the public that are needed to save lives? Or is this an area in need of a mobilized public to provide the education and hopefully detectors to anyone who is vulnerable? This is a great year to add carbon monoxide detectors to your must have survival gear for winter storms and perhaps an item for some gift lists.

I hope that an awareness of the dangers of carbon monoxide make everyone take pause when seeing a story of a family affected regardless of the surrounding circumstances. Because time and again we are seeing illnesses and deaths that were so easily preventable. The dialogue needs to be going to educate everyone and drive home the fact that if it burns fuel, it requires proper installation, proper care and maintenance,  and proper use.

Rebecca Martin contributed to this blog.

 

 

 

Carbon Monoxide Physiology – In Words and Pictures

To being our topic of carbon monoxide physiology, we must go back to Claude Bernard, a 17th century physiologist who first discovered the affinity of carbon monoxide for hemoglobin and the mechanics of the toxicology which results. With coal coming into the picture as a primary source of fuel and the invention of the internal combustion engine the science of health turned its attention to the effects on the population. Seventy-five years after Bernard’s initial findings, Warberg used yeast cultures to prove that not only did carbon monoxide inhibit the transport of oxygen via the hemoglobin but it also inhibited the intake of oxygen by cells.

As carbon monoxide physiology was explored, it was quickly determined that not only did carbon monoxide have a far greater affinity to hemoglobin, it also was able to bond in a more perfect way than oxygen. This made carbon monoxide a deadly asphyxiant as it was able to quickly block the absorption of oxygen at high concentrations. By blocking the oxygen absorption of the cells, it was also able to cause tissue damage and a resulting inflammation  which could have long range effects. The great affinity of carbon monoxide for hemoglobin (210 times greater than oxygen) is only surpassed by its affinity to myoglobin. When carbon monoxide binds to cardiac myoglobin it can cause depression, hypotension and arrhythmias. This can result in further hypoxia and ultimately death.

The carbon monoxide bonds with the mitochondrial cytochrome which can lead to demyelination in the brain. One of the most understood areas of pathology associated with carbon monoxide poisoning is its effect on the basal ganglia because of their high oxygen consumption. Other common areas of impact are the white matter, hippocampus and cerebellum.

If a survivor has lesions or structural abnormalities in the basal ganglias, particularly the globus pallidus, then it is probable that the cause was carbon monoxide. Only a few other pathologies are on the differential diagnosis, and if there is CO poisoning and no other severe ischemic mechanism, then even the neuroradiologist may be able to conclusively link the MRI abnormality to the poisoning.

But keep in mind the difference between a finding being specific for carbon monoxide poisoning and the absence of that finding ruling out poisoning. See Hopkins, et. al. While almost everyone with basal ganglia abnormalities post CO exposure will be diagnosed with CO brain related brain damage, not everyone who has CO related brain damage has globus pallidus lesions. Even in severe poisoning cases, more than half of the survivors did not have basal ganglia lesions.

The basal ganglia are typically associated with movement but encompass other functions such as motor learning and movement choices which facilitate desired movements and movements which avoid adverse stimuli. It’s a complicated network which controls our ability to perform actions, or block actions. To simplify; you reach out to pick something up, you realize it’s a spider, you withdraw your hand…that is your basal ganglia at work.

Carbon Monoxide Physiology –  Basal Ganglia, Hippocampus and Amygdala

The noteworthy subcortical structures (beneath or inside the cerebral cortex) are the basal ganglia, the hippocampus and the amygdala.

The basal ganglia consist of the caudate, putamen, and globus pallidus. The basal ganglia cross into both the midbrain and to the subthalamic areas. The basal ganglia are closely interconnected with the cerebral cortex, thalamus, and brainstem, as well as several other core brain pathways. The basal ganglia contribute to control of voluntary movements, procedural learning, habit learning, eye movements, cognition, and emotion. It is the connection of the sensory pathways to the basal ganglia that makes them so central to so many functions. The basal ganglia are one of the central interchanges of the brain, as core to proper information traffic flow as the interchange between two major interstate highways.

