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

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

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

Dose of Carbon Monoxide ­- Symptoms Imperfect Correlation

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

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

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

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

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

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

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

Winter is Worst Carbon Monoxide Season

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

Pulse CO-oximeter by Masimo

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

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

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

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

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

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

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

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

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

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

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

Disability in those Who Survive

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

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

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

Becca Martin authored this blog

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

Preexisting Conditions Protections- More than an Election Catch Phrase

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

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

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

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

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

Preexisting Condition Protections is Core to Obamacare

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

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

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

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

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

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

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

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

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

Current Election Impacts Preexisting Condition Protections

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

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

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

Lifetime Caps another Trap

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

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

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

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

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

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

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

This blog was written by Rebecca Martin

The Season for Chicago Carbon Monoxide

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

Chicago carbon monoxide risks

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

Chicago Carbon Monoxide Risks linked to Snowstorms

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

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

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

Chicago Carbon Monoxide Poisonings from Generators

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

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

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

Portable Electric Generators Can be Hazards in Winter

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

Utility Disconnections Can Cause Poisonings

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

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

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

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

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

CO Poisonings from Ovens

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

Perfect Storm for CO is Coming

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

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

Rebecca Martin contributed to this blog.




Carbon Monoxide Physiology – In Words and Pictures

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

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

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

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

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

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

Carbon Monoxide Physiology –  Basal Ganglia, Hippocampus and Amygdala

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

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

The Putamen and Globus Pallidus Pathology

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

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

Carbon Monoxide Physiology

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

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




Limbic System

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

Globus pallidus

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

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

Globus pallidi lesions

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

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

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

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

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

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

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

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

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

Carbon Monoxide Physiology – Oxygen Administration

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

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

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

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

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

Carbon Monoxide in Children Requires Expert Assessment

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

carbon monoxide in children is complicated

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

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

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

COHb Assessment Different after Carbon Monoxide in Children

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

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

COHb Half Lives are Shorter

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

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

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

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

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

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

Brain Damage Behavioral Issues

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

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

Future Needs for Care

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

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

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

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

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

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

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

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

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

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

Becca Martin contributed to this blog.

Hotel HVAC Maintenance Neglect is Systemic

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

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

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

No Hotel HVAC Maintenance University

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

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

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

Assumptions about Hotel Maintenance

Let’s test your assumptions about Hotel HVAC Maintenance:

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

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

What Causes Systemic Hotel Neglect?

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

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

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

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

The Principles of Combustion

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

Natural Draft Draws Oxygen to the Flame

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

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

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

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

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

Hotel HVAC maintenance needs systemic change

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


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

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

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

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

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

Attorney Gordon Johnson wrote this blog.


How to Avoid the Dangers of Carbon Monoxide in Boating

Last week we touched on the subject of the dangers of carbon monoxide in boating. Click here for that blog. Though we covered the dangers faced by the public and addressed issues the public needed to be aware of, can we realistically say that public awareness is the only issue needing to be addressed? This week we will look at the other side of the issue and examine legal cases as well as the role of both boat manufacturers and legislators. And ultimately address what actions you can take as a boat owner or boater to address the issue on a practical level.

Carbon monoxide in boating is still a major cause of mortality, including drownings

Avoiding the danger of carbon monoxide in boating requires cleaner engines, better exhaust systems and carbon monoxide alarms.

Now that boating season is drawing to a close in many areas, the dangers of carbon monoxide in boating may not seem to be a timely subject. But winter maintenance is upon us and this is the time of the year when repairs and modifications can be done in preparation for next year’s season. As a long time boater, myself, last week’s blog left me wondering about how many times I had been in a situation which could have turned deadly? I think about all the times I sat as a child in the rear of the boat while underway, or the hours trawling keeping an eye on the fishing poles, or any number of activities we all enjoy on the water. If you share this pastime then you will undoubtedly be taking a harder look at your boat as it comes out of the water with a higher awareness of safety issues. We hope you have a new understanding of how carbon monoxide poisoning can occur even in open air, but what is being done about the source of the problem?

Identifying the Dangers of Carbon Monoxide in Boating

In 2003, the Society of Automotive Engineers published an article saying that the only safe form of exhaust in houseboats was the vertical stack which carries exhaust above and beyond. They further stated that this was the only safe form of exhaust and urged all boating organizations to promote this solution. This conclusion was the result of studies by The National Institute of Occupational Safety and Health (NIOSH) and the Society of Automotive Engineers (SAE). It is elsewhere cited that such retrofitting is relatively easy and inexpensive, costing around $500. Manufacturers have also developed low carbon monoxide generators for marine purposes[1] which have reduced those emissions by up to 99%. Problem solved? Not when those in the recreational boating business fail to make changes to existing vessels and also fail to disclose the dangers that exist.

We assume that in most cases we are speaking about boats in motion or idling. But generators are also used to power everything onboard from appliances to air conditioners. And these generators can produce as much carbon monoxide as 300 cars. We have seen that many boats, including house boats and ski boats, have been fitted with side vents to circumvent the problem. This did nothing to protect 11-year-old Joshua Murphy who was enjoying a Lake Mead , Nevada vacation on a rented houseboat with his family. Joshua had been playing on a raft beside the houseboat when he was overcome with carbon monoxide from the side venting system. He was found floating face down in the water. A lawsuit was brought against both the boat rental owner and the manufacturer of the generator and settled for an undisclosed amount.

