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Preparing for a Winter Emergency

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“Preparing for a Winter Emergency” Robert M. Blumm, MA, PA, DFAAPA, PA-C Emeritus

Karen is a 43-year-old RN who has worked as an emergency room nurse for the past twenty years. She awakened at 0200 hours on a cold winter’s day with a severe headache and slight shortness of breath. She walked down the stairs from her bedroom, passing her children’s rooms and entering her kitchen, feeling slightly dizzy.  She reached into her closet for a bottle of aspirin and realized her family pets had not accompanied her. She became cognizant of the signs of an admission presentation that she had seen in the past, noticed that she was still dizzy and made a call to her 911 fire department dispatcher and gave her address. This is all she remembered before she fell to the kitchen floor. The ambulance arrived, entered the home and gave oxygen to Karen as they searched the house. They found the husband and two older children unconscious in their beds, along with the family dogs. Simultaneously, they discovered the presence of carbon monoxide and found that the roof and chimney had been worked on and was covered by a large tarp, preventing the carbon dioxide from escaping the home. The entire family was brought to the local emergency room and then to a bariatric chamber for oxygenation. What caused this winter emergency? Can you see the potential patients and understand the serious diagnosis and treatment?

PAs and NPs usually associate the words “silent killer” with hypertension; it is also, in fact, used to describe CO2 poisoning. In 2016, CO2 was the causative factor in 397 deaths. CO2 poisoning presents with a myriad of similar symptoms which, if they cascade, can definitely end in death. CO2 is colorless, odorless and tasteless, yet its cumulative effects are deadly. Where does this condition originate? It is usually associated with a deficiency in a heating system where CO2 can build up. This can be from a space heater in winter, from wood burning and charcoal burning fireplaces or heaters, from propane gas heaters and from running a gas operated vehicle or generator in an enclosed space. It can also occur because of a clogged fireplace or flu vent. Precautions are simple maintenance on these devices and the presence of CO2 alarms on each floor of a home, near bedrooms. The batteries need to be changed twice yearly and the alarms need to be replaced every two years.

The physiology behind this disease is the exchange of CO2 for oxygen in the hemoglobin, thus causing cell and organ failure. The treatment is immediate removal from the source, oxygenation and, in more severe cases, hyperbaric chambers. Emergency rooms and fire departments have a device for measuring the amounts of CO2 in the blood. Symptoms include severe dull headache associated with dizziness or fainting, shortness of breath, confusion, nausea and vomiting, generalized flu-like symptoms without fever, as well as ophthalmological signs such as blurred vison and neurological signs such as seizures.

Because there is an overlap of signs and symptoms, CO2 poisoning can be easily failed to diagnose and the differential diagnoses can be headache syndrome, pneumonia, influenza or migraine syndrome. This is what make medicine a difficult specialty and what can bring the unsuspecting patient to an urgent care facility withholding the major additional fact that others in the family are all having the same symptoms. Because of these other potential diagnoses, it is essential for the HCP to be adequately insured with a policy that would protect them for failure to diagnose or failure to treat. I consider myself fortunate as I have seen this presenting diagnosis on three families within two years while working in a good ER and I was adequately insured by a personal liability policy. This has given me much peace over the years as I am aware that regardless of how good we may practice medicine, we are still “practicing” and we continue to learn by our mistakes. Smart people go around the risks, not through them. Fortunately, if I make a medical error, I have CM&F as my insurance carrier, an A.M. Best A++ Superior policy, that is my safety in a time of storm.

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