The Putamen and Globus Pallidus Pathology

The putamen and the globus pallidus combine to make a structure that looks something like a lima bean. When the early anatomists dissected this part of the brain and looked at these two structures together, they decided it resembled a bean. These two structures stand out together on autopsy because they have more gray matter. Thus collectively, these two structures have been referred to as the lentil, for bean.

The figure below  shows the Lentil, consisting of the outer Putamen and the inner Globus Pallidus.

Carbon Monoxide Physiology

An understanding of the physiology of carbon monoxide poisoning should include an understanding of the limbic system.

The outer side of this lentil is the putamen and the inner side is the globus pallidus. Thus, in two-dimensional anatomy diagrams of the subcortical structures, the globus pallidus appears hidden, because it is on the inner side of the bean.

 

 

 

Limbic System

Two different views of the coronal view of the subcortical structures are shown. In the picture on the left, the Putamen obstructs the Globus Pallidus. The image on the right  has been sectioned so that the inner structure can be seen. The Globus Pallidus is a light purple, where the Putamen is dark purple, the Caudate is green and the Thalamus tan. The Globus Pallidus is a triangular structure seen on both the coronal and axial planes, sandwiched between the Brain Stem, the Thalamus, the Putamen and the Caudate.

Globus pallidus

The globus pallidus is shown by itself in a coronal view on the left and an axial view on the right. (The red line is the sectioning mark in the program.) The globus pallidus is triangular in both views.[2]

Shown below is the same globus pallidus lesion side by side in two different MRI views.  The coronal view is on the left and the axial view on the right. In viewing on either plane in MRI, look for this triangular shape of the Putamen and Globus Pallidus.

Globus pallidi lesions

Different views of the same lesion in the globus pallidus are shown on an MRI

While not everyone who has carbon monoxide related brain damage will have visible lesions on MRI in the globus pallidus, it is clear when lesions show up in here after a poisoning, that they were caused by carbon monoxide. The reasons that the differential diagnosis for globus pallidus lesions is almost always CO poisoning is multiple.

First, the exposure to CO poisoning has probably already been established from extrinsic facts, such as ambient CO levels or abnormal COHb levels. Second, the globus pallidus is fairly immune to most mechanical forces of trauma. It is buried deep within the brain protected from most contact phenomenon. Any rotational force that would impact the globus pallidus is likely to also impact the brain stem, resulting in significant coma or death. Further, the globus pallidus is an area of the brain that has constant information flow through it, meaning its need for blood flow is intense. Finally, the  globus pallidus is highly vulnerable to any pathology as the entire structure is too small to work around any pathology. Evolution buried the basil ganglia out of the way of clubs and falls for a reason.

White matter provides a communication relay between different areas of the brain. The hippocampus has a major role in learning and memory. The cerebellum has a big part in the planning and execution of movement. While this is a very simplified look at the functions of the parts of the brain that can be most affected by carbon monoxide, the overall picture is of diverse parts of the brain working in conjunction with each other.

Click here for a further treatment of brain damage from carbon monoxide poisoning.

There can be a difference in the effects of exposure to low concentrations over a period of time and exposure to high concentrations in a short period of time. In low-level-long -term exposure, the effects may seem to resolve as soon as the person is outside of the environment. exposure, the effects may seem to resolve as soon as the person is outside of the environment. Those with repetitive exposures, particularly where the repetitive exposures would have exceeded 10% COHb concentrations can have serious brain damage – that the repetitive brain trauma may have worse consequences than a single higher dose. This is likely due to similar phenomenon as makes multiple concussions in the same time period so disabling.

Generally, there is about a 40% risk of long-term brain damage. Thus, if you expose five people, two may have permanent brain damage. But if the same five people are exposed to a bad furnace for weeks, then it may be that everyone has brain damage.[2] These problems can include a greater vulnerability to higher levels of carbon monoxide.