Fatal Carbon Monoxide Poisonings Sounded Alarm

In 1995 a man died at the Holly Bluff Marina in Orlando , Florida. J. Gary Russell died of carbon monoxide poisoning while doing engine repairs on the houseboat he had purchased from the marina in 1994. The lawsuit maintained that the marina had been negligent in its maintenance of the houseboat and sold it knowing it had a dangerous defect. Also named in the lawsuit were a Kentucky boat maker, Stardust Cruisers Inc. and a Wisconsin company, Kohler Co. who had manufactured the generator. Did the respondents come forward in a sincere attempt to address this known problem with carbon monoxide emissions which could prove deadly to those doing engine repairs or simply clearing debris? No, they countered with a request for discovery of Mr. Russell’s entire psychiatric history, claiming that alcohol abuse affected damages significantly. This was in response to a known problem and within the context of being fully aware that lethal conditions could arise very quickly and without warning in such a situation. But as we shall see, cases like this prompted big changes in the boating industry.

On April 22, 2007, the Deseret News, a Utah newspaper, ran an article regarding the carbon monoxide poisonings on Lake Powell. They quoted Jane McCammon, one of the scientists who had identified the problem and has worked tracking accidental drownings nationwide “There could be as many as 250 boat-related drownings per year (nationally) that are carbon monoxide poisoning first,” and she went on to explain that many areas were not doing the necessary follow up to rule out carbon monoxide poisoning as the initial cause. Due to the concentration of deaths brought under full scrutiny at Lake Powell, it was determined that between 1994 and 2004, 48% of the drowning deaths were carbon monoxide poisonings first. The number of deaths dropped drastically after a vigorous campaign to educate the public to the dangers. But are warnings enough?

Families Led Advocacy for Safer Boating

Some of the most vocal and effective advocates for carbon monoxide poisoning awareness in boating are the families who have lost loved one in drowning accidents. They have brought awareness to the public through signage, media, education and appearances at boating venues and boat shows. But wait. Where are the boat and generator manufacturers in all this?

Manufacturers Response to Carbon Monoxide in Boating

Curious, I did some searching. I first found the page for the National Marine Manufacturers Association. In 2018 they launched a Boating Safety Awareness Series campaign to spread awareness.  On this page it says:  “The best boating experience is a safe one and NMMA has compiled comprehensive safety information in this series of concise, easy-to-read brochures to reach boaters worldwide,” said Robert Newsome, NMMA’s senior vice president of strategy, engineering standards and membership. “This is a big step forward for our industry to have such comprehensive safety information available for all members of the industry to access easily and quickly online. However, when I clicked the link it took me to a page to order the paper brochures for information on the dangers of carbon monoxide poisoning in boating. Obviously that information is not as accessible online as I might have wanted. In fact, a search of popular manufacturers did not turn up anything regarding carbon monoxide safety as the prime concern. I was hoping to find some reference to safety in the product descriptions, but unlike cars, the pitch seems to be amenities not safety issues (unrelated to flotation). I would dig deeper, however my goal was to see the danger of carbon monoxide poisoning highlighted as a responsibility to the public and that was not the case. Searching boat manufacturers in the role of Joe Public did not provide me with relevant information regarding the dangers of carbon monoxide poisoning. Technically it was available, but accessibility was questionable.

However, going a step further, I found a very positive note in speaking to boat manufacturers themselves. Jason Stockton of Trifecta Houseboats in Monticello, Kentucky provided an encouraging view of the current boat houseboat manufacturing industry. Although regulations have not changed much in over two decades, their company has risen to the challenge of addressing the safety concerns raised after the Lake Powell deaths. All new boats are equipped with generators with catalytic converters and CO safe emissions and are side vented, virtually eliminating high CO emissions.[2] They are regulated and inspected by the US Coast Guard regularly.

Educating the Public About CO Risks

In regards to educating the public, the focus is on the exposure dangers in older boats which had exhaust systems venting into the swim platform area and other issues such as mooring too close with improper venting systems in older boats. In addition, all new boats being manufactured are equipped with carbon monoxide detectors. So very proactive and positive changes have been made since information about the dangers of carbon monoxide poisoning in an outdoor setting by the manufacturers themselves. This shifts the focus of liability to older boats which have not been properly retrofitted to eliminate the danger. And we begin to understand that merely retrofitting to change venting is not enough without CO safe generators.

Evidently the role of educating the public has been delegated for the most part to the many boating associations who in turn educate at boating events and shows. However, the American Boat & Yacht Council does maintain a set of standards for all boats available at https://abycinc.org/page/standards. They state that  ‘In product liability lawsuits, ABYC Standards are the authoritative reference for evaluating issues of design, construction, maintenance, and product performance.’ These standards apply to building ,maintenance and repair. In addition, they offer many certification programs for maintenance and repair. They do not set standards requiring vertical stack exhaust systems, however. But obviously new standards for generators have had a large impact on boating manufacture and public safety.

Legislation for Safer Boating

So, as promised, I want to turn to the topic of legislation. In 2016, Minnesota became the first state in the country to require carbon monoxide detectors on boats. Remember our timeline? We had already expanded our understanding of carbon monoxide poisonings to include outdoor poisonings in addition to in-cabin poisonings for two decades. According to the Minnesota Star Tribune, the law mandated that all enclosed areas on a boat be equipped with a hard-wired, marine-certified carbon monoxide detector. The legislation is called Sophia’s Law named for 7-year-old Sophia Baechler who died of carbon monoxide leaking from a hole in an exhaust system. Her family lobbied for passage of the legislation. Her family, not the boating manufacturers. Not the generator manufacturers.

The American Boat and Yacht Council got on board with the idea, calling for mandatory carbon monoxide detectors in enclosed areas the same year. The National Marine Manufacturers Association’s David Dickerson was quoted by the Star Tribune as saying: “It could be a good step forward for safety,”. To date, 27 states require carbon monoxide detectors in enclosed areas on boats.

