Robert Baron, MD presents about Boat-Related Carbon Monoxide Poisoning at the International Boating and Water Safety Summit (March 2012).

1. Boat-Related Carbon Monoxide Poisoning
Robert Baron, MD
Medical Advisor, Glen Canyon National Recreation Area
Director of Quality and Risk, Emrgency Professional Services, Phoenix, AZ
Special Thanks to:
Jane McCammon, NIOSH Retired
16th International Boating and Water
Safety Summit
San Diego, CA
March 6, 2012

2. We only see what we look for,We only see what we look for,
andand
we only look for what we knowwe only look for what we know
McCammon & Baron Nov 2009

3. NIOSH Disclaimer
Disclaimer: The findings and conclusions in
this presentation have not been formally
disseminated by the National Institute for
Occupational Safety and Health and should
not be construed to represent any agency
determination or policy
• Disclaimer: Mention of any company or
product does not
• constitute endorsement by CDC, NIOSH

4. Contributors:
• US Coast Guard: Phil Cappel and his team at the
Recreation Product Assurance Division past and present
• NIOSH: Jane McCammon, Kevin Dunn, Alberto Garcia and
all of the NIOSH staff past and present
• National Park Service: Steve Luckesen, Sara
Newman, Kerry Haut, Brian O’Dea and their administrators and staff
past and present.
• US Department of the Interior: Tim Radtke
• McCuneWright, LLP: Richard McCune

5. For a copy of this presentation please
send requests to:
erfpmd1@cox.net

6. CO Overview
How big of a problem is this?How big of a problem is this?
What are the high risk areas on a boat?What are the high risk areas on a boat?
What needs to be done?What needs to be done?
What has been done?What has been done?McCammon & Baron Nov 2009

7. CO % in
Blood
At about 10%
Headache,
nausea,
confusion
At 20-30%
Loss of
conscious-
ness (LOC),
disorientation
At 50 -60%
Coma
and
Death
CO
CO
CO
CO
HemoglobinCarboxyhemoglobin

8. After exposure ends, how long
does CO remain in the blood?*
After exposure ends, how long
does CO remain in the blood?*
• In room air, after exposure ends,
COHb will decrease by half every
2 - 6 hours.
• Oxygen therapy reduces that time
to 1 - 2 hours.
• Hyperbaric oxygen therapy
reduces it to 20 minutes
*Half-life varies widely by individual and activity level*Half-life varies widely by individual and activity level
CO
CO
CO
CO

9. How Many Boat-Related CO Poisonings?How Many Boat-Related CO Poisonings?
879 poisonings in 39 states (96% occurred 1990 – 2009)879 poisonings in 39 states (96% occurred 1990 – 2009)
160 people died160 people died
*Excludes Lake
Powell cases
14
8
62
8
31
37*
31*
16
20
24
6
21
5
1
12 14
56
7
7
44
2
8
38
15
23 1
20
6
3
Location
unspecified
92
Lake
Powell
211
(24% of
the total)
1
Nov 2009
Remember: Lake Powell data collection is the most extensive.Remember: Lake Powell data collection is the most extensive.
1
8
2 6 3
2
1
7
4 9

10. Lack of Recognition
Lack of Reporting
But How Many Poisonings?
Is it 879?
McCammon & Baron Nov 2009

11. Drowning and CO at Lake Powell:
1994 - 2004
12 (48%) of the 25 boat-related drownings12 (48%) of the 25 boat-related drownings
were CO poisonings firstwere CO poisonings first
McCammon & Baron Nov 2009

12. National Estimate ?
1997 – 2005:1997 – 2005:
Drownings off of boats = 4676*Drownings off of boats = 4676*
*Based on US Coast Guard Boating Accident Report Database
If 48% of those were CO-related …..If 48% of those were CO-related …..
250 per year nationwide.250 per year nationwide.
McCammon & Baron Nov 2009

13. Outdoor Fatal Poisonings
Why wasn’t the extent of the problemWhy wasn’t the extent of the problem
recognized earlier?recognized earlier?
Because it’s unbelievable.Because it’s unbelievable.
McCammon & Baron Nov 2009

14. A sunny day on Chesapeake Bay
What’s wrong with this picture?What’s wrong with this picture?

15. Cabin Cruisers—Station Wagon
Effect
• The use of the canopy top increases the
station wagon effect.
– Often, boaters leave the back panel(s) completely
or partially unzipped, which will cause exhaust
fumes to funnel directly into the cockpit

16. Dixey Boys
Arizona Republic Newspaper
August 4, 2000
Divers Find Bodies of
Brothers in Lake
“Divers recovered the bodies of two brothers who drowned
while swimming at Lake Powell. The brothers, 10 and 7,
from Parker, Colorado were swimming at the rear of a
houseboat Wednesday night … when they disappeared.”
COHb: 59 and 52% after a brief exposure in the “Death Zone”

17. Circumstances of Poisonings - Houseboats
McCammon & Baron Nov 2009

18. Inside the “Death Zone”

19. Inside the “Death Zone”
Children playfully enter the area.
Adults enter to clear fouled
propellers or to do maintenance.
Resulting COHb :
26 – 72 % within minutes
of exposure
WHY?