Exposure to high concentrations of carbon monoxide can very become life threatening toxicity. In cases where portable electric generators are the source of the CO, victims often “drop where they stop.” Once consciousness is lost in such an event, death may quickly follow. This is due to its exceptionally high affinity for the hemoglobin, which not only blocks oxygen, it makes a more efficient attachment. Our oxygen absorption is a process designed to sustain life but far from perfect as we are unable to glean oxygen for survival in the carbon monoxide model. Asphyxiation and death results if we are not reintroduced to an oxygen rich environment.

In cases of death, it is usually as a result of cardiac arrest. The heart doesn’t have enough oxygen to keep beating. The body soon dies.

Carbon Monoxide Physiology – Oxygen Administration

The use of oxygen to treat carbon monoxide poisoning was first explored by Claude Bernard. Early research was limited by the lack of access to a source of usable oxygen to conduct studies. It is a line of research that continues today as scientists explore different forms of oxygenation and delve into the effects of carbon monoxide on the different components of the hemoglobin itself. As we delve deeper into the actual structure of hemoglobin we discover new explanations for how it works and the impact each component has on different functions of cells and tissues. We are able to look at the inflammatory issues in greater depth and their part in long-term damage as a result of carbon monoxide poisoning.

A key to understanding carbon monoxide physiology is understanding DNS which is largely caused by inflammation and other immune responses. Inflammation is the result of our own body perceiving a threat and fighting back. Often this results in our own body fighting the healthy recovery of damage in a misguided attempt to eradicate the threat. We see an excellent example of this with the Covid virus, where infected patients’ own bodies go into overdrive to eradicate the virus and cause severe consequences. The mechanics of inflammation in carbon monoxide poisoning can also cause damage which may not be apparent until a period of time has passed. When this is occurring at the cellular level the impact on different functions may range from mild to severe depending on the cells and tissue affected. In carbon monoxide poisoning we see injury to the neurologic and cardiac systems. Delayed neurological sequelae can appear 3 to 240 following severe exposure. While myocardial injuries increase the risk of death from heart failure up to three times the rate of the healthy population.

There are more areas of the body which can be affected by severe exposure, however. It can impact the kidneys leading to renal failure. It can affect the electrolyte and glucose levels. It can affect the blood lactate level. Blood traveling to sensitive organs can bring injury as tissues are damaged by lack of oxygen and consequently faulty oxygen. We function on oxygen with certain levels of other gases like carbon dioxide which increase the rate of our oxygenation and those levels are normally in a balance meant to increase efficiency. When those levels are not functioning properly, decreased efficiency is a result which can further exacerbate the breakdown.

[1] These pictures are created in a program called Freesurfer from an actual MRI. The color coding is done in the program.  The color coding here doesn’t have any special significance, other than distinguishing between this outer part and inner part of the lentil. These structures have complex networks the process and relay motor function, motor control and emotion.

[2] Understand of course that in any one family poisoning event, the statistical probabilities do not reach statistical significance, so that there may be no one with permanent brain damage or it could be one, two, three, four or five out of five with permanent brain damage. We have as many cases where people contact us after a poisoning and have a complete recovery as we do who need the remedy of a lawsuit to compensate for the long-term damage. The Brain Injury Law Group only undertakes litigation for those with permanent deficits and symptoms of CO poisoning.

Carbon Monoxide in Children Requires Expert Assessment

This week I want to cover a difficult subject that has been interwoven into many of our blogs; the impact of carbon monoxide poisoning in children. Children and those with medically compromised health are at greater risk for carbon monoxide poisoning. Children are specifically at greater risk due to their higher metabolism. According to the National Institute of Health, approximately 1600 children are hospitalized annually for carbon monoxide poisoning. 5000 children per year seek medical treatment of some type for carbon monoxide poisoning. As we have noted previously, those numbers could be higher as there are cases where carbon monoxide poisoning occurred but was not suspected. Carbon monoxide poisoning is the leading cause of poisoning in children in the United States as well as globally. Carbon monoxide is also the leading cause of death in fatal poisonings.

carbon monoxide in children is complicated

Assessing brain damage after carbon monoxide in children involves more complex assessment tools, from the ER all the way through adulthood.