The question is, what guideline, regulation or legislation is in place to require vertical stack systems on boats? The United States Coast Guard lists federal regulations governing exhaust systems at https://uscgboating.org/regulations/assets/builders-handbook/VENTILATION.pdf  If you notice, The American Boat & yacht Council is cited as the ultimate authority on specific standards regarding exhaust systems. Although studies are ongoing there is no regulation or legislation in place to require vertical stack exhaust. Even though NIOSH found  “The vertical exhaust stack on Fun Country Marine houseboats performed well during the current study. Based upon the results of this and previous NIOSH evaluations of the vertical exhaust stack, NIOSH research indicates that when properly designed and installed, the vertical stack is a viable, low-cost, engineering control that will dramatically improve the safety of houseboat users. “

In conclusion: can we really trust that awareness and education are an adequate action to ensure public safety on the water?  What should we be requiring of our boating and generator manufacturers? What regulations should be in effect regarding older boats, particularly in resale and rental? And what should we be requiring of our legislators?

This is truly a field where litigation has been and may be the best catalyst for change. Thank you to the families who have turned their losses into actions and started the process.

Written by Becca Martin

[1] See Kohler’s Low CO generator http://www.kohlerpower.com/onlinecatalog/pdf/g2129.pdf. A personal note from Attorney Gordon Johnson, Jr. My father, Gordon Johnson, Sr. was the chief electrical engineer for Kohler Company from 1942 to 1986. He spent his career designing Kohler Electric Generators. My career has taken a very different trajectory than my father’s, who was proud of me, but didn’t think too highly of trial lawyers. Though my father was a pioneer, this entire era of CO awareness came after his retirement. Kohler originally did very badly on marine safety with their marine generators, but after some serious litigation, completely reversed itself with the Low CO generator, a marine only generator. Unfortunately, my home state of Wisconsin is home to other manufacturers of generators who are still leading from the rear in fighting US CPSC proposed regulations to make generators safer.  The same safety mechanisms that are now the standard in the marine industry are not found on portable electric generators. Every time I take a bike ride, I go past a plant where these deadly machines are manufactured.

[2] Unfortunately, the same thing cannot be said for portable electric generators outside of the marine area. These generators, powered by lawnmower sized engines, produce as much CO as 1,000 new cars.

 Boating carbon monoxide poisoning

Boating carbon monoxide poisoning is a big problem because high performance engine exhaust is not vented away from where people breathe.

This week we will focus on a topic which has achieved the status of a fast-rising epidemic in regard to carbon monoxide; boating carbon monoxide poisoning. For many years the concern has been raised over this particular hazard in houseboats. However, now we are beginning to realize that these concerns reach farther, encompassing ski boats, cabin cruisers and even personal watercraft. We have discussed previously that the danger of carbon monoxide poisoning goes hand in hand with any fuel burning engine or equipment, but it is now becoming apparent that these dangers can exist in areas that we might not consider due to the false sense of security we feel in the open air.

boating comes with great risk of carbon monoxide poisoning

Boating carbon monoxide poisoning is far more common than expected because high performance engines don’t have same efficiency and exhaust protections that cars do. Boat engines are high performance without the efficiency and emission controls of modern cars. 

When you hear Boating carbon monoxide poisoning, you probably assume that the danger would be restricted to being in a closed cabin or area aboard a boat. But let’s examine some of the lesser known dangers which have impacted the public because they were unaware of the dynamics involved. Both the US Coast Guard and the National Institute of Occupational Safety and Health have been investigating the dangers of CO poisoning and it is truly shocking how many fatalities and injuries have occurred in a very short period of time. The findings have dispelled beliefs the CO poisonings only occur indoors.

We have to first understand that typically, boats with gasoline engines vent near the rear of the boat or the stern,  logically keeping the cabin areas or living areas free from any fumes. Safely vented from the stern area, we feel secure that those fumes are dispersed and pose no danger to boaters.

I want to pause for one moment to stress that carbon monoxide poisoning can occur inside the cabin or living areas as well due to several factors. First and foremost, lack of maintenance of the exhaust system can contribute to the presence of carbon monoxide. All boaters are encouraged to do proper maintenance prior to taking their boats out for the first trip of the season. Another risk is purely physics when certain air pressure and air flow conditions arise to create backdrafts which may draw toxic fumes from the stern back into the cabin area. This largely depends on the motion of the boat, existing wind conditions and certain structural aspects which may create a vacuum effect. For that reason, all boats should be equipped with adequate CO detectors placed properly. As CO is lighter than air, positioning the detectors in higher locations would be recommended. Please note that carbon monoxide poisonings have occurred when detectors have been disconnected to stop the alarm from sounding in a percentage of in-cabin poisonings.

Other causes of in-cabin poisoning are an actual blockage of exhaust vents resulting in fumes entering even when the cabin is secured. Moving at a slow speed can cause an accumulation in the cabin, especially in conjunction with tailwinds – back drafting because the boat is too heavily loaded and the bow is riding too high can result in high levels of CO.  And simply mooring next to another vessel that is running can result in dangerous levels of CO. It is important to observe the 20-foot rule when mooring next to another boat which is running a gasoline powered engine.

But let’s talk about a phenomena which has claimed the lives of many boaters and which may come as a surprise to many of you: The dangers associated with rear swim decks and how they can become deadly traps. I want to start this off with stressing that teak surfing, dragging or waterskiing within 20 feet of a moving boat can be fatal. Teak surfing or dragging is when the occupants hang onto the swim platform while the boat is in motion. Since the exhaust exits through the stern of the boat, carbon monoxide can build up to a fatal level in seconds underneath a swim platform. Often swim platforms are lowered to produce bigger wake and the dynamics create an air pocket where CO gas can accumulate and create a lethal bubble around the person in the water.

Swimming near boats with idling engines is very dangerous, but the most dangerous situations are swimming under swim platforms, which is in essence like being trapped in a small room with an operating portable electric generator. 

