A Strong Connection Exists between Gun Availability and Suicide

There is a strong connection between gun availability and suicide because guns are so much more lethal than other means and too easy to get in a crisis.

By Rebecca Martin

If one raises the issue of gun availability and suicide, a counter cry is immediately raised by gun advocates. However, gun availability and gun control are two distinctly separate topics. Gun availability embodies the issues of screening and background checks for gun accessibility. In contrast, gun control covers a much wider issue of constitutional rights and their interpretation in the courts and legislative bodies.  I preface this article with a clear statement of the topic, the issue of gun availability and suicide, as our focus is on those predisposition towards self-harm as a result of brain damage.

Gun Availability and Suicide are connected.

The high degree of connection between gun availability and suicide exists because a person acts before the fog of depression and desperation can clear.  Take handguns out of that equation and either the person becomes less desperate or chooses a method which is far less lethal. 

Even with that clarification, I want to address the objections which might arise with an article on this topic, which is specifically directed at potential or successful suicide rates in the US. I also want to further stress that my intention in undertaking  this article was to gain knowledge and understanding of a topic which we could all know more about.

23,000 Fire Arm Suicides

According to Everytown Research & Policy, a program of Everytown Gun Safety Support Fund[1], firearm suicide claims the lives of 23,000 Americans every year. An average of 4200 veterans die by firearm suicide annually, about 11 deaths a day.  In fact, nationwide, 53,230 military veterans died by gun suicide between 2005 and 2017. The rate of suicide by firearms has been rising steadily for the past decade.

One of the commonalities between those who have suffered a brain injury and those who have a military history is a decreased ability to cope with life after the event. Whether it be a brain injured person’s increased difficulty in navigating once familiar systems or a returning military personnel learning to cope after a tour of duty, the dynamics become very similar–inner disruptions occurring which are often invisible to other people. And when both of these events are experienced by one person, the impact can be elevated to levels which immediately become troublesome.

Why are we focusing on firearms when discussing suicide? Because, though many people attempt suicide by other means, firearms are the most lethal method of suicide. Suicide attempts by firearms have a 90% lethality rate.

Factors Connecting Gun Availability and Suicide

We determine lethality by examining several factors. One is Inherent Deadliness. There are multiple factors in the means which predict death after a suicide attempt. Though something might be determined to be lethal, the attempt may be carried out in a way that is not successful. The intent may be present but the means may be faulty.

Another factor is Ease of Use. In this category, the person making a suicide attempt is most likely to choose the easiest means possible rather than research the technical specifications needed by another method. And choosing something which requires some preparation is likely to give the person time to reconsider their actions.

Another factor is Accessibility. The most likely choice may be the method with the quickest access.

The fourth is Ability to Abort. The person may have a change of heart and there is a chance of medical intervention or rescue in many methods which is not  the case with firearms. The last factor we will consider is Acceptability. There are many ways to die but some methods are too gruesome to be considered by most contemplating ending their lives. These factors are identified by Harvard T.H. Chan, School of Public Health. See https://www.hsph.harvard.edu/means-matter/

Firearms embody all of the factors which can lead to a successful suicide. Readily accessible in many homes, easy to use, inherently deadly with very little successful intervention once used, and sadly, widely accepted as a means of suicide. When all of these factors are combined with a person undergoing a moment of extreme suicidal ideation, the act may be committed before the action is completely thought through.

Research Supports Connection between Gun Availability and Suicide

An article by E. Michael Lewiecki MD and Sara A. Miller, PhD, enunciates this point:

“Psychiatric disorders are present in at least 90% of suicide victims, but untreated in more than 80% of these at the time of death. Treatment of depression and other mood disorders is therefore a central component of suicide prevention.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3518361/

Other factors can include physical illness, alcohol and drug use, access to lethal means and impulsivity. It is important to note that access and impulsivity may be present when we refer to the lethality of firearms. And when we are referring to firearms it is in general handguns which account for the majority of suicide by firearms.

I think it is important to address the issue of impulsivity. Impulsive attempts at suicide often involve a trigger occurring when an individual is undergoing extreme changes in their psychological state. The trigger might seem insignificant from the outside but due to the psychological distress being experienced, it can lead to the impulsive, spur of the moment decision to end one’s life. Survivors of such attempts have been found to have entertained the thought of suicide roughly 5-10 minutes before making the attempt. In these cases, ease of access and ease of use are a deadly combination in many cases. Those who attempted suicide by firearms but were unsuccessful were reported to have contemplated their suicides for less than 24 hours prior to the event. This has been referred to in literature as an “accident of the mind”, a momentary lapse in judgement leading to an impulsive act which has not been thought through prior to the attempt.

It is generally acknowledged that a restriction of access is one way to combat these types of suicides. For instance, I reside in a state with a very stringent law regarding barbiturates and pain killers in order to combat the prescription drug addiction problem. This is legislation designed to protect the public from itself and though I have heard complaints about the limited access to pain killing drugs by legitimate patients, there has been no public outcry demanding freedom of access to these pharmaceuticals for all. We really need to delve deeper to discover why restriction of access to firearms is so vehemently opposed by so many and what has led to this almost immovable stance on the part of gun rights advocates.

Other Countries Reduce Suicide by Restricting Means

All over the world, countries have placed restrictions on certain devices or locations in an attempt to stop suicide attempts. We see fences erected at once common jump sites. The UK limits access to analgesics and coal gas.  All over the world legislative bodies have identified common means of suicide and enacted laws restricting access to those means for public safety.

Yet in the US, we have the highest number of firearms and the highest rate of suicide by firearms. In states which require waiting periods, safe storage requirements, and a minimum age of 21, we see lower numbers of deaths by firearms. In these states, there is a restriction of access which is working.

Can’t Presume Other Means

The argument always goes back to the point that if someone wants to commit suicide they will find a means to accomplish it. Then we return to the factors of accessibility, ease of use, and acceptability. And studies which conclude that those who act on impulse are working within a very narrow timeframe with thoughts of self-harm. Perhaps the argument of seeking different means might apply somewhat to those acting non-impulsively who may plot out their suicide attempt over a long period of time, but it seems the highest risk group involves those who act on impulse whether over several hours or minutes.

Stanford University has conducted one of the largest studies to date, following 25 million California residents over a 12-year period. The study was published in The New England Journal of Medicine. They agreed that suicide attempts are often impulsive acts.

“Suicide attempts are often impulsive acts, driven by transient life crises,” the authors write. “Most attempts are not fatal, and most people who attempt suicide do not go on to die in a future suicide. Whether a suicide attempt is fatal depends heavily on the lethality of the method used — and firearms are extremely lethal.” See https://www.nejm.org/doi/full/10.1056/NEJMsa1916744

Stanford found that people who owned handguns had suicide rates four times that of people who did not own handguns. In addition Stanford discovered a very high risk for female handgun owners. Women historically have been known to use less lethal methods when attempting suicide but this was not true when considering women handgun owners. Women have also been known to have a higher rate of suicide attempts so the introduction of an easily accessible firearm was a concern that had not been foreseen.

“Handgun ownership may pose an especially high risk of suicide for women because of the pairing of their higher propensity to attempt suicide with access to and familiarity with an extremely lethal method.”

One of the points of the study was to determine whether those purchasing a handgun already had thoughts of self-harm or whether the introduction of a handgun to their home created new risks. But it appeared that both were factors with some new gun owners at high risk for suicide immediately after their purchase and half of all the suicides by firearms occurring a year or more later. What was determined that gun access contributed to more successful suicide attempts. https://med.stanford.edu/news/all-news/2020/06/handgun-ownership-associated-with-much-higher-suicide-risk.html

It becomes clear that impulsivity coupled with ease of access can easily make gun availability and suicide a deadly combination. And it follows that this is a group of people which would benefit from restriction of access the most when discussing gun accessibility. They are the group more likely to act in a shorter period of time, least likely to seek out counseling or help and least likely to send out warning signals to family members and friends.  This then leads to the question of existing protocols and legislation and where it goes from here.

Veteran Suicide

The former secretary of Veterans Affairs, Robert Wilkie, held veteran suicide as a top priority. But he focused on the mental health component of suicide while refusing to address the gun issue. His presidentially commissioned group which he headed released a 65-page report regarding the subject of veteran suicide which did not mention the word “firearm” once.  The VA removed data sets on veteran suicide which were publicly available on its suicide prevention website at roughly the same time. In the 30 months, Wilkie oversaw the VA, approximately 10,000 veterans died by gun suicide. According to the Military Times it is hoped that Denis McDonough, President Biden’s newly appointed secretary of Veterans Affairs will again address the issue of suicide by firearms and discuss the role guns play.

However, McDonough is backing the Hannan Act which seeks to bolster the VA’s mental health workforce, increase rural veteran’s access to care, expand veterans’ access to alternative and local treatment options, increase coordination with the Department of Defense and conduct veteran suicide prevention research and oversight. But according to Moms Demand Action, For Gun Sets in America: https://momsdemandaction.org/everytown-applauds-confirmation-of-va-secretary-denis-mcdonough/

“Secretary McDonough has long been a gun sense champion. During his time as White House chief of staff, the Obama administration twice (2013, 2016) signed executive actions to address our nation’s gun violence crisis, and pushed vehemently for the passage of the Machin-Toomey background checks proposal –– legislation to strengthen America’s background check system. Secretary McDonough was also chief of staff for the administration’s 2014 suite of executive actions to fulfill “our promises to service members, veterans and their families,” which included a good first step of encouraging firearm safety as part of the plan to address suicide among veterans.”

We will see which stance McDonough takes in regard to veteran suicide in the coming months.

According to the American Public Health Association suicidality is transitory. If a person makes it through the initial impulse to commit suicide, the prognosis is often good. As a result removal of lethal means from someone with a past history of suicide attempts, a history of depression or other mental illness, alcohol or drug abuse, a family history of suicide or violence or a feeling of isolation, is the single best preventive measure that can be taken.

This can be accomplished several ways, according to the APHA.

(1) relocation of household firearms away from the home when a family member is at risk for suicide, (2) safe storage at home if relocation is not possible, (3) working with leaders in the gun community to develop and implement messaging about the preceding two strategies that will be favorable to most gun owners, and (4) increasing screening for access to firearms by health professionals and other gatekeepers.

The APHA also repeats that impulsivity is a very common factor in firearm suicide. That suicide is pre-meditated in most cases is simply not backed up by research. Most people who attempt suicide and fail do not go on to attempt another suicide according to studies. And this is tied to the fact that most people who fail did not use the most lethal means available on their first attempt. In fact most people who succeed at suicide made their first attempt by lethal means and that means that suicide by firearms is the most frequent method to result a fatal outcome.

There are also other methods which can work to diminish the danger from firearms in these cases. Proposals have been made to adopt gun violence restraining orders which could be exercised by partners or law enforcement personnel to limit access for someone threatening harm himself/herself or others. Smart gun technology could be used to allow only the gun owner to have access to a gun in their possession and thus limiting access.

However it is agreed that access to mental health help, education about gun storage and access to temporary offsite gun storage, and further research into the issue of gun accessibility are all steps towards creating a safer environment for those at risk.

State laws regarding offsite gun storage vary. You can contact your local police or search gun storage nearby. It is different in each state. Sticking it in your garage or a storage unit is not an option. It is illegal to store firearms in a storage unit.  If you are storing a gun with a friend, there are forms which must be completed for the registry of ownership. I did a simple google search and came up with many approved options in my state. If you feel someone in your home might be at risk, this may be the safest option until mental health issues can be addressed

Keep in mind it is never ok to store a loaded gun anywhere. Not even in your house. Guns should be loaded when in use only. Some states have laws prohibiting keeping a loaded gun in your home, or safe. My state requires a gun be stored separate from ammunition. Check your state for gun regulations.

