Carbon Monoxide, The Silent Killer by Sam Williams, Dec 11, 2003 TwitterÂ When James Tyrrell dreams of a white Christmas, it isn't your usual Bing Crosby, Currier & Ives fantasy. Director of the Jacobi Medical Center's Hyperbaric and Underseas Medicine unit, New York City's primary treatment center for carbon monoxide poisoning and smoke inhalation, Tyrrell knows firsthand what a nightmare the year's first major snowstorm can be. "Last year, at one point, we counted 26 patients for carbon monoxide poisoning within a single 24 hour period," he says. How so many patients ended up in the Bronx hospital's submarine-shaped pressure chamber is, of course, the real nightmare. Unlike lead, asbestos, and radon -- much-publicized household toxins that do their damage primarily through long term exposure -- carbon monoxide needs only a few minutes to ambush its victims. Odorless and colorless, it is a stealth killer that avoids the environmental and public health spotlight almost as easily as it evades the eyes and nostrils. When carbon monoxide does finally make an appearance, however, the results tend to be cringe-inducing. For New York City residents, the first cringe of the winter season came early this year. On Nov. 21 Bronx firefighters responding to an emergency call in the Morris Heights section made a grim discovery. When they got to the house of Patrick Williams, 26, they found Williams, his two month old daughter Patricia and his 54 year-old mother Erna Dennis all lying dead, victims of suffocation. According to a Daily News story filed the next day, the family's electric service had been cut off by Con Ed for nonpayment, and the family was relying on a gasoline-powered electric generator for power. Fire crew found the generator, sitting idle with an empty tank, in an attached garage. Noting the lack of a carbon monoxide detector in the house, New York Fire Department inspectors have little doubt that the improperly ventilated generator and its resulting fumes were the chief culprit behind the deaths, says Battalion Chief John Salka, commanding officer of the responding fire units. "If you don't have a smoke detector, there's a small chance you might smell the smoke in time," says Salka. "If you don't have a carbon monoxide detector, your chances of smelling carbon monoxide fumes in time are literally zero." According to an August, 2002 issue of the Journal of the American Medical Assocation, carbon monoxide suffocation accounts for 2,000 American deaths each year. Local totals are hard to come by, but Dr. Michael Touger, a specialist at the same hyperbaric unit, says his facility treats the most severe carbon monoxide-related cases in the metropolitan area and handles up to 150 emergencies each year. Many of those emergencies, including the Nov. 21 Bronx emergency that sent a surviving family member to Jacobi Medical Center's hyperbaric chamber, could have been easily avoided with the help of a home carbon monoxide detector. Unfortunately, getting those detectors into homes has been a slow-going process. Ken Giles, a spokesperson for the Consumer Product Safety Commission in Washington, D.C., estimates that less than 15 percent of American homes have a carbon monoxide detector somewhere on the premises. Comparing that to the 93 percent of American homes that consistently report smoke detectors in industry surveys, Giles considers the number pathetically low. "We think and recommend that every home should have an alarm," he says. "We also recommend that every furnace system be checked by a professional before you turn it on for the winter." Getting that message out in any sort of a consistent manner is no easy task. New York state law mandates carbon monoxide detectors in all one- and two-family houses, condominiums, and co-ops built after January 1, 2002, but in a city like New York City, where the vast majority of buildings predate this cut-off, it falls on tenants to police their own dwellings. Even with printed warnings on heaters and furnaces, however, Touger estimates that a full third of the emergency cases that demand treatment in his unit stem from faulty heating and ventilation systems. "We certainly are eager to engage any type of public education this time of year, because a lot of the cases we see should have been preventable," Touger says. The sad irony of carbon monoxide poisoning, however, is that it usually takes grisly incidents such as last month's triple suffocation to send local residents to places like the Forest Ave. Home Depot on Staten Island, where detectors sell for $26 and up. Once there, the dust-covered plastic encasing each detectors offers a quick testimony as to why many still call carbon monoxide "the silent killer." How Carbon Monoxide Kills The primary challenge in elevating carbon monoxide to the A-list of feared chemicals is the molecule's own insidious nature. A natural byproduct of any combustion process involving carbon-based fuel, carbon monoxide is generally present any time you have a steady flame. Gasoline motors, natural gas