The possibility of CO poisoning from rear ventilation systems came to light in around 2000 when boating deaths occurred on Lake Powell in the Glen Canyon National Recreation Area were examined. One incident involved two brothers (aged 8 and 11 years) who had been swimming in the airspace underneath the swim platform. One brother lost consciousness and the other had convulsions and they both drowned. Another incident involved three boys who were using a rear mounted slide. One boy became very dizzy and fell into the water and drowned. And one incident involved an 18-year-old teak surfing or hanging onto the boat’s swim platform while the boat was in motion. Several CO poisonings were associated with people doing maintenance or clearing propellers.  This brought the attention of several agencies after initial concerns by the National Park Service and the US Department of the Interior.

The National Institute for Occupational Safety and Health (NIOSH)  and US Coast Guard issued warnings and studies were undertaken to determine what factors were responsible. Their research found that levels of carbon monoxide were so high that death could occur very quickly and even more disturbingly, that because unconsciousness was a factor, that many drowning deaths were most likely related to the presence of CO so the number of fatalities might be much higher than documented. Even sitting on a swim platform while a boat is in motion can be fatal. A thorough examination of the incidents at Lake Powell revealed that between the years 1990-2000, 111 cases of carbon monoxide poisoning could be absolutely verified. Nine of these cases were fatal. 67% of the poisonings occurred on houseboats and 50% of those were outdoor poisonings. It is also difficult to determine how many other incidents occurred because the symptoms of carbon monoxide poisoning can be mistaken for so many other things. And training of EMS and first responders to the possibility of carbon monoxide poisoning in these instances is also an important component.

All types of boats from many manufacturers were examined and it was determined that this is a problem that exists across the board, regardless of design or engine type. And the dangers rose sharply in boats running in a stationary position or at a slow speed. They discovered concentrations so high that they exceeded CO sensors. The main difference in CO levels factored in many of the things I have discussed; the particular environmental conditions, exhaust systems, engine types, wind conditions, and speed. The consensus was that the only solution would be to require boat manufacturers to use cleaner burning engines. Boat manufacturers and lawmakers have been reluctant to work towards stricter standards for the boating industry despite the findings. We would be right to surmise that new technology for cleaner engines is easier on outboard motors so the prospect of retrofitting inboard motors, very common in ski boats, is meeting the most resistance.

Houseboats, on the other hand, can be retrofitted easily and inexpensively with vertical exhaust systems which carry fumes above and away from the boat’s occupants. In 2001, the US Coast Guard recalled the rear venting houseboats produced by six manufacturers to be refitted with side venting systems, but this was not a complete fix of the problem.

Part of the solution to boating carbon monoxide poisoning has to be to clean up the engines. We don’t have actual statistics, but from what we know about gas engines in other applications, if you are working off of 1960’s engine technology, an engine will be will exhaust as 1,000 times the CO as a modern car. Portable generators using lawn mower sized engines, emit nearly 100,000 ppm in the exhaust. The two big components to reducing CO emissions from gasoline engines are the electronic fuel injection (EFI) and catalytic converters. EFI alone can reduce CO emissions by 90%. That should be required on all marine uses, for the reasons stated herein. If EFI isn’t workable, then some other method needs to be utilized to make sure that all the fuel in an engine is burned at the time of ignition. We are hearing that most marine engines are meeting current California EPA requirements. https://onlineoutboards.com/blogs/outboard-motors-basics/efi-vs-a-standard-4-stroke The irony of this whole issue is that the Clean Air Act requirements are there to improve atmospheric levels of air pollution, not reduce CO poisoning. But the net effect of reducing pollutants in engine exhaust is to insure complete combustion of the fuel. Incomplete combustion equals on boats equals boating carbon monoxide poisoning.

For our treatment of carbon monoxide poisoning from portable electric generators, click here.

CO Detectors not enough to stop  Carbon Monoxide poisoning

Boat builders have readily agreed to the installation of CO detectors in boats but this hardly addresses the problem associated with the rear swim platform. The Center for Disease Control (CDC) states that the presence of CO above a swim platform is dangerous but the concentration below a swim platform can be deadly in  matter of seconds. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4949a1.htm

“(H)ouseboats with a rear swim deck and a water-level swim platform are an imminent danger to persons who enter the air space beneath the deck or spend time near the rear deck. The presence of features … that attract occupancy of that airspace enhances the risk for severe injury and death. To prevent (boat carbon monoxide poisoning) and deaths, boat manufacturers should immediately devise engineering changes to new and existing boats to prevent the collection of CO in airspaces around the stern deck.”

And like CO poisoning in other scenarios this is especially hazardous for children. The only way to ensure a safer boating environment is through public awareness, education and ultimately through regulation of the boating industry. The US Coast Guard has undertaken a program for public awareness but there are still many hurdles to overcome on the regulatory level. Research is also essential in finding ways to create cleaner burning engines and alternate venting solutions as well as changes in the formulation of fuels. Some of these solutions are very much tied into current EPA standards which are threatened at this point in time. Stricter regulations are called for at a time when we are loosening the regulations needed to solve this problem.

So, in the interim, much more public awareness needs to surround the dangers of carbon monoxide poisoning in all arenas. Whether it’s a weekend stay at a hotel, or a day out enjoying the water. Our safety is directly connected to the regulations that are put in place by our lawmakers. Education and awareness is only one part of an equation, and legal actions are very much required to push lawmakers to act. We have known about the dangers associated with swim platforms for well over a decade and it really is time for some accountability.

Engine Exhaust Equals CO

Never forget that when you are around a fuel burning engine, that unless there is adequate engineering to assure complete combustion (like in a modern car) that CO emissions will be almost unimaginably high. Use a concrete saw indoors, and you are at high risk of death. Portable electric generators have been the subject of attempted regulation by the U.S. CPSC for a generation, because of the known risk. Boats contain more powerful engines by many magnitudes than either of these but may never have been forced to clean up by EPA regulations.  If you can smell fumes, you are undoubtedly inhaling CO. Keep that in mind when you are onboard, and remember that even if outside, you can be poisoned by carbon monoxide fumes. But CO can be there in concentrations above 10,000 ppm, before you can smell it.