There are many sources for carbon monoxide exposure which pose a risk to children. The most common cause is being exposed to a fuel-burning appliance like a furnace of boiler. And in many of those cases, improper maintenance, installation, use, or prevention can be found. Let’s focus on the dynamics of immediate inhalation of carbon monoxide gas, stage by stage.

In an earlier blog we had discussed the Boone Hotel incidents which claimed the lives of the elderly Jenkins couple and 11-year-old Jeffrey Williams. We had noted that in between the two incidents, the mothers of several girls attending a birthday party in the room above had gone to the hotel staff with concerns that the girls had fallen ill due to exposure to chemicals in the pool. The pool was examined and deemed safe and the girls’ symptoms were dismissed as possible food poisoning.  Because carbon monoxide symptoms (nausea, headaches, dizziness, vomiting) can be mistaken for many things including food poisoning, viral infection, etc., it is extremely vital when these types of symptoms present themselves that medical care is sought out and a thorough interview ensues. Was there a possibility for exposure? Were others, including adults, impacted? And if there is a valid concern that carbon monoxide poisoning has occurred, then proper testing and treatment must be done. Adherence to these protocols might have alerted officials to a problem at the Boone Hotel and averted the tragedy of Jeffrey’s death.

COHb Assessment Different after Carbon Monoxide in Children

Children have faster metabolisms and more immature nervous systems. Carbon monoxide binds to the hemoglobin in the blood with an affinity more than 200 times that of oxygen. The binding of oxygen to hemoglobin creates condition, creates carboxyhemoglobin (COHb). When COHb rich blood is delivered to tissue and cells, it takes the place of oxygen, potentially asphyxiating the cells. As a result, tissue hypoxia occurs. This hypoxia is most evident in those organs with high metabolic demands, such as the heart and brain. When the immune system senses this poison, it begins to fight back. Inflammation can then occur resulting in temporary or permanent damage to the nervous system. And in children, the true extent may not be assessed until puberty and beyond.

Diagnosing carbon monoxide poisoning in children on the day of the event is more complicated than with adults because the children re-oxygenate the blood faster than adults do. The reason they do so is that they breathe faster. Respiration rate is directly related to how quickly COHb is removed from the blood.

COHb Half Lives are Shorter

However, because of a child’s higher metabolism, the carbon monoxide in the blood may be reduced quickly after removal from the source of poisoning so blood tests may not detect the extent of the poisoning or potential damage when presenting at the emergency room. And also, due to the nature of children, getting a timely blood test done may factor into the diagnostic process. Children are not the most cooperative patients when needles are involved.

Think of respiration as opening a window to allow poison and then later fresh air in. During the poisoning event, the faster the respiration (the wider open the window) the faster the CO builds up in the blood. After the poisoning, the faster the respiration, the faster the CO gets out of the blood. Thus, if you test a family all expose to the same level of ambient CO in the air, at the moment of the peak CO concentration, the smaller the child, the higher that person’s level will be. In contrast, COHb blood measurements are always done hours after the survivors leave the poisonous air, sometimes several hours later. An adult’s COHb level will halve about every four to five hours (called a half-life.) Children may have half-lives,much shorter than that. The half-life of a child on oxygen may be under a half an hour.

We have seen a family where the adult levels taken two hours after the event were 15, the teenage girl 9, and her four-year-old sister 3. This is exactly what we would expect to see.

The most common symptoms which should arouse suspicion, but are not immediately conclusive, are nausea, vomiting, headache, fatigue, dyspnea (labored breathing), confusion, abdominal pain, visual changes, chest pain and ultimately, unconsciousness. Nausea and vomiting are the most frequently reported. Other symptoms can include, weakness or clumsiness, fast or irregular heartbeat, or loss of hearing. Severe cases present with a Glasgow Coma Scale (GCS) of below 8, altered mental state, unresponsiveness, cardiac arrest, respiratory failure and/or seizure. A GCS below 8 indicates severe injury and is based on scores for eye opening, verbal response and motor response.