We have often heard people say, after the fact, that they had no idea someone was about to end their life. And I hope I have clearly addressed why that is. The vast majority of successful suicide attempts were initiated after only a short period of time and were only successful due to accessibility and ease of use. There are some high risk factors but not everyone who suffers from depression or suffers from addiction is going to make an attempt on their life. What our concern is here is how to diminish the risk for those that are high risk. Especially in regard to those who have suffered some life altering experience such as a brain injury or a tour of duty in a war zone. And that is something a family can educate itself about and become aware of how the cycle of depression can spiral out of control if it goes unchecked.

It is time to stop ignoring the issue of Gun Availability and Suicide. Gun deaths in the United States are more likely suicide than murder.

National Suicide Prevention Lifeline

Hours: Available 24 hours. Languages: English, Spanish. Learn more

800-273-8255

[1] a non-partisan organization dedicated to understanding and reducing gun violence.

Major Concerns with Suicide After Brain Injury

Suicide after brain injury is a serious concern as emotional centers may have suffered discrete physical damage causing depression and anxiety, but the added burden of dealing with disability and deficits can severely tax the injured mind.

By Rebecca Martin

Navigating our modern world is a difficult task for the most capable of us. We deal with stressors in our lives which would make the average person from 1950’s America throw their hands up and yell “stop!” We all hoped technology would make our lives easier and less complicated.

Suicide after brain injury is a major concern

Suicide after brain injury is a topic that we of the Brain Injury Law Group have been concerned about for more than a generation. Rebecca Martin illustrated this story of the struggles to adapt of her fictional Sue nearly 25 years ago.

These days, however, a simple question about a phone bill can entail hours of maneuvering through automated voice systems with the slim hope that eventually a human will appear to listen and assist with a simple problem. In many ways our voices have been muffled as technology takes over. Increasing feelings of powerlessness and isolation are often the result. I often wonder while navigating modern day to day life, how are people with compromised coping abilities able to navigate modern life? And the answer is that, in many instances, they are not able to successfully map out a road to a successful existence in our new societal dynamics. Depression is often the outcome and suicides continue to trend upward for the last two decades.

Many years ago when I was working on the brain injury support page waiting.com I was struck by the fact that due to advances in automobile engineering and medical technology more people were surviving with brain injuries. We were beginning to understand how even so-called “mild” brain injuries could exhibit far reaching long term deficits that could ultimately derail the most resilient among us. And we were beginning to understand the interplay of depression and brain injury and the increased risk of suicide among survivors.

Society places an almost criminal connotation on suicide. The term “commit suicide” in itself denotes a criminal intent to do violence to one’s self and carries a burden of guilt. This alone has driven those struggling with suicidal thoughts into hiding. In the medical profession, intake questionnaires for any type of significant treatment often include questions regarding depression and suicidal ideation. Medical records themselves label attempts as “successful”, the person succeeded in the suicide attempt or, “failed”, the person did not succeed. Even when desperation has driven someone to the brink of suicide, to have failed is labeled as a failure. This nomenclature has effectively made depression and suicide taboo subjects for discussion.

Suicide after Brain Injury Starts with Depression

Brain injury is now acknowledged as a leading indicator in the potential for depression and suicide. For more on brain damage after carbon monoxide poisoning, click here.  Let’s examine a hypothetical instance to study the dynamics of how brain injury can impact an individual. We have a basic understanding that it is often the type A personality which is at greatest risk for compromise from an acquired brain injury. A person has worked hard and intelligently to establish a lifestyle which is a delicate balance of seeking new challenges and goals, accomplishing those challenges and goals and ultimately balancing those challenges and goals with personal satisfaction in the way of relationships, family life and recreational time. They have established an identity which is able to rationally accept defeats without being defeated. But what happens when we introduce a brain injury?

First of all, brain injury is not immediately evident in the outward appearance of the survivor. Often the reactions of those around them are limited to the endless observations of “you are so lucky to be alive” or “it could’ve been so much worse, how fortunate for you.” This is obviously not the same reaction people might have to say, a severed limb or other outward sign of injury. Yet with a brain injury the person is experiencing problems with thinking, judgement, emotions, coping and prioritizing skills, concentration, flexibility and much more. These deficits begin to impact relationships, family dynamics and work. The person is very likely to feel an increasing isolation and sense of helplessness which ultimately can lead to depression. This withdrawal from social arenas where once the person was functioning in an acceptable manner becomes a spiral which grows worse over time.

Although it is very difficult to have accurate insight into one’s deficits when the facilities for that introspection are damaged, survivors are often affected by a disturbing sense that things are not as they should be. Even if they are able to vocalize what seems to be occurring, it is human nature to minimize such complaints.

Loss of Self Esteem Contributes to Suicide After Brain Injury

I compare it personally to the period of time I was experiencing the dreaded “chemo brain” after cancer treatment which affects memory and concentration much like brain injury. I would express concerns about not being able to remember events or directions to familiar destinations and the response would often be “oh, I forget all the time too”. Those words I searched for or memories I struggled to find became huge roadblocks in my functioning which shook my confidence to the core. Medical professionals glossed over my concerns with promises that it was temporary. But for those with brain injury, it’s not going away. And that makes it worse. But the inclination to minimize those deficits is the same. And it leads to the same type of self-doubt that leads to a constant state of second guessing our ability to accurately assess or assume our place in the world. And when those deficits are the result of physical injury to those parts of the brain, trying harder is not going to make it better.

When one is working so hard to just live up to former levels of functioning, the entire process becomes exhausting. The brain is working overtime to accomplish simple tasks. Focusing on one’s work, concentrating on the task at hand, decreased confidence in our ability to accomplish a task correctly–many of these things can create a confusing scenario. Changes can be due to physical changes in the brain which damage areas specifically involved in emotional responses. Emotional changes can result from the ensuing struggle to deal with the changes after an injury. And there may be genetic, family history or other factors which exacerbate our ability to cope with brain injury. And this can lead to depression.

According to msktc.org

“Depression is a common problem after TBI. About half of all people with TBI are affected by depression within the first year after injury. Even more (nearly two-thirds) are affected within seven years after injury. In the general population, the rate of depression is much lower, affecting fewer than one person in 10 over a one-year period. More than half of the people with TBI who are depressed also have significant anxiety.”

Depression Comes from Both Organic and Emotional Damage

Across the board it is widely recognized that depression is a common outcome of a brain injury. Depression can lead to an increase in thoughts of death or suicide. We wrote previously of the functions of the basal ganglia which was not only responsible for promoting functions to accomplish tasks but also to control inhibitions that might counteract those actions. And that it is now understood that deficits in this area could affect judgement. When you throw depression into the mix you may now have a cocktail of negative thoughts with inappropriate inhibitions on those thoughts meant to rationalize behaviors and ultimately preserve life. Those feelings of worthlessness, a decreased self-confidence, fatigue and interrupted sleep and rest patterns, increased social isolation–all of these things may contribute to an increasing perseveration with thoughts of suicide.

The severity of injury may play a role in the prevention of depression as well, but often in an inverse relationship to the severity of injury. If one is hospitalized for treatment of a brain injury, it is more likely that a course of treatment to address depression will be implemented. Often in the case of a more “mild” brain injury, the rising symptoms of depression may be written off as symptoms of the brain injury itself. In this case, the depression may not be addressed as actively and can escalate. And unfortunately, a misguided approach to treatment for depression specific to brain injury may contribute to an escalation of suicidal thoughts through improper medication or an inadequate intervention.

In a 2020 Medscape article authored by Percival H. Pangilinan, Jr, MD and associates, it is estimated that 40% of patients hospitalized for TBI have been found to suffer from depression and further, with cognitive decline. Cognitive decline includes “anxiety disorders, substance abuse, dysregulation of emotional expression, and aggressive outbursts.” See more at https://www.medscape.com/answers/326643-121901/how-is-depression-treated-in-traumatic-brain-injury-tbi

Further findings by Whitnall L, McMillan TM, Murray GD, et al reported “that persistent disability (5-7 years after TBI) was strongly associated with depression and anxiety, and that it was more poorly associated with initial severity or persistent cognitive impairments.”

Need for More Research on Suicide after Brain Injury in Mild Cases

Many studies point to increased rates of suicide after brain injury amongst those who previously suffered a moderate/severe brain injury. However, an increase in the rate of suicide extends to all levels of brain injury. As I pointed out earlier, those who might be more likely to be impacted by a mild brain injury show a direct correlation to personality type with a high achieving individual being the most at risk. And not because they are predisposed to the impact, but because a mild brain injury is going to have the most impact on someone juggling the difficulties of modern life and thus more likely to result in causing the whole stack of cards to fall. Failure is often not an option in these cases. This is not to discount other personality factors that may lead to increased risks for depression but our focus is on those who functioned in an acceptable societal norm prior to injury and were unable to function at those levels post injury.

We are likely to have more research which links prior mild brain injury to suicide as patients with mild brain injuries were not typically followed up with prior to 1995. as noted in the Danish Study which established a definite connection between brain injury and depression/suicide. Even so, this study found that

“Even people who had milder brain injuries like concussions without any evidence of fracture were still 81 percent more likely to commit suicide than individuals without a history of TBI.”

The Danish study was the largest study done to date. Dr. Ramon Diaz-Arrastia summed up the findings of the study.

“The take-home message here is that mood and affect are commonly impacted by TBI, and that it is part of the organic brain injury, and need to be taken seriously,”

Treatment for Depression Must be Explored

One point that everyone is agreed upon is that ongoing treatment for the psychological impact of brain injury, in all categories of severity, is both needed and under-utilized. Treatment needs to be targeted to deal with specific areas of damage in the brain and could include pharmaceutical, behavioral or rehabilitation techniques. And as the greatest risk is present in the first year following injury, a treatment program should be put in place from the onset of the injury and continued as a long term plan. It is noted in many articles that early onset of depression or suicidal ideation can continue for many years without any decrease in intensity so ongoing treatment remains important. Family members and associates should be educated as to the warning signs that intervention is needed. There is a good article on this at https://www.sprc.org/sites/default/files/migrate/library/TBI_Suicide.pdf if you have suffered a brain injury and have suicidal thoughts, help should be sought immediately.

Another factor we must consider is prevention of brain injury. Whether it is through education about the risks of carbon monoxide poisoning, helmet safety, seatbelt use, to reducing risks associated with falls–prevention ultimately is the most important way to avoid brain injury. Remember, once a person has had a brain injury, they are three times more likely to have a second brain injury.

 

The National Suicide Prevention Lifeline is 800-273-8255

Detectors Save Lives in School Carbon Monoxide Poisonings

Carbon monoxide detectors can save the lives and brains of school children in school carbon monoxide poisonings, illustrated by the tale of two 2015 poisonings within six weeks in the Chicago Public Schools.

The school boiler room has been a popular theme in modern horror movies. Cultural historian, DJ Skas postulated that horror stories are a reflection of our societal fears. But even though Freddy Krueger is unlikely to make an appearance in the basement of your child’s school, an invisible and deadly killer can be there lurking…carbon monoxide.

Schools have traditionally been the central hub connecting communities and the impact of any type of harmful occurrence is felt deeply by surrounding communities. This is something that goes hand in hand with school carbon monoxide poisonings which tend to affect large numbers of people in often unforeseen ways.  Children are among the most vulnerable to carbon monoxide poisoning as the ultimate damage often cannot be assessed until years after exposure. Considering the increased vulnerability of children, why then are schools not the frontline battlefield in carbon monoxide prevention?

No Waiver for School Carbon Monoxide Poisonings

 

school carbon monoxide poisonings are avoidable

One of Chicago’s school carbon monoxide poisonings happened at the Prussing Elementary School on October 30, 2015.