Rebecca Martin contributed to this blog.


Wildfires and Global Health – Toxic Exhaust

In thinking about the Wildfires and global health, I thought back instead of forward. My co-author, Attorney Gordon Johnson[1], and I were teenagers back in the late 1960s and early 70s when air pollution was the concern of scientists, environmentalists and a generation becoming aware of the hazards of an ‘uncontrolled progress for the sake of progress’ mentality. Baby Boomers were enjoying a new prosperity. The car industry was growing to fill demand and industrialization was in overdrive. Our largest population centers were becoming accustomed to a perpetual haze enveloping their cities and smog alerts were becoming commonplace. The Air Quality Index became as routine as the daily weather forecast almost overnight. Air pollution was a theme at the media forefront much in the way climate change is now.

Assessing the impact of Wildfires and Global must also include the creatures of the forest. We are measuring the impact of the wildfires based upon human deaths and acreage. The impact on wildlife is incalculable.

Why is a lawyers blog page about carbon monoxide taking the time to discuss wildfires? Because it is all about the air we breathe. The air we breathe is part of the atmosphere which has made Planet Earth a uniquely viable place for life. Add carbon monoxide, CO to the ambient atmosphere we breathe indoors, you get carbon monoxide poisoning. Add too much CO2 to the the atmosphere of Planet Earth and life as we know it may cease.

I first learned about carbon monoxide because it was a principal pollutant. The reason automobiles were equipped with catalytic converters was to eliminate the carbon monoxide in their exhaust, a major component of urban smog. I remember having to take my car for testing every year to make sure it passed standards. I lived in Anchorage, Alaska then. Anchorage was a smog prone city due to temperature inversions that left our entire valley in a cloud of smog many days during the winter. One never forgets warnings to stay indoors due to hazardous air conditions.

The state of California, one of the densest populations of automobiles, has always taken the lead in reducing emissions since the Clean Air Act was enacted. Today, California leads the fight against the Trump administration for fuel efficiency standards. Despite heated opposition, the Trump administration rolled back fuel efficiency standards from 54.5mpg to 40mpg by 2025, a move which would virtually squash any pressure on the industry to improve. As a result, almost a billion more tons of greenhouse gases will be released in the next five years. The only people really happy with the rollback of fuel efficiency standards are the oil companies who will be seeing an upsurge in demand. Even the auto industry is not on board entirely with rollbacks as it sees less support in the marketplace from both the public and government. It is difficult to compete in a global market if your government is not supporting your need to be the most competitive. And it will be difficult for the US auto industry to compete with foreign car makers when the public is value shopping and wanting the best best fuel economy for their dollar. The very door we opened back in the 60s and 70s when the public opted for Japanese autos because of their cost and fuel efficiency.

Wildfires and Global Health – The Clean Air Act

The Clean Air Act has seen many changes over the years. It began in 1955 with the first initial funding of research to determine the nature and seriousness of the air pollution issue. It finally came into law as a means to control air pollution in 1963. In 1965 it was amended to create standards to control auto emissions. In 1967 it grew to look at other sources, stationary and mobile. By 1970, every state had air quality programs in place because of the federal funding and legislation put in place in the 60s. It wasn’t until 1990 that we began to legislate other air quality concerns like acid rain, toxic substances and ozone depletion. At that time the government took a hard look at gas itself, establishing RVP standards to control evaporative emissions from cars and the development of new formulations for gasoline.

Baby Boomers are really the first generation which has experienced a new view of our planet. The human population previously had become accustomed to a belief that all things were unlimited and excess led to extinctions and major changes to the topography of the planet. By the 60s and 70s it was coming to light that all things were not bountiful, and maybe just maybe, things might run out. The planet was not as all forgiving as originally thought.

Which brings us to the next concern of my youth, there was only so much petroleum on the planet. It became clear that either alternatives would have to be found or eventually our entire civilization would be in big trouble. Projections warned that petroleum could be depleted in as little as fifty years. We watched the oil companies gobble up solar and alternative options squashing the competition and worried that those who controlled oil controlled civilization as we know it. We weren’t entirely off. Although oil seems to still be readily accessible, we are delving into any of the more sensitive ecosystems of the planet to meet demand. From attempts to open the arctic to drilling to offshore drilling to sonic exploration, we are impacting ecosystems that are essential to our existence.

In the midst of this unprecedented search for oil we see an escalation in the amount of carbon fuels burned. We still have a public oblivious to the need for drastic lifestyle changes, an administration with a looter mentality and an industry that is profit driven. As emissions begin to rise again, we will see an emergence of more health issues, and a greater impact on a planet already in trouble.

If that wasn’t enough, the surge in devastating wildfires has now been added to the mix. Don’t call it global warming, that term opens the door for bad jokes during blizzards, “so this is global warming?” Call it what it is – Climate Change.  And I want to stress, what we are seeing is not some cyclical change in temperatures theorized by climate change deniers but a real and worrisome change evident in the most vigorous ecosystems everywhere on the planet.

The Cycle of Fire and the Atmosphere

Small changes in temperature are leading to drier conditions, setting the stage for the types of deadly wildfires we have seen in Australia, California, and Oregon. Oregon, of all places! Denser populations and climate change are working together to create conditions which we will not see an end to anytime soon. If Oregon is burning, where next? We need a global assessment of Wildfires and Global Health.

Wildfires and Global Health – A Negative Synergistic Loop

The entire climate change cycle creates a synergistic cycle of negative impacts that build upon each other. While all the smoke in the air might seem like something that would lower earths temperatures, that isn’t the net effect. White snow reflects sunlight, keeping glaciers intact during sunny periods. But when particulates in the air (the unburned hydrocarbons – not the CO2 or CO) fall from the sky to glaciers, it changes the color of these glaciers from white to gray. Gray glaciers absorb more light. Gray glaciers melt faster than white glaciers. See https://www.bbc.com/news/science-environment-50573623 This is one of the least accounted for phenomenon’s used to statistically predict when climate change will require huge population shifts.