The biggest clue to these non-specific symptoms being the result of poisoning is the timing of multiple people getting sick. Only an environmental exposure would explain multiple people getting sick simultaneously. While food poisoning is the other possibility, CO should be considered and if there is a fuel burning appliance as an explanation, 911 must be called. We have been involved in several mass poisoning events, where more than 100 people were poisoned at once. In each of those cases, it was when the second person passed out that the CO cause was suspected.

If your child exhibits any of these severe symptoms, and carbon monoxide is a potential risk, immediately remove your child to an area with fresh air and call 911. Always exit the premises before you call 911http://carbonmonoxide.com. If the poisoning levels are extreme, you might pass out before you finish the 911 call. We have had that happen too. Also never open the windows and doors and wait inside for EMT’s. Leave the premises unventilated and get out. A ventilated premises may misdirect the EMT’s from the CO diagnosis.

Brain Damage Behavioral Issues

Children are not just smaller adults and carbon monoxide can leave them with more complicated brain damage than adults. Further brain damage in children is not just a different category than brain damage than adults, but multiple different categories. Damage to the developing brain comes with infinitely more presentations than it does in mature people, as it directly impacts and can interfere with the maturation process. A fetus is horribly vulnerable. An infant may fall far behind benchmarks. A toddler may be impacted as they learn to walk or talk. A grade schooler will have additional challenges as the parts of their brain that are damaged may interfere with verbal learning. Fine motor coordination can impact not only school but play.

The most dynamic change may be in those transitional years between pre-teen and young adult. The frontal lobes are the part of the brain that evolve in those years, evolved because of the lessons and social interactions that become so challenging for all middle schoolers. Children learn to become adults in their frontal lobes and if the processes are disrupted, maturation set back. Mood and hormones are so challenging for all at this age. Add the burden of cognitive struggles and mood disorders can destroy relationships. I have often talked about the struggle for identity that comes after brain damage. When the identity is just being formed, that struggle is intensified.

Future Needs for Care

Often the biggest component to damages in a personal injury case are the economic damages that come with future care needs. Too many children with brain damage never develop the executive functioning skills where they can live independently. Getting along with their parents becomes so much more difficult but getting along without them may be impossible. What are executive functioning skills? I have written much about this over the decades of my web advocacy for brain damage, but essentially they are the skills that adults do differently than children. Adults need to self-regulate their behavior. Adults need to make plans. Adults need to initiate when to start a behavior, how to exercise it and how to complete it. So often, executive functioning involves a break down in that process.

Frontal lobe functioning also involves learning, memory and integration of new information into the collective individual maturation experience. Specific lesions to brain regions, can disrupt that. Interference with axonal development and communication can completely distort the process. The axons are the connections between different groups of neurons within the brain.

Most have heard stories of overt misbehavior after brain injury which can happen in those  first few months after brain injury. Yet, even when the violent tendencies fade, the anger, irritability and rapidly cycling moods make relationships difficult. But the omission aspects of behavioral changes are clearly a challenge for relationships as well. Without initiation, motivation, planning and follow through, the survivors life will lack any vitality and the caregiver may just give up having to interact with an adult as if they were an eight-year-old child.

The core of behavior begins in our frontal lobes, as this is where we learned to become adults. As we reach puberty, the frontal lobes are still growing. The frontal lobes still have “empty hard drive space” to absorb the complicated nuances of human interaction. They continue to change and evolve long after most of other cognitive abilities are largely set. We learn math and reading skills in early grade school yet getting along at work can be substantively different at 30 than at 20. There is certainly no question that the behavior of a 30-year-old lawyer is dynamically different than that of someone in their first year out of law school.