As parents we are familiar with waivers signed at the beginning of school years. There are Activity Participation waivers which are used for student activities, clubs, special classes, after school programs, work experience programs, off-site training, team participation, band, cheerleading, dance team and field trips. These waivers include transportation to and from events. But no where do I find waivers which ask parents to agree to disregard the school’s responsibility in providing a safe environment to learn in. Yet as we will see, schools have failed to provide basic protection against carbon monoxide poisoning in many cases. And in some cases only when litigation for injury enters the picture

School carbon monoxide poisonings keep happening. USA Today found that more than 3000 students had been evacuated in at least 19 incidents of findings of dangerous carbon monoxide levels in schools since 2007. https://www.usatoday.com/story/news/nation/2012/12/05/schools-carbon-monoxide/1748361/

In 2012, an Atlanta elementary school was evacuated and at least 49 people were treated for carbon monoxide poisoning.  The school was not equipped with carbon monoxide detectors.

In 2014, a malfunctioning boiler sickened kindergarten students in a Douglas town complex in Massachusetts. The complex housed the Town Hall, police station and elementary school. There were no carbon monoxide detectors in use. This inspired Douglas Fire Chief Kent Vinson to advocate repeatedly for carbon monoxide detectors in schools. His disappointment was that year after year such legislation withered before the end of each legislative session. “It’s extremely frustrating because this is really a no-brainer,” he said. “And it’s obviously political, which is sad, because we’re trying to protect children.” https://www.newburyportnews.com/news/regional_news/bills-requiring-co-detectors-in-schools-languish/article_89e8ea72-13ac-5b91-abd5-0f825a17ee4c.html

In Springfield, MN in February, 2014, thirty children were taken to the Mayo Clinic Health System after suspected carbon monoxide exposure in their school. Children experienced extreme nausea and other classic symptoms though initial tests of the premises were inconclusive. It was later determined that the possible cause was “mass psychogenic illness” even though no details were released regarding the possibility that the building had been sufficiently aired out prior to testing. And public information on the findings of the Mayo Clinic are not available though it was presumed that carbon monoxide poisoning had been ruled out. There is little information on the details surrounding this incident. A mass psychogenic illness seems to be an unlikely explanation.

Brain Damage or Psychogenic Illness?

In fact, a little research in the incidence of mass psychogenic illness produces some very bizarre scenarios. Not only is it extremely rare, but is often not associated with physical illnesses.  One of the most recent being the phenomena of clown sightings in 2016. This seems quite a stretch when comparing this type of event to an incident involving a negative physical response by a number of children. Historically, many of the cases of mass psychogenic illness, related to illness specifically, seem to point to some type of toxic element in the environment which may have been undiscoverable at the time it occurred due to lack of technology. Other cases involve hysterical behavior instigated by a single person which spread to their peers. There is very little proof in all of recent global history that would point to mass psychogenic illness as a likely explanation.

Illinois School Carbon Monoxide Poisonings

school carbon monoxide poisoning - North Mac

The North Mac school carbon monoxide poisoning occurred because this pipe broke. There were no CO detectors in the school.

In Illinois, September, 2014, the campus of the North Mac Intermediate and Middle School were evacuated. There were approximately 640 students on campus. That morning, 150 students and faculty were showing symptoms of carbon monoxide poisoning and nearly 60 people were transported to local hospitals. The contractors involved in installing and maintaining the hot water heaters were negligent. In this case, carbon monoxide was indeed detected on the scene. The Brain Injury Law Group represents survivors from this poisoning.

As a result of this incident the school determined that carbon monoxide detectors would be installed. This is of very little comfort to those who had already suffered from exposure and the potential for permanent damage which followed. One can only wonder about how insignificant the cost of having previously installed detectors might have been when weighed against the costs of shutting down to address the problem after the fact. As well as the emotional aftermath which parents and students must have felt during that traumatic episode. It is not uncommon for children to exhibit fears over returning to a site they have experienced as dangerous in some way.

One would presume that the recurring incidents in our schools would bring immediate action of the part of legislators. But in Illinois, even after the North Mac incident, legislators were slow to act on a statewide level. Legislation was indeed finally passed but would not go into effect until January of 2016. As we shall see, that enactment of statewide legislation came too late for some, but just in time for others.

It is often argued, especially when pertaining to older structures, that the children do not sleep on the premises so carbon monoxide detectors shouldn’t be required. I can imagine the parents might cringe at this statement as we send our children, by law, into someone else’s care and thus we expect that the hours spent on those premises are safe and conducive to health, not potentially deadly. And carbon monoxide can kill in minutes, regardless of the time of day.

I think that what is the most astonishing is the number of actual incidents that don’t make headlines. Fire departments in every state recount the number of times they are called to a school for suspected carbon monoxide poisoning. It is almost impossible to determine how widespread positive tests for carbon monoxide are. And sadly how many go unreported because symptoms are overlooked. But one must wonder when one state reports 40 suspected incidents per year and yet only a handful nationwide ever make headlines.

Regardless of whether the legislation is influenced by economic factors or politics, only a handful of states require carbon monoxide detectors in schools. But statewide or federal regulations are severely lacking.

There has been one ongoing argument over who is financially responsible if legislation is passed. Should the burden be on the school system or taken on by the state itself? In most cases it is agreed that the state take on the financial responsibility which makes it a political issue in some instances. What does it take to pass a carbon monoxide detector mandate? At what level is the danger considered significant enough to take action on?

Two Chicago School Carbon Monoxide Poisonings

The school carbon monoxide poisonings, in the same school district, six weeks apart show the dynamic difference detectors can make. Both were before the effective date of the Illinois law that was passed as a result of the North Mac Poisoning discussed earlier. But in the first, the Chicago Public Schools didn’t put in detectors, in the second, because of the litigation from the first, detectors did get put in.

On October 30, 2015, seventy-one students and seven adults for the Ernst Prussing Elementary School were transported to Chicago hospitals on a Friday morning in October.  Dangerous levels of carbon monoxide were found at the scene while all of the students were assembled for a Halloween parade in the school hallways. A student had passed out and soon 10 ambulances were dispatched and evacuation proceeded. The school reported an “environmental situation on its website.  The Chicago Tribune reported:

“A fire engine and an ambulance were initially called to the school for a “sick child in the gym,” said Fire Commander Curtis Hudson. Ambulance crews were equipped with carbon monoxide meters, which “started going off with readings over 200,” Hudson said.”

A boiler was determined to have been the source of the poisoning. First responders were able to bring the carbon monoxide levels down by shutting down the boiler and ventilating the building. Further investigation revealed problems with the ventilation system, inspections and maintenance. As a result, many parents waited for two hours to discover whether their child had been hospitalized, an unnecessary trauma for both parent and child. It is particularly poignant to read the accounts of children dressed in their Halloween costumes undoubtedly excited by the holiday season and ultimately victims of sub-par maintenance and inspection in their school.

The Chicago Public Schools got sued over the Prussing school carbon monoxide poisoning early in November of 2015. That lawsuit generated more negative publicity for the school district than the initial news accounts did. Lack of carbon monoxide detectors in Prussing was a big focus of that negative publicity for the school. The Chicago Public Schools moved up the timetable to put CO detectors in every school, including the  Horace Mann Elementary where detectors were installed a month before the January deadline. Shortly after the alarms were installed, they were tripped as staff entered the school around 6:30 AM  on a Thursday morning. However the school administration did not contact the fire department until 2 hours later, around 8:30 am. 104 students and 7 staff members were hospitalized for precautionary reasons as a result. In this case the failure to act was questioned by the Chicago Teachers Union organizer, Curtis Bynum, and many parents as well. But this situation might have been much worse as the detectors did alert early in the day even if response lagged unnecessarily. The exposure which occurred was minimized regardless. CPS had installed 5900 carbon monoxide detectors in the area just days prior to this incident. In this case, students were not evacuated but rather relocated to an adjacent campus.

In 2019 another Chicago school, this time in Burnside, was closed due to a gas smell noticed by the building engineer on duty. As the incident was reported 5:30 AM, there were no students in attendance and classes were moved to another location. A faulty boiler was determined to be the cause.

In 2019, in Alabama, Rainbow Elementary was evacuated and closed due to carbon monoxide levels. The cause was, again, a faulty boiler.

At some point, you must be wondering, are carbon monoxide detectors the only problem we need to address or does the problem go a lot deeper? Perhaps we should be looking in the boiler rooms for some answers? As I said in the beginning, the monsters we imagine may not be real, but the danger is. And somehow, we as a society, recognize this on a very primal level.  We are aware that many schools are in older buildings and many are underfunded. Yet every day we send our children to these less than ideal situations, trusting that the most basic care has been taken toensure their safety. At the same time we applaud politicians who find ways to cut taxes and decrease funds for new construction and school funding in general. There must be a middle ground that does not place our children at risk.

It also brings up the question of air quality in schools in general. And the many ramifications of improperly installed ventilation systems. Especially in view of promises to increase safety in schools during Covid. How confident are we that air cleaning systems with be properly integrated with existing venting systems? Will inspections be done to ensure that all systems are compatible? Many questions for us to consider in the upcoming months as work to update ventilation systems begins.

This blog was written by Rebecca Martin.

 

 

 

 

 

 

Carbon Monoxide Detectors Mandates Needed for All Indoor Premises

Carbon Monoxide Detectors Mandates must be extended to include all indoor premises that have fuel burning appliances, anywhere in the structure. Just having them in the same room as the appliance is not sufficient as CO fumes can invade into any part of the indoor premises. 

By Rebecca Martin

I had my first apartment back in college. It was one of those complexes in which my neighbor and I both lived over a semi enclosed garage situated in a natural hollow which captured the morning air. A pleasant location during hot weather but not very conducive to air quality. My neighbor routinely went down to the garage in the wee hours when the sun was just coming up and started his Jaguar to let it run a good half hour to an hour before work. And as it was situated directly beneath my bedroom window, I was routinely awakened by a very loud engine and the smell of exhaust. Annoying to be sure. During that year at school I suffered from inexplainable headaches and visited the infirmary and my doctor often to ask for some explanation. I was sent for scans and injected with dye and even referred to an ophthalmologist to rule out a visual problem. It never occurred to me or anyone that the problem might be carbon monoxide seeping into my bedroom every morning.

All places where people sleep must be subject to Carbon Monoxide Detector Mandates

Carbon monoxide detectors mandates must extend to all rooms in any hotel that has a boiler, regardless of whether there is a fuel burning appliance in a given room. The chimney shown here leaked into the adjacent rooms, causing a severe carbon monoxide poisoning at this Days Inn.

These days we know better and that 1) cars don’t need to be warmed up and 2) carbon monoxide detectors would have gone a long way in protecting the residents of the apartment complex. Back then the dots weren’t immediately connected to raise any concerns that I might have been suffering from some long term carbon monoxide exposure. This is just a mild example of what can occur in an apartment complex, housing development or any living situation which involves tenants and a landlord.

Carbon Monoxide Detectors Mandates for all Apartments

In January, 2020 over 100 people were evacuated, and nine people hospitalized in a Long Island apartment complex. The assistant chief of the Hempstead Fire Department noted that his meter was going off even before entering the location. The landlord had illegally installed heating units in all of the apartments without permits. Because the installation was not professionally done, carbon monoxide had permeated the entire complex. To add insult to injury it was discovered that the landlord was charging each tenant $100 more gas each month over and above the agreed upon utility costs.

In April of 2020, a Northwest DC woman perished  from carbon monoxide poisoning when her stove was left on. There was not a carbon monoxide detector in the apartment. The 12-unit building was evacuated and ventilated.

In January of 2021, one person died, one person was hospitalized  and 36 apartment units were evacuated in Orlando, Florida after a gas leak which produced elevated carbon monoxide levels. The leak was discovered after another resident noted that the gas burner in one apartment had been left on for over 24 hours. Hazmat crews discovered a burner on a gas range had been left on high for at least 24 hours and the resident was found deceased.