And if the triple apocalyptic events of this week (wildfires, hurricanes and COVID-19) weren’t enough, yesterday we got word of a huge crisis with the Antarctic glacial shelf. See https://www.washingtonpost.com/climate-environment/2020/09/14/glaciers-breaking-antarctica-pine-island-thwaites/ Ice on water floats, so a melting floating glacier doesn’t have a net effect on sea level. But glaciers on land are nature’s way of lowering ocean levels to store on land. When glaciers on land melt, the oceans rise. Glacial melt on Greenland and the Antarctic will result in a rise in sea level. This isn’t a political debate, it is simple physics you can demonstrate in your bath tub. But that ice floats is only the beginning of understand Wildfires and Global Health.

If you believe you are not impacted by fires in Oregon or California, please consider. Wildfires produce CO2and other greenhouse gases which affect the climate for years. So while burning gas has contributed to climate change globally creating a surge in wildfires, the wildfires themselves are producing gases and particles which in turn affect the climate. It’s a cycle of destruction that will impact all earthlings on many levels. One immediate concern involves a study of plants. Plants reacting to more CO2 in the air, either from pollutants or from wildfires, grow quickly and as a result mature with a lower level of nutrition. Studies involving the insects that feed on plants indicate that the insects had to ingest much more plant material to survive and predict that humans also will be seeing a drop in the nutritional value of plants. This impacts an entire food chain. Last year’s wildfires alone basically matched all the auto emissions for the year, in essence doubling the carbon footprint. It is a loop that it seems impossible to escape. This year, just the last two weeks, has been far worse.

Anyone who has ever flown in a small airplane understands the additional impact of bare acreage. If you have never experienced the sudden uplift you get when flying over a bare field after a patch of woods then you can’t appreciate the huge difference in hot air rising from bare ground. It creates strong currents that also impact our climate. And wildfires are now thought to release many more particulates into the air which deflect light. There are so many components involved in wildfires, all acting together, merging with the products of an industrialized planet and it becomes impossible to still claim that this is all part of a natural process.

Even now, scientists are warning that the changes seen in many ecosystems, both fragile and vigorous, are raising alarms for massive changes in a far shorter period of time than thought. It is impossible to pinpoint all of the cause and repercussions of Wildfires and Global Health as there are so many forces at work. Human expansion and population growth, toxic contamination, temperature changes due to burins carbon fuel, loss of water…it all becomes a web of intertwining elements that reach far beyond the destruction of natural wildfires. But in conjunction, we have yet to determine the ultimate result.

Insects have proven a very reliable early warning system for the environment as a whole. Several studies world-wide have reported a substantial decline in insect populations. We think of a wildfire’s devastating impact on the wildlife within its scope but the damage to ecosystems is far wider reaching. Especially in combination with human caused changes. While scientists want to argue both ways, consider this: CO2 makes plants develop faster, becoming less nutritious. Insects eat more and mature faster in a shorter period of time but due to decreased nutrients, insects produce fewer offspring, and carry that on up the food chain and you begin to appreciate how a small change in temperature and CO2 begins to impact entire ecosystems. Some scientists will argue the opposite, the accelerated plant growth will cause a surge. But that is simply not substantiated. The only surge will occur in those species not considered necessarily beneficial. An ecosystem thrown off at the basic level is an event that is unprecedented. We simply have nothing to measure that type of devastation against. We have been very absorbed with what happens with those at the top of the food chain, humans, for many years. Our planet’s history provides enough warnings to give us scenarios to worry about. But we have never faced a total breakdown of the ecosystem from the bottom up.

In 1970, we had our first Earth Day. At the time, Earth Day was a fairly tame political issue, in contrast to the Vietnam war protests and the fight for civil rights. While it was billed as the big jumping off point for protect the planet environmental causes, it largely got lost in otherwise turbulent times. Our concern is the 2020 wildfire crisis will as well. Like Covid, atmospheric catastrophe’s don’t discriminate. And we won’t just be able to wear a mask, even a gas mask, to minimize the impact of this crisis. The current world population is 7 billion, projected to reach 11 billion by the time sea level threatens cities. But climate change will make it so that we can’t raise enough food to feed a billion people if we don’t stop listening to climate deniers.

Rebecca Martin

[1] Rebecca Martin and Attorney Gordon Johnson co-authored the seminal brain injury advocacy page, http://waiting.com in 1997. Waiting.com was the first comprehensive brain injury website. It still can be found, in its orginal verson at the above link. Rebecca also did the web design work on the original http://tbilaw.com in 1996.


Demand Carbon Monoxide Alarms at Hotel Chains

Why is there no guarantee of carbon monoxide alarms at Hotel Chains? In most states, every landlord must supply a carbon monoxide alarm. Most states require them in all new residential construction. For a list of state requirements of alarms, click here. Yet, hotels are every bit as dangerous for CO poisoning as homes and apartments. The reason: people sleep there. Yet, few states and no franchises uniformly require them in all places people sleep.

Carbon Monoxide Alarms at Hotel Chains

Shown here is a smoke detector (not carbon monoxide alarm) hanging on the ceiling of a national hotel chain. Why is there no statutory requirement of Carbon Monoxide Alarms at Hotel Chains? Lobbying, not common sense. 

There are close to 30,000 hotel franchises operating in the United States. (We will refer in the blog to the hotel companies as the Hotel Chains.) The generic definition of a franchise follows:

“The overall principle of a Franchise Agreement is that the franchisee operates its own hotel, in compliance with the brand standards. The franchisee is required to pay: A franchise fee, including the brand trademark, based on a percentage of the hotel’s turnover.”