Frontal lobe injury can clearly manifest itself in the following symptoms:

  • Executive functioning disorders;
  • Delays or failures of complex processing;
  • Mood and emotional changes, otherwise called neurobehavioral changes;
  • Impulsivity
  • Decision making
  • Loss of Maturity and
  • Loss of insight;

This is not an exhaustive list. The frontal lobes make up largest portion of the brain and contain much of what makes humans different from other mammals. The frontal lobes are the “hard drives” for learning and behavioral memory storage. Focal injury to the frontal lobes can impact a wide variety of thought, memory and behavior. Further, damage to the white matter of the frontal lobes – the neuronal connective tissue underlying the outer layers of the cerebral cortex can have even comprehensive impact.

Never presume that a child has had a full recovery from brain damage because they are not exhibiting specific cognitive or emotional symptoms at a given age. Certain areas of the brain are not challenged before middle school years. So, what seems like a full recovery at 10, may seem very different at 13. Likewise, inability to transition into independence may not become apparent until 18-22. A child may grow to number one in his or high school class but have major compromises when expected to live independently of parents. Brain damage in children is a longitudinal process to assess.

But there is also a flip side to that. As the brain is still developing, brain plasticity, the process of getting a different part of the brain to take over tasks done by a damaged area has more chance in children than adults. The concern, however, is that plasticity can also work in negative ways and then brains internal organization may be thrown off.

So many carbon monoxide events involve children because homes and schools are often the place where the poisoning occurs. Children require a more careful acute examination and greater assessment of the brain damage that might have occurred.

Becca Martin contributed to this blog.

Hotel HVAC Maintenance Neglect is Systemic

Neglect in hotel HVAC maintenance happens because of inadequate training, lack of maintenance standards and thinly capitalized ownership. Over the past couple of months, we have blogged about two main topics, carbon monoxide poisoning in boating and carbon monoxide poisoning in hotels. This week we want to revisit the hotel topic with some insight into how large public businesses – that are in the business of providing a place for people to sleep – can do such a bad job of keeping people safe.

Hotel HVAC maintenance neglect starts with the franchising system. You see a brand name on a hotel, you automatically think you are going to stay at a hotel that is run with the same quality of standards that you associate with that chain. That is an appropriate expectation and what the large brands want you to think. But the reality can be completely different. While some brands have started to become more proactive in avoiding carbon monoxide poisonings, the majority are still hiding behind a fictional theory that they are only responsible for your reservation. Expectation: you stay at a Hilton, it is going to be up to Hilton standards. You stay at a Days Inn, it may not be quite as nice, but it will at least be comfortable and safe, because it is part of Wyndham.

To keep customer loyalty, all of these chains have their loyalty programs, much like the airlines. To reinforce the impression that it is all the same, franchisors make sure the signs are the same, the rooms are similar, the towels and the shampoo bottles are the same. Understand, that the franchisor can control any aspect of the local operation of the hotel that they desire. And to ensure that the local operator stick to the brand standards, the do inspections and the local operators have to pass the grade, at pain of losing the franchise.

No Hotel HVAC Maintenance University

If the national chain wanted to mandate CO alarms in every room they could. Since the Boone, North Carolina catastrophe, some of them have.  Yet, others are still hiding behind this fiction that it is only the reservation that they can control. Most of our experiences with franchises starts with McDonald’s. McDonald’s has something cleverly called Hamburger University. https://en.wikipedia.org/wiki/Hamburger_University

The theory of Hamburger University is that all management people who work at a McDonald’s, have to go to a specialized school where they learn how to properly run a McDonald’s franchise. Now running a hamburger restaurant is in many ways a lot easier than running a hotel. Yet, there is no Wyndham University, IHG University, etc.

Does your comfort level change about staying at a hotel if you were to learn that no one who actually worked at that hotel knew anything about managing or maintaining a hotel?

