CO: It’s Not Just About the Gas
The Hyperbaric Oxygen Therapy Unit at John T. Mather Memorial Hospital in Port Jefferson, NY, is one of the few units still providing 24/7 care. It has effectively dealt with many dramatic situations. To illustrate the ongoing issues surrounding carbon monoxide (CO) as well as the global issues it raises, I present here a case of CO poisoning the unit encountered.
Six people with potential CO poisoning were transported to the Mather Hospital emergency room (ER) and its 24/7 hyperbaric unit. A power outage had been reported secondary to weather conditions, so the victims had borrowed a generator from a friend. They were aware of the potential dangers of CO, so to mitigate the issue, they left open the windows in the house but made the mistake of putting the generator in the basement.
Despite their precautions, one victim was awoken when she heard her husband moaning in his sleep. Immediately upon waking, she had a tremendous headache and realized the problem could be CO. She had difficulty arousing her husband but was finally able to get him up. He also had a tremendous headache as well as dizziness and confusion. She was also able to wake her two children, two other family members in different areas of the house, and call 911.
The victims were transported on 100% oxygen to the ER, where three adults had levels between 20 and 28, the children (ages 5 and 10) had levels of 9 and 12, while the fourth adult had a level of 11.
After evaluation, three of the four adults were offered hyperbaric oxygen (HBO) treatment on Dr. Lindell Weaver’s protocol. The fourth adult, who had the level of 11, had a significant heart issue with an ejection fraction of 20% and had been on a life vest. Our hyperbaric cardiologist’s evaluation recommended he not be put into the chamber but to remain on 100% oxygen. One child refused to stay in the chamber.
All patients were doing better after treatment, but they declined completion of the Weaver protocol.
I will discuss a few of the issues this case of CO highlights.
First, no matter how you try to mitigate it, machinery that can produce CO, a generator in this case, should not operate in an inhabited space. It is difficult to track the path of air currents throughout the space, and the locations of the victims during the intoxication can cause a significant variation in both CO levels as well as resultant symptoms.
These patients actually knew CO could cause harm and left all the windows open, believing it would prevent the problem. Consider what the results might have been if they had closed the fresh-air source.
A second point is the need for CO detectors. Despite all the information about CO, there are still many homes and other inhabited spaces, including work areas, that go without detectors. Our patients had detectors but had removed them and placed them in the moving van on the driveway since they were relocating in a few days. Continued education and legal requirements remain the mainstays of evoking the change needed for CO monitoring.
An issue we have experienced is the resistance of patients to accept a three-course HBO treatment protocol despite a maximal educational effort by the HBO staff, focusing on the possible long-term sequelae CO may cause.
Those reading this magazine are probably already woefully aware of the issue regarding the availability of acute hyperbaric access as discussed in this case and raised in the article “Emergency and Critical Care Hyperbaric Medicine in the United States” by Enoch Huang, MD, in the Fall 2016 issue of WCHM. Thankfully, 22 years ago our hospital agreed to establish a hyperbaric program, which has served our community with 24/7 coverage since its inception.
There has been a massive exodus of 24/7 hyperbaric units in the country for various reasons, but I would postulate a lot of it is directly related to the cost of maintaining a unit, staffing and lack of appropriate insurance reimbursement. There is, in my opinion, an absolute need for access to immediate HBOT for certain medical issues such as dive injuries, gas gangrene, certain CO accidents, some necrotizing infections and some acute ischemic perfusions cases. If the exodus continues, there will be even less opportunity to treat these patients.
If indeed there is a difference between levels of hyperbaric unit care (levels 1–3), cost is probably the overwhelming factor leading to closure of 24/7 units, and then the payers should reimburse on standards based on these levels. Perhaps if this occurred, it would encourage centers to remain available, and others who are considering initiating a program may opt into a more encompassing level of service.
The constant battle that occurs between providers and payers continually grows. Part of the responsibility, in my opinion, belongs to the hyperbaric community. There have been many hyperbaric treatments and reports of units that will treat disease processes not amenable to hyperbaric treatments and bill erroneous codes. This can lead to such scrutiny that it becomes very difficult to get payment for appropriate HBO care.
I am sorry to say that after 22 years and more than 35,000 treatments, even our unit is struggling with the concept of changing to a 9-to-5 outpatient radiation and wound-care only facility. That will leave our county without any HBO 24/7 unit, and any acute HBO case will now have to travel about 20-50 miles to get to one. In other areas of the country, patients need to travel hundreds of miles, which in many cases can lead to no access to HBO treatments.
The hyperbaric medical communities have been championing the need to keep these important centers and chambers viable, but it is a relatively small community of providers. Until there is a strong medical, patient and politically supported movement to halt the loss, we will soon cease to exist in any meaningful quantity. Some will argue we are there already.
I strongly encourage everyone to bring this issue to the forefront to those who can help ensure the viability of hyperbaric medicine in our country.