It is clear that the franchise concept permits the independent hotel owner to take advantage of the Hotel Chain’s market image in exchange for fees and an operating plan approved by the parent franchise. We would assume that training, safety precautions and guidelines would be well covered in the franchise agreement. As the public we expect a certain level of reliability based on the name brand of the hotel we check into. That assumption is core to the reason that the number of chain hotels increase every year.

Hotel franchising began in 1954 with the well-known Howard Johnson franchise. It was an idea that appealed to a more affluent and mobile population who really wanted to take the guesswork out of hotel reservations. The idea grew rapidly and quickly became the extensive network we see today.

Not one of us questions calling national reservation line to book stays at any of the major franchises we have become so familiar with. We believe we are under the watchful eye of the parent company who values our patronage. More importantly we feel that the parent companies observe standards of operation in all of their franchises, including those for safety. We also expect that the Hotel Chains would make sure that the people who are operating the hotels are competent to do so – and have the requisite training in not just the reservation system, but all of the aspect of operating a hotel.

But are we actually under the protective umbrella of the parent company when we confidently book our reservation? We should be as that is the expectation that we have when we book a room and it is the expectation that the Hotel Chains want us to have. That is the reason they control everything from the type of towels, sheets in each room, interior paint colors and the lighted signs we see from the freeway as we pull up to their hotel.

In our previous two blogs we explored in depth the incidents which occurred in 2013 that  led to the fatalities of three guests on two different occasions at the Boone Best Western due to carbon monoxide poisoning from a faulty pool heater and ventilation system. For our previous blogs, click below:

Why Are Hotel Pool Heaters So Dangerous

Boone Best Western Carbon Monoxide Poisoning – The Rest of the Story

Carbon Monoxide at Hotels

We discovered event after event leading up to a perfect storm. We explored building code violations, violations of manufacturer guidelines, unlicensed maintenance men, untrained hotel management and much more. And we touched on the criminal charges which followed, ultimately finding the Appalachian Hospitality Management company guilty of three counts of manslaughter. This decision which paved the way for the family members of the deceased to file wrongful death lawsuits against both the hotel owner and the parent company.

We have also touched upon the lack of carbon monoxide detectors in individual guest rooms which was a decision made by the American Hotel & Lodging Association based on cost considerations. And disappointingly we also learned that North Carolina, acting in response to the three fatalities, weakly opted to enact laws requiring carbon monoxide detectors only in areas adjacent to fuel burning equipment and ventilation output sites.

Prior to the 1980’s, major hotel brands owned their real estate, carried the debt of construction and were basically the legal owners of their properties. But the move began to develop an asset light strategy wherein the major franchises collected fees in exchange for the use of their names and the assets switched to independent ownership. The intent behind this move was to allow the parent companies to turn their focus to the brand management and development, and out of the realm of construction and real estate debt.

This focus manifested in many ways. Understanding local markets and their needs, following trends to attract guests, and solidifying their particular niche in a competitive market. As part of that new approach to managing franchises, the parent companies focused on the training for new owners, and also supplying them with a wealth of information on all the technical aspects of their hotel’s operation. The owners received advantages like national and global reservation systems, but most importantly the use of the established brand and all the confidence of a public familiar with that brand.

Now we turn to the series of events at the Boone Best Western. Based on our explanation of the current operating philosophy of the parent companies, we would expect that the owner of the hotel had received full training on all aspects of the hospitality industry. From training staff to maintaining the property in a manner which guaranteed the safety of guests to a standard one might expect from a national/global brand. We would also expect that the parent company would provide the technical expertise for all systems in the hotel as failure to do so would reflect badly on the brand as a whole. We don’t expect that dining at a national restaurant franchise would consistently result in food poisoning due to inept management, nor do we expect to end our stay at a hotel franchise dead or injured. Our trust is in the parent company … even when we are in the hands of the franchisee owner.

Because the parent companies operate nationally and globally, they are familiar with differing regulations in a multitude of markets. In some of these markets carbon monoxide detectors are required in every guest room and the parent companies have adjusted to those requirements in order to compete in as many markets as possible. As such, they are well aware of the dangers of exposure to carbon monoxide due to the specific systems in operation in all hotels. This danger is no surprise to the part of the industry proudly touting their training programs for owners. It is impossible not to conclude that their decisions regarding voluntary placement of detectors is conscious and intentional and that the focus here has been shifted to reducing costs at the expense of safety.

We Expect Carbon Monoxide Alarms at Hotel Chains

The hotel chains require a standard of operation on many levels. From signage and amenities to safety and security standards to protect guests during their stay. Our public understanding is that all aspects of the particular establishment are routinely inspected to make sure the brand image and operating guidelines are being followed. Our expectation are that these inspections include operations and maintenance of equipment. As the public we expect all rooms and areas in a given hotel chain to have fairly identical amenities and standards no matter where the particular establishment is located.

At this point, we must ask, how did a well-known hotel franchise totally miss all the danger signs which led up to the deaths of three people? And on not one, but two separate occasions? And more concerning, is this a common shortcoming in the hotel franchise industry? The hospitality industry has long adhered to the statement that the safety and welfare of their guests is the top priority.

Hotel Chains try to Shell Themselves from Liability

Part of the problem is attempts to shield the national companies from liability in the case of death or injury at a hotel. Most franchise agreements separate the parent company from the hotel owner via contract on the grounds that the owner is an independent contractor who bears full responsibility for their operations. But when you are dealing with a high-profile brand that demands a multitude of standards to be met in order to carry the brand name, and requires inspections and very specific training,  then the line between parent company and hotel owner blurs and the argument against the brand bearing liability becomes a good deal weaker. You cannot claim in one breath that the hotel meets the operational standards of the brand and then claim that you have no hand in the operations of the hotel.