Carbon Monoxide Detectors Mandates for any Building Attached to Garage

In February, 2020, a woman was found deceased in her running car in an apartment garage in Tulsa, Oklahoma. The Tulsa Fire Department was alerted by a 911 call from a resident who lived in the apartment above the garage whose carbon monoxide detector had begun alarming and awakened her. They toxic levels of carbon monoxide in the apartment which were rapidly rising prompting an evacuation. They discovered that the garage underneath the resident’s apartment was warm to the touch and slid a gas monitor under the door. The levels were over 500 parts per million which is immediately deadly to life and health (IDLH). The deceased woman was discovered in her vehicle with the carbon monoxide detector in the garage sounding. The carbon monoxide had spread to several of the surrounding apartments and the area had to be cleared by a hazmat crew. The hazmat crew reported the carbon monoxide readings were on high, which meant that the equipment couldn’t even register how high the levels were. The 4 AM 911 call from the resident in the apartment above undoubtedly saved others from possible poisoning. In this case carbon monoxide detectors did their job and an investigation was launched to determine why the deceased woman was unable to respond.

CO Alarms not Always Mandated at Present

This sampling of stories from the news begins to paint a picture of when and if a landlord might be liable for damages due to carbon monoxide poisoning. In only one of the instances did we see carbon monoxide detectors playing a role in averting a disaster. 27 states and the District of Columbia require carbon monoxide detectors in private dwellings though 11 states limit this to buildings with fossil-fuel burning devices, while others may require this only upon sale of the property or unit. Another 11 states have amendments to existing building regulations to require carbon monoxide detectors in new construction. At this time there is no federal regulation governing the use of carbon monoxide detectors in apartments or housing developments. Click here for First Alert’s summary map of where CO Alarms are mandated.

Some states have laws which require landlords to not only provide specific types of carbon monoxide detectors, but also to maintain them in working order and replace when needed. And there are states which have “negligence per se” laws which do not require the victim to prove negligence on the landlord’s part. If the landlord fails to follow the law, negligence is established. In others, blame might be established if tenants can prove the detectors were not installed or maintained correctly, or in some cases, the incorrect detectors were installed. A landlord can be libel under a breach of contract if the property was presented as being or in the process of being, fully equipped with adequate detection and did not follow through. And as we have seen, sometimes neglect falls under faulty maintenance and installation of devices which can produce carbon monoxide, as in the case of improperly installed heating and ventilation. Because we have no universal federal legislation on the issue of carbon monoxide detectors in all residents, whether they be private homes or rentals, the state laws governing carbon monoxide safety in our homes can be complicated to follow without an attorney.

Carbon Monoxide Detectors Mandates in Building Codes

States which go the building code route do so by attaching a carbon monoxide detector amendment to existing building codes or by adopting the International Residential Code. The International Residential Code covers four main points in regard to installation of carbon monoxide detectors.

First is that, in all new construction which contains a dwelling unit or unit, in which fuel-burning appliances are installed; that a carbon monoxide detector is installed in the immediate vicinity of each bedroom or individual sleeping area. In some cases this requirement is modified to allow for combination smoke/carbon monoxide detectors.

Second, that existing dwellings which are modified so that interior alterations, repairs, or appliance replacement or alterations, requiring a permit, conform to the requirement for carbon monoxide detectors. Any bedrooms or sleeping areas added to an existing residence fall into this category.

The third guideline of the code is the requirement that all alarms are loud enough to be heard over any background noise and through closed doors to all bedrooms and sleeping areas.

The fourth point concerns the power supply. It requires that all carbon monoxide detectors be hardwired if the residence is connected to a commercial power source and have a battery backup in case of a power failure. There should be no power cut off switch installed to cut power to carbon monoxide detectors. And if more than one detector is installed they should be interconnected so that when one alarm sounds, all the alarms sound.

As you can see, this code deals with new construction and renovation or remodeling which requires a building permit. It is such an inexpensive requirement to add to a state’s existing building regulations that it is pitiful that this code has not been put in place across all the states.

California is one state which requires carbon monoxide detectors in all single family dwelling units. This was established in 2010 with the passage of the Carbon Monoxide Poisoning Prevention Act. It requires carbon monoxide detectors for all units which have gas appliances, including stoves, gas water heaters and fireplaces. It requires detectors for homes with wood burning fireplaces. And it requires detectors in all homes with an attached garage. It also requires that all equipment is approved by the California State Fire Marshall and in new construction is hard wired in with a battery backup. They have added the locations in which the detectors are installed to include all levels of the house, including the basement, where fuel-burning devices are located. This can include stoves, water heaters and fireplaces.

Grandfathering Leaves Many Dwellings Without Alarms

Despite a strong movement over the last decade for increasing Carbon Monoxide Detectors mandates, most laws do not apply retroactively for existing buildings. Thus, even in places like apartments, the code or statute may not require their installation. This is bad public policy. The older the structure, the more likely there is to be carbon monoxide poisoning as HVAC systems deteriorate over time. Natural draft furnaces have greater risks of poisoning than high efficiency appliances as they don’t have dedicated combustion air and rely on aging chimneys and flues to exhaust air out of the premises.

The question arises as to what a tenant can do in the case of older construction, in a state with no specific regulations. Ideally you have become aware of the dangers of carbon monoxide poisoning and can opt to install your own battery powered detectors.

Where is the proper place to install detectors?  As mentioned, in the vicinity of every bedroom or sleeping area and on any level where a gas-burning device is located as well as in the vicinity of an attached garage. And ideally in the garage itself but just in the garage is not sufficient because an alarm going off in a garage, may not be heard inside the dwelling.  They should be installed 5 feet from the floor and at least 3 feet from any HVAC venting. They should also be at least 6 inches from exterior walls. There are many guides online to help in choosing a carbon monoxide detector. One is available at https://www.safety.com/carbon-monoxide-detectors/ There are many choices, with some featuring ten year batteries. But you should still check your detector every six months to make sure it is working properly.

We will continue to see stories of carbon monoxide poisoning occurring in apartment complexes and housing developments, usually resulting in tenants being evacuated and in some cases, death and injury. Until the Federal regulations currently on hold are finally put through, states have chosen to respond or not to the number of deaths and injuries which do occur annually. Congress passed a bill in December of 2020 requiring carbon monoxide detectors in all federally subsidized housing. The provision was attached to the Covid-relief bill.

There is also military housing to consider. Although carbon monoxide detectors are required in units owned and operated by the DOD, which follows the International Residential Code, it is estimated that 63% of all military families live off base. And many of those in multi-family dwellings.

Hopefully, 2021 will see the passage of federal legislation regarding carbon monoxide detectors.

But the standard of care is for carbon monoxide detectors in all indoor spaces, especially if there is a fuel burning appliance in or near such structure. Just in the rooms where the fuel burning appliance is housed is not enough. The worst CO disasters have occurred in places that were inside the same building as the source of CO, but in different rooms. Think of the Boone, North Carolina Best Western saga. Those deaths were from a malfunctioning pool heater. The room where two different fatal incidents occurred, were not the same room as the heater. Anywhere that exhaust can flow with a defective or backed up exhaust must have a detector. That is even more clear if someone is sleeping in such premises. All hotels and apartments much have CO alarms if there is a fuel burning appliance or engine on the premises. CO poisoning is foreseeable and must be guarded and warned against.

 

 

Understanding Fire Key to Avoiding Carbon Monoxide Disasters

Avoiding carbon monoxide disasters from storms requires an understanding of the principles of fire: adequate oxygen is needed for the flame and exhaust gases must get outside. CO can be deadly before you smell fire.

Another series of bad storms, another round of carbon monoxide deaths. Why does this keep happening? There is much that could be said about the political/policy issues that surround climate change but regardless of cause, that our weather events are becoming more severe is indisputable. When Mother Nature wants to disrupt our industrial world, she continues to prove capable.

A month ago, we would have thought that the big cause of that disruption was tied to power transmission. Windstorms knock down power lines, the power goes out. What Texas has shown us is that not just the transmission of power is vulnerable, but also the generation. Add ice, wind and cold and suddenly people who have never given a minutes thought to how to generate enough heat to survive, are making do with unconventional solutions. In the Dallas Morning News story, the process of sorting out how many people died as a result of the Texas storms is complicated, and includes road accidents, hypothermia and carbon monoxide poisoning. https://www.dallasnews.com/news/2021/03/01/will-texas-ever-figure-out-how-many-people-died-in-the-winter-storm/ While it seems like a can’t win dilemma, risking CO poisoning should never be the choice. CO can kill quickly but disables dozen’s more than it kills.

Carbon Monoxide Disasters from Improvisation

All of these make-do solutions comes with risks, risks that the poor understanding of  combustion, leave people vulnerable to CO poisoning. To help people understand the numerous warnings that come with natural disasters, we felt it would be beneficial to review how CO gets inside the air we breathe and why even at the risk of freezing to death, you cannot risk unconventional ways to warm inside air.

When something burns, the technical term for that is combustion. In combustion, for the carbon in fossil fuels oxidizes. When the carbon in fossil fuels mixes with oxygen, it creates the heat and energy which powers the industrialized world. The C atom (carbon) combines with the O (oxygen) atom to create CO2  (carbon dioxide) and water, H2O, making water vaper. This is cycle of life on our planet, with plants then pulling in the carbon atom in the CO2 to create plant matter and expelling back into the O2 for animals, including humans, to breath. When combustion is incomplete (incomplete combustion) the carbon dioxide molecules which plants need becomes carbon monoxide, CO, a potentially lethal molecule. What makes carbon monoxide so toxic is that it replaces oxygen in our blood (technically binds with hemoglobin), without any clear warning of its existence because it is while odorless and colorless.

Carbon monoxide is the number one cause of poisoning deaths in the world. Deaths are higher outside of the United States because much of the world does not have central heat like in the U.S. What happened in Texas in February of 2021 a result of the break down in the way in which people heat their homes. As generally Texas is a mild climate, electric and space heat is used far more than in colder places in the country. But in February, Texas got as cold as it typically might in the Midwest. Failure to plan for that cold, even though the risk has been well understood for at least a decade, is the overarching cause of the disaster.

Carbon Monoxide Disasters more than Deaths

In the United States, for every person who dies, there are likely more than 45 times that number who survive after getting treatment for CO poisoning. Some of the best epidemiological research on CO survivability come from a study done on the impact of portable electric generators by US Consumer Products Safety Commission’s. That research showed 751 CO deaths versus were 8,703 CO injuries seen in emergency departments. In addition, that study also found that 25,400 CO survivors were seen outside of the ER. Thus, there were 34,103 treated compared to the 751 CO deaths, 45 times as many. That may actually under-estimate how many people likely survive carbon monoxide poisoning as the probability of death from generators is much higher than from other causes.  In the generator death cases the ambient air CO levels are much higher because generators put off nearly 100,000 ppm in their exhaust. [1] The U.S. government CDC estimates that 400 people die annually from carbon monoxide poisoning in the U.S.,.[2] Portable generators and furnaces are biggest contributors.

Thus if the death toll in Texas from CO is ultimately determined to be of a magnitude of plus or minus 50, that likely means more than a 1,000 may have suffered permanent brain damage from this one winter storm event. And the problems are not just in Texas. Most of the southeast had similar problems, if not on the scale of Texas.

Are any of the poisonings avoidable? Of course. Let’s start with a simple one. Iced up chimneys on commercial buildings. Hot air goes up chimneys, so they are not expected to freeze. But if it is cold enough (see Polar Vortex in Michigan in 2019) or there is ice, the heat coming out of the chimney may not be hot enough to prevent the ice from building up. Think of it like a defroster on your car. Generally, the defroster keeps condensation and ice from building up on your windshield. But that may not work in an ice storm. It becomes especially troublesome if you keep turning off the defroster. Well a commercial boiler rarely runs constantly, especially one that might be used solely for hot water for showers and laundry. If there is ice falling, that is going to build up in the cycles when the boiler isn’t firing. When the boiler kicks back on, the ice if it melts at all, it may only partially melt.