Assumptions about Hotel Maintenance

Let’s test your assumptions about Hotel HVAC Maintenance:

  • The manager/owner of the given hotel has been to hotel management school.
  • The manager/owner of the hotel understood what all of the equipment in the hotel was designed to do.
  • The manager/owner of the hotel understood about the dangers of carbon monoxide.
  • The manager/owner of the hotel had been trained in how to provide not just a clean, comfortable room, but one where the air that was breathed was free of poisonous gases.
  • That the hotel would have fully trained maintenance people on staff who understood all of the workings of the HVAC system.
  • That the hotel would have a maintenance contract with an HVAC firm, so that four times a year, they would do preventive maintenance on the HVAC equipment.
  • That the management of the hotel would have a budget and an obsolescence plan where all HVAC equipment, including smoke detectors and CO alarms are replaced when they got to the end of their useful life.
  • Hotel operators replace the batteries in smoke detectors every six months, or at least when they started to chirp, like we all should be doing at home.
  • That when there is a life-threatening condition, regardless of budgeting, repairs and replacements are made immediately.

These are all reasonable assumptions, assumptions that experts in the hotel industry will testify are standards, are rules of reasonable conduct required to properly operate a public inn. Yet, in every hotel carbon monoxide poisoning case we know about, one or all of these basic assumptions about hotel safety has been violated.

What Causes Systemic Hotel Neglect?

How does this happen? When I first started doing carbon monoxide in hotel cases, I thought the only time this would go completely haywire was when a franchise sold a hotel to an inexperienced owner. For example, an old chain hotel that is sold at bottom dollar prices to someone who is acquiring their first hotel business. You would think that before the franchise executed the franchise agreement with this inexperienced person, they would demand that person go to some type of intense training program. They don’t. So, what we have is a moderately successful business type person, who has scraped together enough money to buy a 30-year-old hotel suddenly in charge of the safety of 100’s of people every night. The building says Days Inn on it, but no one from Wyndham has made any effort to make sure that the manager knows what the mechanical systems in the hotel do, or that there is even a well-trained maintenance person on the property.

The less money it takes to buy a hotel, the greater the danger. Thus, there exists an inverse relationship between the how great the need for high level maintenance and the likelihood that any given hotel will get it. The older the hotel, the more likely the HVAC equipment will fail. The older the hotel, the less likely it is that the new owner will have the capital to replace obsolete equipment. The older the hotel, the less likely there is money for emergency repairs. The older the hotel, the lower the room revenue, the narrower the margin of profit, the less likely the hotel will have an outside HVAC company doing periodic preventative maintenance. These older properties are death traps. The franchisors have to know this. Yet they continue to franchise poorly capitalized properties nearing the end of their useful lives, to inexperienced operators with just enough capital to buy the building.

This is what happened in my first hotel carbon monoxide poisoning case. A middle-aged couple had borrowed money from relatives and put all they had into a 40-year-old Days Inn. The mechanical room was in the basement and a complete disaster.  It had huge old boilers cobbled together with replacement hot water boilers to try to keep the hot water flowing. While replacing HVAC equipment is rarely a problem, the domestic hot water does tend to get attention. When there isn’t enough hot water for guest showers – which happen when the laundry is also going full tilt – action must be taken. This hard-working couple did what could be expected of people with no training and little capital. They scraped together enough money to replace the domestic hot water boilers, with new high efficiency boilers. Yet, as they didn’t have any actual training in hotel management they didn’t undertand the warnings the HVAC companies were giving them. When the HVAC companies told them that the system wasn’t working right because of negative pressure, they didn’t understand how dangerous that was. They didn’t make the connection that negative pressure equated to carbon monoxide danger.

I understand that many of our readers won’t know why negative pressure means WARNING CABRON MONOXIDE DANGER, but someone in the hotel business must know that. I will use the videos below to try to demonstrate. As we have discussed on this page repeatedly, carbon monoxide poisoning occurs when all of the natural gas that is burned in a furnace, boiler or other fuel burning appliance doesn’t burn completely. We call that incomplete combustion. In complete combustion, natural gas/propane oxidizes with oxygen to produce CO2 and H2O, water vapor. When the combustion isn’t complete – you get CO – as not enough oxygen is available for the amount of fuel being burned to create complete combustion.