Hotel Chain’s Control not Contract Determines Fault

More specifically, if the hotel chain has determined that a swimming pool is an amenity which is important to the hotel’s demographics and the decision to install and operate the equipment necessary is guided by that vision, then obviously there are certain technical specifications linked to that amenity. And certainly not any less important than any of the amenities offered by that particular hotel per the parent company. The franchising company would not be happy with twenty hotels with elevators that routinely plunge its occupants to death. That would be a marketing disaster. Then why would they be complacent about the installation and maintenance of pool heaters and other fuel burning devices known specifically to create a risk of carbon monoxide poisoning if not installed and maintained properly.

As the public, we hope that the specific guidelines related to any type of equipment are followed and that the equipment is maintained by licensed professionals. And when considering a national/global brand we hope that those requirements go above and beyond as the hospitality industry rests on the statement that our safety and security are the priority in all decisions and actions.

Hotel Chains are the business of franchising, inspecting, licensing and training hotel operators to operate the name brand hotels in their system, such as all Hiltons, Embassy Suites, Days Inns, etc.  Thus, all Hotel Chains should have knowledge of the risks of carbon monoxide in hotels and the necessity of having carbon monoxide detectors in all places where fuel burning appliances are operated. Hotel Chains have a duty when licensing, inspecting and training the hotel operators of its hotels to assure that the operators and owners of the franchised hotels understand the need for carbon monoxide detectors and to require that carbon monoxide detectors be installed in each room at their chain properties.

In a typical chain hotel franchise, the Hotel Chain will sell a franchise and enter into a franchise agreement for the specific hotel where they mandate that they do inspections, supervision, provide operation support and training in hotel operations and maintenance to the franchisee of the specific hotel. These rules and inspections are required to make sure that any customer who books a room with any member of the chain, can have a room of comparable quality.

Likewise, hotel chains own and operate a common website for all of its hotel brands and locations. Further, they own and operate a common rewards program where members can earn points towards an extensive array of products and services, including free hotel nights, dining, retail, entertainment gift cards, merchandise and airline miles.

Hotel chains will also operate their own schools, often referred to as School of Hospitality Operations or SoHO.  Each SoHo will have an online learning management system called the where they provide General Managers access to dozens of professionally designed training courses to create high-quality experiences for their guests.  SoHO’s stated purposes are usually to help franchisee owners provide a high quality guest experience by providing them robust and comprehensive training opportunities and customized learning paths for franchisee team members.

Hotel chains don’t just talk about a good game about these compliance and rewards programs. They expend significant resources marketing their brands to the public and encouraging guest loyalty.

At a minimum, Chain Hotels should mandate and inspect for compliance that carbon monoxide alarms are in every guest rooms that has a fuel burning appliances. As an example, every hotel room that has a gas fired furnace in it should have a carbon monoxide alarm.

As the franchisor and brand managers, Hotel Chains have the means, ability and right to control many aspects of the day-to-day operations of its brand hotels, including the right to require carbon monoxide alarms in guest rooms or in any other location in the individual hotel. Chain hotels can require its franchisees to meet various brand standards it establishes. These standards include the appearance of the hotel building, signage, furnishings and appliances located within guest rooms and common areas and standards relating to security and safety of hotel guests and building occupants. For example, HOTEL CHAINS typically require all of its properties to provide frequently requested guest amenities and services. It is also worth noting that as almost all Chains are nationwide, that their chains include hotels in states and countries where carbon monoxide alarms are required.

It is almost undeniable that all Hotel Chains know that incidents involving carbon monoxide sickness or poisoning occur with alarming regularity throughout the hospitality industry. See for example the Hampson article, cited in our previous blog.   Hotel Chains also know that installation of carbon monoxide detectors would greatly reduce the potential for incidents to occur involving carbon monoxide sickness or poisoning of hotel guests.

Thus, the only conclusion that can be made is that Hotel Chains have made a deliberate and conscious decision not to require the installation of carbon monoxide detectors in areas of where fuel burning appliances are located in hotel buildings. That conscious decision  exposes their guests and employees to an ongoing risk of carbon monoxide poisoning.

Despite this corporate/institutional knowledge, all over the Country hotel guests get poisoned by carbon monoxide in rooms with no CO alarms. Carbon Monoxide Alarms at Hotel Chains must be mandated by the Hotel Chains, the national corporate franchisor. It is the only way that you can truly trust that when you choose a name-brand hotel, you will be able to safely sleep when you put your head on the pillow. Every single slogan you can associate with a brain hotel, implies that you are being promised that. It is time to deliver on at least that much of the promise.

And how did this struggle for corporate attention impact the decision to repurpose an old pool heater in Boone, NC rather than purchase a new one and to refit that pool heater against the manufacturer’s warnings? And where does it leave the issue of public safety and security when sub-par hotels do not receive the corporate support they thought they signed on for? This is a situation in which the hotel owners have determined the operation of the franchise and not the other way around. The franchise is presenting its name to the public as a promise of standards it has no intention of enforcing and the theme appears to be guests beware rather than public safety and security first. When this mode of operating within the hospitality industry is unchecked, tragedies can happen.

We saw the results of this careless approach on the behalf of the hotel franchise in the three tragic deaths at the Boone Best Western. And the tragedy really sits upon the shoulders of both owner and parent company for presenting themselves as a trusted brand when in fact no franchise standards were in place or reinforced. A fact not known to the casual traveler checking in for a stay.

What is the solution? Each time we sue a Hotel Chain in a carbon monoxide poisoning event, we believe we are moving closer to that solution. Hotel chains must understand that they have responsibility and unfortunately, the only way to bring that responsibility home is to force them into the Courts. We continue to believe that liability lies Hotel Chains for failure to demand carbon monoxide alarms in every room. If the legislatures are too influenced by the lobbying pressure of the hospitality industry, then it must be for the Courts and juries to demand carbon monoxide alarms are everywhere that someone sleeps.

Rebecca Martin contributed to this blog.