furnaces, charcoal grills, and propane space heater all contribute varying amounts of carbon monoxide to the atmosphere. In most cases, however, circulating air keeps the amount of carbon monoxide molecules below the 9 parts per million threshold set by the Environmental Protection Agency as a suitable safety standard. During the winter, however, windows seal up, aging furnaces and ventilation ducts go back to work, and snow rises to block automobile tailpipes. As the number of escape routes diminish, the amount of carbon monoxide in the air can quickly accumulate, rising to unhealthy, even lethal levels. Early symptoms of carbon monoxide exposure include nausea, dizziness, and splitting headaches. All are signs of the brain expressing its extreme discomfort at the lack of oxygen coming in through the bloodstream, but because they share a similarity to common flu symptons which also hit this time of year, many go overlooked until too late. "Carbon monoxide is hard to diagnose," says Touger. "You have to have a high index of suspicion, especially this time of year." Carbon monoxide's insidious nature extends to the molecular level as well. Carbon monoxide and ordinary oxygen molecules share a similar structure. Hemoglobin, the molecule responsible for transporting oxygen in the blood, binds aggressively to carbon monoxide almost as if tricked. As more and more oxygen-carrying hemoglobin molecules become carbon-monoxide carrying hemoglobin molecules, the amount of oxygen that actually reaches the bodies oxygen-dependent tissues starts to plummet. Slowly but surely, the body's own respiratory system is tricked into betraying itself. "If you give a red blood cell the choice between binding to carbon monoxide and binding to oxygen, it will favor CO over oxygen 200 to 1," says Tyrrell, summing up the grim calculus. The primary purpose of Jacobi Medical Center's hyperbaric chamber, he says, is to simulate the high pressure of a scuba dive. Just as scuba divers experience altered blood oxygen concentrations chemistry at extreme depths, a patient breathing pure oxygen inside a pressurized chamber will experience a surge in bloodstream oxygen. More oxygen means a higher likelihood that carbon monoxide, when it finally dislodges from hemoglobin, loses its place to an in-rushing oxygen molecule. With nowhere else to go, the carbon monoxide is then flushed out of the patients system through ordinary respiration. Simply put, hyperbaric treatment can tilt the 200-to-1 ratio back into a poison victim's favor. "It's the quickest way to get rid of CO," Tyrrell says, noting the chemical shorthand for carbon monoxide. Next to home heating systems and improperly ventilated appliances, the most common culprit in most poisoning cases is the automobile. Dr. Bob Hoffman of the New York City Poison Center says a statistical analysis of carbon monoxide-related calls coming into his center reveals two yearly "spikes." "The first spike is early winter," Hoffman says. "That's when everybody turns their heaters on for the first time. The first couple of cold days always make us nervous." The second spike comes after the first major snowfall. Drivers who fail to notice snow-blocked tailpipes often experience the initial symptoms of poisoning and call in seeking help. Such cases often don't require treatment once the victim has removed himself from an enclosed area. In the case of children exposed to carbon monoxide, however, automobile-related calls tend to be the saddest ones received at the poison center. "A parent will put the child in a running warm car to keep it warm while he or she shovels out the tires," says Hoffman, relaying a scenario that plays out at least once a winter. "In the worst case, the parent mistakes the child's sudden unconsciousness for sleep, giving suffocation a better chance to occur." Hoffman says his center has the budget and the media channels to get the message out. The only thing missing is the general sense of dread for these messages to tap into. Outside from the occasional tabloid headline, most New Yorkers can spend an entire year blissfully unaware of the menace lurking in their homes and cars. Even a city law mandating detectors in all homes, something Hoffman doesn't see coming anytime soon, would require a fatal accident or two to spur the proper outrage and enforcement. "Every winter there's a lot of education both through the media and through the health commissioner's office: notices to check your boiler, check your heater, clean out the tail pipe in your car," Hoffman says. "Despite all that work, CO is the number one killer in terms of poisons, both in the city and across the nation." Hoffman notes the recent suffocation deaths in the Bronx and expresses hope that, with the publicity such sobering events generate, the number of detectors in New York City homes will continue its slow climb. "If any good ever comes out of anything, if you can save a couple lives because of these three, you've done a good job," he says. 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