An iced up chimney is an obstruction to the flow of exhaust out that chimney. If the exhaust can’t go all the way out the chimney to the outside air, it will back up into the building. Counterintuitively, it is more likely to back up into the crawl space underneath the roof, than back into the boiler room. While the boiler room may have a CO detector, as the rooms on the top floor may not. The result: carbon monoxide poisoning with the only warming, a human being getting sick.

Another truly dangerous storm related phenomenon is the use of portable electric generators. Most people are smart enough to not put the generator in the basement but putting it in a garage or within 20 feet of a window can also cause serious levels of CO. Opening the garage door or a window won’t prevent CO poisonings. Any level of CO above alarming levels, can cause permanent brain damage. The higher the levels, the longer the levels exist, the worse the poisoning will get. 300 plus levels can kill. Generators are putting off nearly 100,000 ppm so even if diluted with some outside air, they will still be deadly. What doesn’t kill can severely disable, dozens of times more people.

I have often argued that generators should come with cords that are at least 20 feet long, to make the point that they can’t be used within 20 feet of a dwelling.

Combustion Air Problems create Carbon Monoxide Disasters

One of the reasons poisoning deaths are so high in Asia is that in many places they still use charcoal to heat dwellings. That phenomenon occurred in the United States in February. From the Dallas Morning News: “If a family is found in the living room around a grill.” Grills are meant to be used outside, where there is adequate ventilation and unlimited oxygen for the combustion. As explained above, if there is not enough oxygen for the amount of fuel that is to be burned, two things can happen: the fire will go out, or it will continue to burn with incomplete combustion. A fire going out is far less of a problem than incomplete combustion. Incomplete combustion causes smoke and more dangerously, the creation of CO instead of CO2.  Smoke smells and it may be visible, thus if the primary by-product of incomplete combustion is smoke, people will be warned. But smoke often doesn’t begin to be noticeable until CO in the exhaust gets to 4,000 to 5,000 ppm. Human’s noses are sensitive enough to smell it at lower levels. Dogs and other pets often warn of CO events because they can smell smoke at lower concentrations of CO. Humans can die before our noses will smell the smoke. This is why CO detectors are so important, because we can’t smell the CO.

Ovens and Stoves Need More Combustion Air

Warnings often include not to use a gas stove or oven to heat during power disasters. A first reflex when electric heat is out is to turn to gas burning appliances in a house. While this warning is given, reasonable explanations rarely follow. Why is it dangerous to use an oven to heat when it isn’t to bake? There are a couple of explanations, both which likely relate to how the oxygen gets to the flame. The first is a simple one: depending on how airtight the house is, there may simply not be enough oxygen inside the house to keep the oven/stove tops on continuously. A simple example may help: A candle can burn continuously in almost any indoor space without running out of oxygen, but if you light enough candles, and burn them for long enough, perhaps the oxygen is used up. A stove top uses a lot more fuel than a candle. All of the burners on a stove going at once, uses that much more oxygen. That oxygen has to come from somewhere. Houses have been made progressively more airtight to make them more energy efficient. But a perfectly sealed house may run out of oxygen if there are too many appliances using up the available oxygen.

People of course are fuel burning appliances too. Too many people, too many candles, not enough fresh air can equal of deficiency of oxygen. A deficiency in oxygen leads to CO.

The other concern with ovens is that they may be designed to only burn efficiently with the over door closed. With the oven door open, it may disrupt the flame in such a way to make it burn inefficiently. All burners are designed to burn with a predictable intake of oxygen. If the fresh air is coming from an unpredictable direction, it may interfere with the flame (much like blowing on a candle does) in such a way as to disrupt the burners. This is caused quenching of a flame. A quenched flame, creates CO. https://www.sciencedirect.com/science/article/pii/B9781483197531500099

For a more detailed explanation of why not to use gas ovens to heat, click here. https://allairsystemsnj.com/using-an-oven-to-heat-a-house-heres-why-its-a-bad-idea/

What is the takeaway to avoiding carbon monoxide disasters? A modern household is not intended to be heated by anything other than a furnace or electrical heat device. Improvising can be dangerous. Always remember that using a fire, be that in your oven, your car, or in a generator, comes with the risk of exhaust, which must be presumed to include CO. If that exhaust isn’t removed from the dwelling, poisoning may occur.

CO Alarms Save Lives

A properly maintained carbon monoxide alarm will warn of most poisonings and should certainly alarm before anyone dies. Many of these storm related deaths and poisonings would be avoided if all dwellings had carbon monoxide alarms installed. Such alarms should always be where anyone sleeps, regardless of whether there is a fuel burning appliance in that space. As in the commercial boiler with an iced up exhaust flue, CO may migrate to occupied spaces, distant from the actual fire.

Attorney Gordon Johnson

 

 

[1] We have personally seen levels as high as 90,000 ppm in generator exhaust but never more than 9,000 from a furnace or other HVAC device.

[2] https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6303a6.htm?s_cid=mm6303a6_e and https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5650a1.htm

 

 

Carbon Monoxide Warning is Implicit in Disaster Warnings

Every storm warning should parenthetically contain the words: Carbon Monoxide Warning as well. When power is out the risk of CO exposure rise.

By Rebecca Martin

Everyone who faced the wave of winter and ice storm warnings the past few weeks probably remembers those words and the rush to prepare for some late winter weather.  We made our trips to stock up on necessities and prepare for the possibility of icy roads and limited travel. Grocery store shelves were soon stripped of staples and if we were lucky, we were safely hunkered down at home when the ice began to fall. However, the ice storms that swept across parts of the country brought about the most dangerous of conditions for which many of us were unprepared. And if we were prepared, desperation brought about some desperate actions…even for those of us who know better. As temperatures dropped below freezing, the power went out. Water pipes began to freeze and no relief was forthcoming. And the days dragged on. Nowhere did that scenario become as potentially deadly as in Harris County, Texas where the Winter Storm Warning could have been a broad based Carbon Monoxide Warning. Over 580 people were poisoned by carbon monoxide poisoning in Harris County, Texas in the last week.

Winter storms should come with a carbon monoxide warning as well.

Inspecting chimneys and furnace flues should be part of every Carbon Monoxide Warning. Shown here is a chimney that ice over causing carbon monoxide poisoning in the 2019 Polar Vortex that hit the midwest. Much of the focus in Texas was in generators being run indoors but iced chimneys also contributed to CO poisoning events, including at name brand hotels. https://www.hometownlife.com/story/news/local/wayne-county/wayne/2019/02/04/carbon-monoxide-kills-woman-hickory-hollow-apartment-wayne/2770060002/

As temperatures plunged and the electric grid failed I am sure people searched local power outages and were reassured that the power companies were aware and crews had been dispatched.  What  many people didn’t realize is that it would be days until the power was restored and as the hours went by, desperation deepened. The desperation was due to the bitter cold that swept across the area and concerns about not only keeping one’s self safe but also the very young, those who are disabled and the very old safe in those conditions. Worry mounted as pipes began to freeze and the ensuing damage that burst pipes could cause to homes became increasingly present. Very quickly people were forced into survival mode in order to cope with days without power and little information about how long the outages would last. And all of these concerns brought to light a power grid that was intrinsically inadequate to keep up with the frigid temperatures and extreme conditions which occurred.

Carbon Monoxide Warnings Should Accompany Winter Storm Warnings

Carbon monoxide poisoning is a secondary disaster which often accompanies natural disasters. Wherever there is a potential for loss of power the danger of carbon monoxide poisoning rises. Let us follow the course of carbon monoxide poisoning as a result of natural disasters.

The National Institutes of Health warns that carbon monoxide poisoning can kill in as little as a few minutes.

People suffered from carbon monoxide poisoning running vehicles in attached garages in order to warm up, or maybe even to charge a device.

For those who were prepared with portable generators, some of the most common mistakes were made such as running a portable generator in the garage or other enclosed space. The Consumer Product Safety Commission (CPSC) has data showing that 900 people died of carbon monoxide poisoning due to portable generators between 2005 to 2017. Thousands have been injured. Yet every year we see the news stories relating these types of injuries or deaths. While these incidents are often due to a lack of knowledge on the safe operation of generators, what we don’t see is the utter desperation which leads to lapses in judgement. The unique weather conditions and ensuing problems of the past couple of weeks is a true study in how brutal a winter weather advisory can become.

Portable generators are the most highly recommended types of generators for natural disasters. They were built to be easily wheeled outdoors in case of an emergency and to be connected to appliances through the use of extension cords or a transfer switch. They are highly recommended in emergencies such as fires to stay informed as to evacuation routes and overall recommended as a means to charge cell phones and other devices to stay in contact with others, including emergency services. Portable generators are capable of powering a refrigerator or a sump pump, hot water heaters and lights. All manufacturers warn that a portable generator should not be used indoors or in any enclosed space. Manufacturers also recommend that you choose the correct model for your family’s projected needs during a power outage to avoid overpowering the system during an outage.

Recommended maintenance of portable generators includes an oil change after the first 30 hours of use and every 100 hours thereafter. Spark plugs and filters should be changed every 200 hours of use. The fuel tank should be emptied when not in use. Those with an electric start should be fully charged before storing or kept plugged in using a trickle charge. It is also recommended that once a month the generator is started and allowed to run a few minutes to guarantee an easy start during an emergency.

Generators Should be at Least 20 feet from Home

Newer generators may feature a sensor that triggers an automatic shut off should the concentrations of carbon monoxide rise too high. And some produce less carbon monoxide to begin with. But this implies that it is sometimes ok to run a generator in a more enclosed space which is not the case. A portable generator should be no closer than 20 feet to your home with the exhaust directed away from the home and especially away from windows and doors. When using extension cords they need to be of the approved outdoor variety and appliances should be directly connected to the generator. Generators should be equipped with an approved cover to protect it from the elements. Generators should also be allowed to cool thoroughly to avoid another common hazard associated with portable generators; burns and fires when gas comes in contact with hot generator parts.

A transfer switch can also be installed to directly connect your generator to a circuit panel to power all your hardwired appliances. This is a safer option as it eliminates extension cords and allows you to monitor the usage while in operation.

Under no circumstances should a generator ever be plugged back into a wall outlet in an attempt to back feed your house. This poses an electrocution risk for electrical workers and other residents who share the same electrical transformer as your home.

Carbon Monoxide Warning Should be Part of Disaster Declarations

But why did the power fail in Texas and why did it fail for such an extended period of time? The answer involves another perfect storm of events which led to the total lack of preparation for the frigid weather that was predicted. According to a Houston Matters interview, the Houston Public Works Director, Carol Haddock stated that most utilities are underfunded  which played a role in the failure of the power grid. Houston has a revenue cap which limits the growth of property tax which ultimately limits funds available for infrastructure improvements. Thus the overall failure was not due to damage due to a storm but rather due to a lack of power generation by the utilities themselves. Though generators were quickly being brought back online, they were as quickly failing as they were just inadequate to the task.

However, all 254 counties in Texas were under a disaster declaration. This has led to a request by Gov. Greg Abbott to the Texas legislature to update the state’s power generators, an investigation of the Electrical Reliability Council of Texas (ERCOT) and a hard look at the state’s preparedness for emergencies.

It wasn’t just Texas which fell victim to the cold weather. Deaths related to the frigid weather and ice storms spread across eight states. A 61-year-old woman died of carbon monoxide poisoning in Kentucky after running a generator indoors. A mother and child died of carbon monoxide poisoning in Houston, Texas while over 500 Texans reported into emergency care for carbon monoxide poisoning. Four people died of carbon monoxide poisoning in Oregon. Other deaths occurred due to frigid temperatures, vehicle crashes, house fires, falling through or on ice while other weather related deaths also occurred due to tornadoes; a total of 30 weather related deaths in the past several days.