The Principles of Combustion

The fire that happens inside a fuel burning appliance is not fundamentally different than a campfire, like the ones in the below videos. Fire needs oxygen. When fires get enough oxygen, they burn efficiently. If they don’t get oxygen, they go out.  But in between burning properly and being extinguished, there is the incomplete combustion/not enough oxygen phase.

Natural Draft Draws Oxygen to the Flame

Traditionally, the way in which most fuel burning appliances got enough oxygen to the flame was through the principle of natural draft. When I was a Boy Scout, I was taught to build a fire like a teepee. Below is a picture of a just such a campfire. This almost always works because of the principle of natural draft. As hot air rises, the vertical structure of the teepee fire, forces the exhaust fumes vertically and drawing oxygen to the fire.

Systemic hotel HVAC maintenance breakdowns include lack of training of hotel management and maintenance personnel about the basic principles of natural draft and negative pressure.

An even better demonstration of this principle is in when you put a hollow log (I call them campfire logs) vertically on a campfire. See the below video.

Natural draft furnaces and boilers work on the same principles, except that they are built inside of buildings. Inside of a building, you not only have to engineer a way for the fumes (which might include CO) out of the building by way of a chimney or flue, but you have to ensure that there is enough oxygen inside the building for this fire to burn properly. Older systems simply had window to the outside air to provide this oxygen, called combustion air. They don’t look like windows because they have louvers on them. See below.

But having a window open in the middle of the winter isn’t ideal, so these louver systems may be designed to only be open when the furnace/boiler is actually firing. A mechanical device to open and close a louver, will require maintenance. The more moving parts involved, the more often something will go wrong. Further, louvers have bird screens on them and tend to get clogged with leaves and other seasonal plant material, like cottonwood debris such as the cotton-like fibers that come from the cottonwood tree.

Hotel HVAC maintenance needs systemic change

The bird screen of this louver is clogged with cottonwood debris, interrupting the combustion air to the HVAC appliances inside this equipment room. A clogged louver can directly result in carbon monoxide poisoning. 

 

Newer appliances, called high efficiency appliances will have direct vents out the sidewall of a structure. The combustion air will be directly piped into the appliance from the outside air and the exhaust, which is not as hot as that from lower efficiency appliances, is mechanically vented out the sidewall. Negative pressure should never be a problem in high efficiency appliances, so long as the integrity of these sidewall vents is maintained.

But lower efficiency appliances can have negative pressure problems. What is a negative pressure problem? It is when the flow of combustion air is interrupted to the flame when the natural draft is disrupted. Below is a demonstration of the principal with a campfire.

What I did was set up a floor fan next to the fire, a fire where the natural draft is disrupted by knocking over the teepee. As soon as I knocked over the teepee, I got more smoke from the fire. In the first, the fan is blowing on the fire, and it is making the fire burn brighter and the smoke blow away from the fan.

In the next video, I reversed the fan so that it was blowing towards the camera. While the wind which is blowing somewhat the opposite of the fan is neutralizing the effect, I believe that this will help you visualize the principle of negative pressure. Negative pressure is essentially a suction, like the fan, that is causing the exhaust products to reverse the natural flow of up the chimney, backwards. And like in this video, the upward flow (the wind driven smoke) still exists, it is just not the only force on the air flow. If some dynamic in the building is creating a cross current with the natural draft, incomplete combustion will occur. Negative pressure equals incomplete combustion. Incomplete combustion equals carbon monoxide. Inside of a building, these concepts can be complicated to understand. When looking at a campfire, they become clear.

No one should ever manage a hotel unless they understand that negative pressure equals carbon monoxide poisoning. No one should ever be allowed to own or manage a hotel unless they have been taught these basic principles. When chains sell franchises to untrained people and don’t require them to learn these things, the chains must be held accountable.

Attorney Gordon Johnson wrote this blog.