As I personally live in one of the areas affected by the storms and frigid temperatures, it is very easy to see the problems which were not reported in the news.  I was not even able to reach my portable generator due to the icy conditions outside. Just a trip to use my car to recharge my phone proved almost impossible during our extended power outage. Everything outdoors was instantly solid ice and even salt wasn’t having much effect. It was a very unusual type of storm which immediately resulted in power outages. At first I checked the outage map and was reassured that crews had been dispatched. What I didn’t grasp is that the date of restoration was not until the following day and when that projected time came and went, real dread set in over the unknown.  Especially living in a more rural area where the roads not only became treacherous but also impassable due to fallen trees and branches. As temperatures dropped to 13 degrees and visions of burst pipes began to create real anxiety, I truly understood the desperation people can feel in that situation. And how judgement becomes impaired. I can only imagine how much more difficult it is for families who have young children, the health compromised or the elderly to be concerned about.

What do we do when the temperatures are frigid and the power is out for an extended period of time?

First and foremost it is important to conserve body heat.  Extra layers of clothing, a hat…and settling down under a heavy blanket, especially with the kids,  will help conserve heat.

Do not burn anything larger than candles in your home. If you have a wood burning fireplace make sure you have routine inspections and chimney cleanings to insure proper combustion and exhaust. Quality hardwoods which have been cured for at least six months provide the most heat and the least smoke. Do not burn charcoal meant for barbecuing in your fireplace. Many gas fireplaces are equipped with a battery backup for use during a power outage. Older gas fireplaces can be lit manually while most newer models have a safety system which requires electricity to ignite. Check your manual or consult your dealer on the recommended use of your model during a power outage. Remember that electric starters can ignite when the power comes back on and ignite standing fumes.

Carbon monoxide warmings should include gas stoves Gas stoves should never be used for heating an indoor space and electric stoves were not designed to be a space heaters. Gas stoves were never meant to be left on for long periods of time, first of all. Most gas stoves have electronic igniters and controls. So the danger lies in having a possible spark igniting fumes when the power comes back on. Although gas stoves can be lit manually to cook with, leaving them unmonitored can be a recipe for disaster. In most modern stoves you will not be able to bypass the protections to light the oven, or even the burners. Older stoves may be very inefficient and therefore at greater risk for carbon monoxide. If you must use your gas stove during a power outage, you should cut the power off to the stove to avoid an electronic start and possible spark when the power comes back on and use proper ventilation (sometimes impossible without power).

Even Gas Stoves May Require Outside Oxygen

But I much prefer this answer to the question posted on google. The question: “How long can I leave my gas stove top burning while lit?” Answer: “Until the gas runs out, the oxygen in the space has been depleted, or your house burns down.” A fair carbon monoxide warning is that no source of combustion should be left unmonitored. Always keep a method for extinguishing fires handy as well.

A commonsense list of actions to take when your power goes out is available at https://www.bobvila.com/slideshow/10-things-you-should-never-do-when-the-power-goes-out-51457

Here, in Kentucky we had initial storm warnings which I took with a bit of a ‘what else is new’ attitude. The initial warnings did not include carbon monoxide warnings. But after being without power for a few days I took the warning for the second round of storms much more seriously and was able to ride out any ensuing outages a little more comfortably with appropriate preparation. The lesson learned was it is better to over prepare than under prepare. Now, following these winter storms,  is a good opportunity to jot down a list of things which were lacking in your preparation: From batteries, to water pipe insulation, to a product to allow for safe footing on the ice, to food items which require no cooking and water in case the water supply is compromised as it was in Texas. For instance, I keep gallons of water in unused space in my freezer to help keep my freezer from completely failing and to keep a supply of water on hand at the same time. Portable chargers are available for phones and other devices. It really would benefit all of us to do routine checks of our disaster preparedness and develop plans for emergencies, especially those lasting more than 24 hours. When you hear the phrase winter storm warning, think carbon monoxide warning.

A list of items for an emergency preparedness kit is available at https://www.ready.gov/kit This site offers advice on preparing for any type of emergency, local or national, natural or manmade,  with very specific plans for seniors, families, people with pets, people with disabilities, etc.

One last point to consider is that as our planet changes we are seeing more instances of extreme and unexpected weather. We have recently witnessed extensive fires, powerful weather fronts and record weather extremes which have challenged our nation and world increasingly the past few years. In conjunction we have seen greater delays in federal response as disasters pile up on top of each other.  We really need to be realistic that we need to expect the unexpected and prepare for the worst while hoping for the best.

We also need to know where to turn for assistance after being impacted by a natural disaster. Information on assistance on the federal level can be found at https://www.usa.gov/disaster-area-helpAdditional information on where to turn for federal aid following a natural disaster is also available:

Call USAGov at 1-844-USA-GOV1 (1-844-872-4681) to ask us any question about the U.S. government for free. We’ll get you the answer or tell you where to find it. We are open between 8:00 AM and 8:00 PM Eastern Time, Monday through Friday, except federal holidays.

            I think one thing we can agree upon is that we should plan for natural disasters beyond the days or few hours leading up to the expected impact. Having emergency plans, essential emergency kits and supplies and routine maintenance and inspections of alternate energy sources are necessary and essential. Preparedness is more than stocking up on milk and bread.

            And always make sure you have not only carbon monoxide detectors installed but they are installed/replaced/inspected when needed. Keeping an extra battery powered detector on hand is also a good idea when dealing with portable generators, use of a gas fireplace or stove and anywhere combustion may cause carbon monoxide build up. Carbon monoxide is invisible and odorless; a detector is the only method of detecting its presence in your home.

For those interested in helping Texans impacted by the recent storms go to https://www.cnn.com/2021/02/17/us/texas-winter-storm-how-to-help-iyw-trnd/index.html

           

Basal Ganglia Lesions After CO – More than Movement

Basal Ganglia Lesions after carbon monoxide poisoning cause more disability than disfunction related to movement.

We have mentioned in several blogs that one of the long term effects of carbon monoxide poisoning can be basal ganglia lesions in the brain. We have also addressed many of the long term symptoms which can arise due to carbon monoxide poisoning.  One of the most recognized conditions of carbon monoxide poisoning is damage to the basal ganglia lesions which form as a result of both hypoxia and the inflammatory effects of the reaction to the poison.

Basal ganglia lesions can occur in any of these structures

Shown here are the basal ganglia and there relationship to the brain stem and the hippocampus and amygdala. This is a coronal view, as if looking straight at the face.

The basal ganglia are associated with motor control which also expands to include motor learning , executive functions, behaviors and emotions. The basal ganglia are involved in the fine tuning of many voluntary motor functions, a control center adjusting and modulating signals to the skeletal muscles via the cranial nerve nuclei and spinal nerves.

Other functions deal with our processing of rewards and modulation of addictive behavior as well as language processing, learning, goal pursuit, decision making, eye movement, motivation and emotional response. Because it is influenced by dopamine it helps determine the level of euphoria we may experience from rewards such as sex, drugs and other external stimuli and keep those in balance

The basal ganglia, according to the Physiopedia “ are a cluster of subcortical nuclei deep to cerebral hemispheres. The largest component of the basal ganglia is the corpus striatum which contains the caudate and lenticular nuclei (the putamen, globus pallidus externus, and internus), the subthalamic nucleus (STN), and the substantia nigra (SN).”

 

 

Basal ganglia lesions include globus pallidus lesions

Basal ganglia lesions can occur after carbon monoxide poisoning. Shown here is the globus pallidus as lesions there are quite specific for carbon monoxide poisoning. As can be seen, the globus pallidus is tightly tucked in among other structures, including the putamen which is cutaway here to show the globus pallidus.

When the basal ganglia are damaged after a brain injury such as carbon monoxide poisoning it can result in any combination of the following deficits.

Chorea can Occur as a Result of Basal Ganglia Lesions

Chorea is when small repetitive movements start in one part of the body and then randomly move to another part of the body. Chorea comes from the Greek word for “dance”. The person may appear to be restless, fidgety or dancing. These movements are completely unpredictable. Yet individuals with chorea will sometimes incorporate these movements with voluntary movements in order to appear normal.

Athetosis is a stream of writhing effects most commonly in the hands and feet, and in some cases in the arms, legs, neck and tongue. These are called athetoid movements and are slow and rolling movements.

 

Chorea and athetosis tend to occur together. Another type of chorea called hemiballismus involves the involuntary flailing of the arm in a violent manner.

 

There are a number of good videos on Youtube on brain anatomy in general and specifically about the basal ganglia. Linked here is one of the good ones.

Dystonia After Basal Ganglia Lesions

Dystonia consists of sustained, involuntary muscle spasms that can force people into unusual body positions.  It most commonly affects the eyes, jaw, mouth, neck, arms and legs. Rarely it can affect the torso as well.

Segmental dystonia affects two or more adjacent muscle groups.

Parkinsons can Originate in the Basal Ganglia

Parkinsonism displays as a resting tremor, stiff muscles, slow or delayed movements, difficulty initiating movement, difficulty with balance, difficulty with walking and a shuffling gait.

People suffering from damage to the basal ganglia may also exhibit obsessive-compulsive disorder as the basal ganglia are also connected to the prefrontal cortex.

There are several treatments for helping manage these effects of damage to the basal ganglia. There are medications to manage muscle spasms such as trihexyphenidyl and baclofen. Botox injections are sometimes used to block signals to the affected muscles. In extreme cases surgery is an option. But the most common management is through neuroplasticity. Working with a neurologist and physical therapist to retrain the affected muscles and rebuild neural pathways.

Many of these effects of damage to the basal ganglia are painful as well as debilitating. Neuroplasticity treatment works on alleviating the secondary effects of basal ganglia damage, not the damage to the basal ganglia itself

Studies of basal ganglia damaged by carbon monoxide poisoning show a diminished perceptual organization and processing speed function. Carbon monoxide causes permanent brain damage and damage deep inside the brain may actually cause more global brain dysfunction than injury to the cerebral cortex.

As we have seen in the previous blog, many systems in the brain work at regulating the function of other elements, either enabling them or inhibiting them. The job of the basal ganglia is to fine tune the signals and responses. In the case of the basal ganglia it uses two pathways to process signals; the direct pathway and the indirect pathway. The direct pathway selectively activates certain motor or cognitive programs in the brain and the indirect pathway inhibits the execution of competing motor program.

The job of the basal ganglia is not to initiate motor programs but to regulate the execution of commands so that the particular command is completed without competing commands interfering with the actions for the task at hand. It basically acts like a gateway modulating the priorities passed down from the cortex.

It becomes more complex as there are certain cognitive functions that also look through the basal ganglia. Those are often cognitive functions having to do with motor learning and other functions which have a motor/cognitive interplay.  This extends to tasks which require repeated trials and involve unconscious learning. Think of this as similar to muscle memory where through practice your muscles learn a task which then becomes automatic to us. And this works both ways that a cognitive stimulus might impact a certain correlation to a motor response. We might not be able to explain how we learn something through repetition but we learn it anyway.

Think of the basal ganglia as a sort of circuit board plugging in the correct cognitive and motor programs required to complete an action. Someone throws you a ball and aside from the action needed to physically catch the ball, you are using information about size, velocity, etc to perform that task so the basal ganglia is plugging in those programs to assist.

It is thought that obsessive-compulsive disorder due to damage to the basal ganglia may involve a lack of inhibiting certain actions which can be repetitive or in reverse, cognitive functions which become repetitive without an order to stop.

The basal ganglia is one of the least understood areas of the brain and it is through studies of movement disorders such as Parkinson’s Disease that insight is being gained. It is only recently that we are beginning to understand the link between the basal ganglia and emotions.

If we understand that motor responses to stimuli can involve an emotional component then this is easy to grasp. We react to pleasant and unpleasant stimuli differently. This response is divided into valence, which is movement toward or away from a stimulus, and arousal, which is the intensity of the emotional activation. The role of the basal ganglia in emotional response is very complex and reaches into the foundations of our understanding of morality and other abstract thought.

What is not fully understood about the basal ganglia is how it activates with the absence of motion as studies are only able to measure the cognitive and emotional components in the presence of a motor response. For example, test subjects pushing buttons in response to presented stimuli. It is generally presumed though that response inhibition is shared by all aspects including motor, cognitive and emotional response to some extent.

The basal ganglia are such a complex subject which is generally agreed to be understudied and much of our current understanding comes from animal models. It is really only through the study of movement disorders that we are gaining a clearer picture of the complexity of the basal ganglia’s role in all aspects of brain functioning. New advances in neurosurgery and electrophysiological are also advancing our understanding.

We are also beginning to understand that basal ganglia lesions are more likely in acute carbon monoxide poisonings where a more diffuse damage occurs through long time exposure. This is a significant finding in that arguments that damage has occurred over a long period of time may not hold up as an excuse for a severe case of carbon monoxide poisoning.

Of further note are studies that show that basal ganglia volumes may diminish over time after carbon monoxide poisoning.

According to  a study by Hopkins RO, Fearing MA, Weaver LK, Foley JF, Brain Injury, March 2006; 20(3): 273–281.

Carbon monoxide poisoning results in basal ganglia volume reduction 6 months post CO poisoning. Slow mental processing speed and impaired memory correlated with smaller putamen and globus pallidus volumes. Clinicians need to be aware of basal ganglia neuropathologic changes in the absence of observable lesions following CO poisoning.

Their study found 28% of subjects had volume reduction in at least one basal ganglia structure by 6 month leading to a reduction in verbal memory and mental processing speed.

Similar findings regarding reduced volumes in the structures of the basal ganglia have been studied in cognitive disorders such as dementia with Lewy bodies (DLB) where memory was relatively spared while processing speed, attention and other executive functions were compromised.

This expands the scope of damage to the basal ganglia and its impact on not only the motor system but the executive functions as well. In addition, it opens up the connection between the delayed long term effects of carbon monoxide poisoning and decreased volumes in the structures of the basal ganglia in addition to the presence of lesions. Or more precisely, even in the absence of apparent lesions.

The basal ganglia may be one of the least understood structures of the brain but there is no mistake that acute carbon monoxide poisoning can cause permanent and far reaching damage to those structures. And that damage reaches out beyond motor impairments into almost all aspects of the brain’s function in ways we are only beginning to understand. Motor functions, cognitive functions, emotional responses, and behavioral responses relying on the ability of the basal ganglia to put all of the programs together to allow us to act, learn, commit to memory and more.

And so much more than its dictionary definition “a group of structures linked to the thalamus in the base of the brain and involved in coordination of movement.”

Not all CO Related Brain Damage Has Lesions in Globus Pallidus

Basal ganglia lesions have had outsized importance in the diagnosis of carbon monoxide brain damage because for a long time, it was believed that all of those with carbon monoxide poisoning would have basal ganglia lesions. That belief has resulted in a severe under diagnosis of permanent brain damage after CO poisoning. First, lesions deep inside of the brain can be subtle, with most neuroradiologists having little experience in calling CO poisoning damage. Too little time is devoted to reading clinical scans and these lesions are often missed. Further, imaging capacity has increased exponentially over the last decade but much of that technology is not used or understood in the clinical setting.

Better MRI Techniques Do More than See More Lesions

Increased resolution has identified more lesions. Increased lesions has helped differentiate abnormal signal in the basal ganglia that are often ignored. Further, smaller gaps between slices makes it less likely that a lesion, which may be smaller than the gaps between slices, may be missed. A 4 millimeter globus pallidus lesion could be significant, but most clinical coronal imaging has 5 millimeter gaps between slices. A 2 mm lesion would likely be missed. Often, coronal sequences, which are best to see these lesions, aren’t even done on many clinical scans.

Further brain volume can now be accurately measured using 3D MRI tools. A loss of volume in the basal ganglia may identify pathology even though a specific lesion or bleed might have been missed.

This blog was written by Rebecca Martin

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Brain Damage in Teenagers is Not Lessened because it is Hard to Distinguish

Brain damage in teenagers is more complicated than in adults as adolescence creates unique challenges and vulnerabilities for long term problems.

Many adults fail to appreciate the many unique challenges faced by teenagers. The teenage years are a time of huge social and sexual development in a world which is suddenly demanding more of them. Judgment has not completely developed and risk taking behaviors are viewed much more casually than an adult might view them. Our kids are facing career and education choices after they leave high school and in current times, these choices are adding pressures in an increasing manner with each passing year. Look good, fit in, excel–it truly is a time of super stressors while trying to transition from childhood to adulthood.

A greater tendency towards risk taking behaviors and an immature development of judgment can lead to dire consequences which can basically derail a teen if these behaviors result in brain damage. Especially when looking at the delicate balance a high performing teen may be keeping up with in often too busy schedules. With entrance exams and scholarships looming, a brain injury can be just the impetus to throw a promising teen off track.

Brain Damage in Teenagers is Complicated by Puberty

With the onset of puberty, brain injuries sustained in childhood may resurface as different areas of the brain mature and the damage which has remained mostly unnoticed suddenly becomes critical for successful functioning.

Children and teens are more susceptible to headaches following a concussion and it is not unusual for headaches to continue for up to a year following a concussion. And there is good evidence to support that the emergence of migraines after puberty, especially in girls, could likely be linked to a former injury in childhood. This appearance of migraines would be correctly diagnosed as post-traumatic migraine even though the incidence of concussion may not immediately precede the onset of migraine symptoms. And while we may write off headaches as a mild symptom of little concern, we must consider the fine line our teens are balancing on to take the steps they need for success during the short period of time we label adolescence.

University of Washing Research on Brain Damage in Teenagers

Researchers at the University of Washington in Seattle did a study of 512 children with brain injuries and discovered that children who had suffered a mild traumatic brain injury suffered from headaches and that the headaches were more severe in nature. Nearly half of the children suffered from headaches at least 3 months following their injury. And although most of these headaches resolved after a year, we are dismissing that the year is one quarter of the time spent in high school and that can drastically impact scholastic, sport, and other specialized performances.

Even Short Term Problems can Cause Life Disruptions

A year is a long time in the mind of a teenager and some conditions can impact them in terms of self-image as well. If reading gives one a headache for a year, then they are likely to presume that reading gives them headaches. You can quickly see where that perception might impact a young person’s performance in college.

Hormonal Damage in Teens

Traumatic brain injury in childhood may also impact the way hormones are produced and regulated once puberty hits. Hormones control our sex drive, how we reach puberty,  and our growth. In addition they impact the way we gain weight, and our feelings of thirst and hunger. Hormones impact our energy levels which amplifies certain aspects involved with the way the body gains weight or deciphers our need for food.

Brain damage in teenagers can be complicated by pituitary damage, which magnifies hormonal changes. Shown here is an empty sella, where the pituitary gland is expected to be.

These factors are related to the pituitary function and malfunctions are referred to as hypopituitarism. This can present in different ways. Growth may be stunted and a young person may not achieve puberty at the expected time. Menstrual cycles may be delayed to interrupted. There might be a lack of libido or sex drive which can result in psychological issues, especially depression.

 

On the other end children may reach puberty much earlier than expected.  This is called precocious puberty. Children may develop physically before their peers. This can be impactful in a child wanting to fit in with their peers but developing the physical signs of puberty long before their peers do.

Another problem with brain damage in teenagers is its impact on inhibitions. Disinhibition, the term for a loss of inhibitions, may present in multiple ways. It can be of a sexual nature in which a young person may say inappropriate things, have difficulty discerning when the appropriate time and place is to discuss things of a sexual nature, have difficulty following social norms and may even exhibit a lack of  concern for others’ personal sense of space through touch or merely standing too close to others. This type of disinhibition tends to make people uncomfortable and can greatly impact the child suffering from this as it is impossible to judge one’s own behavior when hormones are involved with regulating these behaviors. Insight is very difficult and confusing.

Symptoms Can Impact Young Adulthood

It is widely accepted that adolescence really extends to the age of 25, when the brain reaches full development. Brain injury during adolescence can impact the executive functioning of the brain. This is your ability to plan, organize and defer gratification. This effects one’s ability to make good decisions. Young people in this age range are capable of logical thinking but are not entirely developed when it comes to executive functioning and thus not capable of the exhibiting that same degree of logic in the decision making process. Thus, damage to the executive functioning of the brain can place young people at a far greater risk for poor decision making during this developmental phase.

Brain injury can affect the way executive functioning develops. As a consequence it can also adversely affect the way a young person might view their self and have very dire consequences. This is exacerbated by the teen’s knowledge that something is wrong but unlike a physical disability, it is invisible to those around them and therefore not addressed. This entire process is occurring during the critical time when a young person is discovering their identity and how they fit into society while setting the foundation for their success as an adult.

When looking specifically at teens in the 16-17 year old range brain damage in teenagers becomes particularly problematic. They have just come through puberty and navigated the changes from childhood to adolescence. They have established a basis for who they are in the world. Then we introduce a brain injury and shatter what is already a somewhat fragile sense of identity. It can upset the social structure they have built with family and friends as they begin to see different responses from those around them to this changed person they have become due to a traumatic brain injury. Disinhibitions may create social tensions in what were comfortable social circles prior to a brain injury. This tension can lead to an increased isolation and depression.

The impact of brain damage during adolescences is never more tragic than when it leads to suicide.

For our Pop Warner litigation over brain damage and football, click here.

Some individuals are going to feel the impact in other ways. The straight A student who has never had to work hard for grades is suddenly facing difficulty with comprehension and memory. This involves not only an emotional acceptance of the changes but learning a whole new set of behaviors and expectations. Similarly, the gifted athlete may experience a greater impact when what was automatic, suddenly becomes a hurdle which they must struggle over.

Often in these cases it is the parents themselves who struggle with the personality changes in their child injured during adolescence. They know their child prior to injury and the changes can be written off by lumping the changes into the onset of adolescence. Unlike children who advance into adolescence with a familiar and visible disability, children who suffer a brain injury and the subsequent changes in personality can be become alienated from both social systems and educational systems. All the dreams and aspirations of both the child and the parents may be threatened. The outcome may be that the child simply gives up because they are not living up to prior expectations and no one is really seeing what is going on in the child’s brain.

How do we then avoid losing promising teens to depression and despair due to brain injury and help them to achieve their goals? First, by a better  understanding that outward appearances have no correlation to what a teen might be going through due to a traumatic brain injury. Returning to school should be faced with a transition plan which offers coping and compensatory strategies for the teen.  Proper identification and assessment of the specific challenges each individual may face is also essential. We have to address four different areas; physical , emotional, social and behavioral functioning.

Focus and concentration may be more difficult in a busy classroom making it difficult to retain the information presented. The struggle to focus and concentrate can result in frustration and fatigue. To counteract this we might seat this student closer to the teacher and provide learning aids which minimize the demands of the classroom setting including written materials to study in a quieter environment. We might allow for frequent breaks to allow information to be processed. Schedules, reminders, organizers–there are many tools which can aid a student who has suffered a traumatic brain injury.

Behavioral problems may present and are often triggered by too much stimulation and a lack of predictability, structure or organization. This leads to fatigue and frustration which may grow throughout the day. Add to this the negative response from teachers and other students and we have a situation where behavioral issues get out of control. Ron Savage, EdD, classifies adolescent brain injury as a “developing disability over time” (Savage, 2012). As such, students with traumatic brain injury need to be re-evaluated regularly to ensure the success in navigating the education system.

Because adolescent brain injury can lead to a greater incidence of high risk behaviors, the communication lines at home need to be kept open. Parents need to educate themselves as to how to better assist their child and above all to understand that what is happening to their child is not necessarily intentional or under the child’s control. It is more likely that the child is confused and even unaware pf the changes which have occurred and why everyone is suddenly reacting differently.

It is also highly recommended among professionals that teens have a support group with other teens going through what is happening to them if at all possible. Teens communicate with each other differently than they do with adults and working through the issues with other teens is extremely helpful.

Whether a child is facing disrupted hormonal changes when reaching puberty after suffering a brain injury in childhood or has had their adolescence interrupted by a brain injury, the result Is often the same. A child can be lost in their journey to establish their identity and fail to build the supports to guarantee a successful adulthood. They may fail in the education system and lose social supports so essential to development. This does not seem to be lessened by the time period in which they are affected. Whether it be for a year or a present and permanent change, their self-image can be permanently altered in those periods of time. Their expectations of themselves may fail and their dreams can get lost.

I often hear people complaining about “that generation” but I empathize with the utterly terrifying pressures teenagers face today.  They not only are facing family expectations and peer pressure; they have overwhelming educational expectations and so many activities they are expected to excel at. And then they have the added pressures of media and social media to ensure themselves against. But unlike past generations we do have a greater understanding of brain injury and its impact on the adolescent brain as well as more resources to ensure the success of those impacted.

Whether a brain injury occurs due to carbon monoxide poisoning, a sport injury or an auto accident, it has a unique impact on different individuals. We often see the impact on children explained, and we see the special circumstances for the elderly. The most sensitive function of the human mind to brain damage is behavior.  Yet with the adolescent brain, it is hard to identify such changes without comprehensive and enlightened diagnosis as behavior and problems are so often attributed to “just being a teenager”. And individuals get lost in a system which is slow to recognize and validate the long term symptoms of brain injury. In those cases we see bright lights dimmed who just needed to be acknowledged and supported to achieve their places in society.

As I quoted above, brain injury is a “developing disability” that with diligence can be managed if the individual is set up with a transition plan and a plan for routine assessment for the long term.

This blog was written by Rebecca Martin

 

 

 

 

 

 

 

Carbon Monoxide and Keyless Ignitions

Carbon Monoxide and Keyless Ignitions are causally connected because the physical act of of pulling out the key is no longer required to stop the car engine. Thus people forget to turn off the car, especially in quiet cars like hybrids.

We are in love with technology. From our phones to gadgets designed to make our lives easier.  Gadgets have become a part of universal commercial appeal in multitudes of products. One field which has encompassed this love of gadgets is the automobile industry. I am of the generation that grew up with manual windows you had to roll up and down and radios you had to spin the dial to find a station. I remember having a new car for several years before I realized I could adjust the radio with the steering wheel controls. But what happens when habit overrides technology and places an entire generation at risk? This is the issue raised by the introduction of keyless ignitions.

Carbon Monoxide and Keyless Ignitions

Carbon Monoxide and Keyless Ignitions are causally related because quiet cars do not require the act of physically turning off an engine before leaving them in a garage. This is particularly a problem for people who learned to drive more than a generation ago. One must honestly ask: what purpose did eliminate the ignition key actually serve? 

The Connection Between Carbon Monoxide and Keyless Ignitions

Older people, in particular, after a lifetime of putting the key in the ignition and consequently turning the car off and removing the key, have become victims of the seemingly innocent keyless ignition. A keyless ignition consists of a fob which activates and deactivates the ignition by pushing a button. In some models of vehicles this fob is incorporated into the dashboard as an “intelligent access ignition”.  A convenience which is perhaps enjoyable as gadgets can be but ignores the fact that many of us are creatures of habit. While we are not impacted by the action of using a fob or a button to start the engine, habit can kick in and cause us to forget that we also need to push a button to turn the car off. One might feel comforted feeling the key fob in one’s hand without making the connection that the car has not been turned off. And this can lead to carbon monoxide poisoning as direct result of a keyless ignition.

Older people are not the only ones at risk to carbon monoxide poisoning from a keyless ignition. In 2018, a Louisville, KY father turned on his car which was parked in the garage to warm up while he readied his young children for school. The father placed his three-year-old in the car seat. Both were found deceased at the scene. The eight-year-old died the next day at the hospital. All victims of carbon monoxide poisoning in part due to what can be seen as a somewhat predictable misuse of a keyless ignition system. The convenience of a technology which sometimes bypasses the mindfulness a traditional ignition system.

Carbon Monoxide and Keyless Ignitions – An Invention that Served Little Purpose

Originally the automotive industry touted the safety of a vehicle that continued to run when the fob was not present. It was viewed as a way to avoid being stranded in case the fob was lost or the battery died in the fob. You drop someone at the airport and they take the fob with them, you are still able to drive home but will not be able to restart the car once the engine dies. But vehicles continue to run until they are out of gas and that is where the problem lies with carbon monoxide and the keyless ignition.

Newer cars run with quieter engines as well. And the elderly are less likely to be alerted that their vehicles are still running once they are at their destination. And this can turn into a deadly situation if the car is left running in an attached garage. In addition, the  action of opening and closing the garage door itself can mask the sound of the running engine and increase the possibility of carbon monoxide poisoning.

Another issue arises with SUVs which can experience backdrafts when only the tailgate is left open while the vehicle is running. This can lead to dangerous carbon monoxide levels in the vehicle if the engine is unknowingly left running, i.e. again connecting Carbon Monoxide and Keyless Ignitions.

17 million new cars are sold annually in the United States and over half of these feature a keyless ignition. Toyota and Lexus are responsible for 47% of the known deaths tied to the keyless ignition, but the problem is more widespread I the automotive industry. Were there concerns that keyless ignitions might pose a danger? Years earlier, the Society of Automotive Engineers recommending a warning system consisting of a series of beeps to warn drivers if the car was still running without the fob in the car. It was also recommended that an automatic  shut-off feature was used to shut down a running vehicle after a certain amount of time. The Society of Automotive Engineers were not the only ones concerned about keyless ignitions.

The National Highway Traffic Safety Administration backed federal regulations which would require a software change that they estimated at pennies per vehicle. Opposition from the auto industry left that idea in limbo indefinitely.

In 2015 ten automakers were sued by US consumers who claimed that the automakers concealed the risks associated with keyless ignitions. They sought for the installation of safety shut-off features to be mandatory in vehicles with keyless ignitions. This lawsuit was sparked by 13 deaths which had occurred to that year, citing 27 complaints which had also been filed with the National Highway Safety Administration.  The lawsuit contended that the automotive industry had been aware of the risks since at least 2003 when keyless ignitions had been introduced industry wide.  The lawyers referred to the risk of keyless ignitions as a “deadly defect”. The society for Automotive Engineers had also estimated that adding safety features to the fob itself would result in a cost to manufacturers of pennies for every vehicle.

For Carbon Monoxide Poisoning Frequently Asked Questions, click here.

Hybrid vehicles present another facet of the dangers of keyless ignition. Once parked the engine may not be running at all, until the battery runs low. The car engine then starts and deadly carbon monoxide can follow.

While some automakers have taken the risks seriously and taken corrective actions, just like the boat safety issues we discussed earlier, used cars are still on the market. Consumers are not educated to the special risks these vehicles bring with them. Research into your vehicle’s keyless ignition system is highly recommended whether one is buying used or new.

There is also the possibility that keyless ignitions may result in higher insurance premiums, not only due to the risk of carbon monoxide poisoning, but also due to the fact that there have been  instances of hacking these systems resulting in vehicle theft risks. There is also a risk of the vehicle rolling upon exiting the vehicle as the keyless system does not remind us to put the vehicle in park. Severe injuries and property damage have occurred when a driver has left the vehicle with the fob in hand and neglected to put it in park.

NHTSA recommends a safety checklist for all owners of vehicles with keyless ignitions. This includes always making sure your vehicle is in park before exiting, always shutting off the vehicle, engaging the parking brake, reading the owner’s manual regarding the use of your keyless system and watching their safety video at https://www.nhtsa.gov/driver-assistance-technologies/keyless-ignition-systems

Garages are Incubators for Carbon Monoxide Poisoning

There are many news articles about the people who have suffered deadly consequences and one thing that sticks out is that the victims are often elderly people with distinguished careers who were still leading active, involved lives at the time of their deaths. One can only guess that seniors keeping an active lifestyle might be very prone to falling back to habit as they focus on their schedules and that one slip in focus can become deadly. But younger drivers are also affected because often vehicles are started prior to pulling out of a garage and in the case of the keyless ignition, that fact may be forgotten while they are getting children ready or other distractions. A running vehicle parked in an open garage can also produce dangerous carbon monoxide due to backdrafts. Not having to physically place a key in the ignition results in many scenarios that we all can envision in often hectic lives.

Keyless ignitions were introduced by Mercedes in the 1990’s and spread to other luxury vehicles in the early 2000s. By 2008, 11% of vehicles featured keyless ignitions and by 2018 that number had grown to 62% of all vehicles. A rapid growth for a feature of convenience that few of us are aware could become deadly in the wrong circumstances.

Is Alarming Enough?

Some automakers have added alarms for the fobs when the driver is out of the car with it, or automatic shut-off features. Future safety features might include smartphone apps which can warn us that the vehicle has not been shut down. Having had elderly drivers in my family, I wonder how effective some of these measures are for elderly drivers, especially those hard of hearing or technology challenged? I would encourage those with elderly family members to make sure drivers are aware of the risks when using a keyless ignition system. If federal regulations can’t be agreed to, then we have to be concerned personally with the welfare of our elderly. Even if that means a well-placed reminder to shut the vehicle off.

In 2019, a bill was introduced by Senate Democrats to address the dangers of carbon monoxide poisoning and rollaways due to keyless ignitions. The Protecting Americans from the Risks of Keyless Ignition Technology (PARK IT) Act also called for automakers to include automatic shut-off technology in all vehicles. The cost for this would be around $5 per vehicle which is the amount that General Motors said it would cost to retrofit existing vehicles with this feature. The sponsors of the bill pointed out that new convenience gadgets should be equipped with safety features including appropriate labeling and information about how this systems function. The PARK IT Act has yet to be passed.

The New York Times 2018 investigation into keyless ignitions identified 28 fatalities and 45 injuries since 2006 directly related to keyless ignition systems. Rollaway incidents add to that number. Even so it remains a popular feature in new vehicles and we can only expect that number to grow. Hopefully its growth is accompanied by adequate alarm systems, automatic shut-off features and standardized warning labels. Our cars are equipped with reminders to fasten seatbelts, close doors left ajar, check tire pressure and other warnings. We should then expect appropriate protections be required for keyless ignitions. In addition, adequate education of potential owners upon purchase is needed, especially those at a higher risk for mishap. When any luxury technology is introduced, education about the possibility for malfunction is an absolute necessity to ensure the safety of consumers.

When SUVs became popular in the 1990s we saw an increase in accidents in which children were backed over due to the decreased visibility. Today we see SUVs equipped with cameras to prevent “back overs”. Interestingly these are marketed as a luxury option rather than a safety device installed to reduce injury and death and a response to public outcry.

We have seen a rise in deaths of children left in hot vehicles due to new safety recommendations and rules which require that car seats are placed in the center of the rear seat, facing backwards. This places children out of the line of sight of drivers. Though alarm systems are available in the marketplace, there is no standard system required at this time.

We look at these types of changes in our vehicle use as progress to combat a busier world in which we have also become less mindful. From the father switching on his car in the garage while he readies the children, to the harrowed soccer mom quickly backing out of the driveway, to the elderly person who feels the key in his pocket and gives no second thought to the car left running. These are instances where constant awareness might prevent harm but we must assume that the world is not that simplistic and these lapses can occur. And they can be fatal. And this assumption about human behavior must be foremost on the minds of those who profit through the sale of vehicles touted as equipped with convenience for new generations of buyers. Unfortunately the incidents which result in injury or death are often dismissed as acceptable losses in order to avoid minimal increases in production costs. This is why the first time such a tragedy occurs we do not see immediate action on the part of manufacturers. It is only when litigation ensues that we see a response and a change in legislation.

This blog was written by Rebecca Martin.

 

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