20. Inside the “Death Zone”
CO :
Propulsion engines operating
60,000 ppm (maximum)
Guidelines – CO in Air
(parts of CO per million parts
of air – ppm)
87
WHO limit for a 15-
minute exposure
1200
Immediately
Dangerous to Life
and Health (IDLH)
Oxygen Deficient –
as low as 10%
CO :
Generator operating
30,000 ppm
(maximum)

21. CO: 1 typical boat engine = ??? cars
188
Calculations by Paul Roberts, Sonoma Technology Inc.

22. Outside the “Death Zone”
7,000 – 10,000 ppm CO on
the swim platform
200 ppm CO
10 feet away
Why?

23. Pleasurecraft (ski boats, cabin cruisers, etc.)

26. 26,700 ppm CO –boat moving26,700 ppm CO –boat moving
Poisonings Resulting
in Death/Drowning
COHb: Minutes
Exposed
57% 1
56% <1
56% 5
50% 1 - 2
48% 10-15
41% <1
67, 64, 64, 41, 39% in
“minutes”
Why?
10,000 ppm CO –boat stopped10,000 ppm CO –boat stopped
Death Comes QuicklyDeath Comes Quickly

27. It’s not just teak surfing!
Example:Example:
Saguaro Lake , AZ 2008Saguaro Lake , AZ 2008
22 year old male was sitting on the back deck of boat while the motor
was at idle. Witnesses state he lost consciousness and fell into
water. Bystanders pulled him from the water, at which point he was
unresponsive. After they performed chest compressions for 2
minutes, he regained consciousness, sat up, spoke a few words and
then again lost consciousness. His carbon monoxide reading was
45% upon transport. O2 saturation was 92%.
Incident Information - Medical Transport Record

28. Showers in a Toxic Environment
“Preheat your wetsuit, warm
up after a cool swim or wash
sand and dirt from your feet
and decks.”
To use it, you have to be on
the swim platform while the
engines are running.
4 YO on the swim platform
playing with the shower stopped
breathing after less than 15
minutes. (COHb 2.2 % - 4 half-
lives later)
4 children in various locations on
a canopy-enclosed cabin cruiser.
All found unconscious 45
minutes after last being seen; 1
died. (COHb = 47%)
McCammon & Baron Nov 2009

29. Cabin Cruisers
Deaths and poisonings occur both inside and outside the cabin.
By far, most cabin cruiser associated deaths occur inside the cabin.
McCammon & Baron Nov 2009

30. Cabin Cruisers
Deaths and poisonings outside the cabin -
Why?
41,600 ppm CO measured at the
generator exhaust terminus
570 ppm CO 10 feet away

31. Comparison of Swim Platform CO Concentration
Windy day No wind

32. Congested Boat Traffic – Lake Havasu
On Memorial Day, Independence Day, or Labor Day, there may be as
many as 700 boats in the Bridgewater Channel at any given time. If
each boat has only one engine, and only a third of the boats are
operating, exhaust is roughly equivalent to that of 40,000 automobiles.

33. Congested Boat Traffic – Lake Havasu
NIOSH found that over half of Lake Havasu City public
safety workers in the Bridgewater Channel were
overexposed to CO during 2003 Memorial Day
weekend…..
…And, more than half of the public safety workers in
the Bridgewater Channel reported post-shift symptoms
consistent with CO poisoning (headache, fatigue,
weakness, visual disturbances, dizziness) on days with
highest CO exposures.

35. So… what needs to be done at the scene?So… what needs to be done at the scene?
1. Recognition1. Recognition
• If a victim was anywhere on or near aIf a victim was anywhere on or near a
boat with an engine, think CO.boat with an engine, think CO.
• If a victim has a headache, nausea,If a victim has a headache, nausea,
vomiting or loss of consciousness,vomiting or loss of consciousness,
think CO.think CO.
• Pitfalls: delay in COHb and/or normalPitfalls: delay in COHb and/or normal

37. 2. Treatment2. Treatment
a. Extrication / scene safetya. Extrication / scene safety
b. 100% oxygenb. 100% oxygen
So… what needs to be done at the scene?So… what needs to be done at the scene?

38. Transport patients for further evaluation and treatment,
including consideration of hyperbaric therapy, if they
experienced:
• LOC or
• 1st
COHb >25% or
• Persistent abnormal mental status or
• Abnormal cerebellar function at time of exam or
• Cardiovascular disfunction (chest pain, arrhythmias,
hypotension) associated with the poisoning
or
• If the patient is pregnant

39. So - What do we need to do?
3. Report it3. Report it
This is the key to prevention,This is the key to prevention,
because if it doesn’t get counted, it didn’t happen.because if it doesn’t get counted, it didn’t happen.
Notify the appropriate agencyNotify the appropriate agency
(Sheriff, Boating Law Administrator, State Parks, State(Sheriff, Boating Law Administrator, State Parks, State
Fish and Game, etc.)Fish and Game, etc.)

40. It is time to redirect efforts
from collecting examples of
poisonings to
prevention of poisonings.

41. Prevent it !
Engineering controlsEngineering controls
EducationEducation
Legislation/Legislation/RegulationRegulation

42. Education
• Coast Guard Auxiliary offers boating safety
class at Delta College
• Published: Sunday, March 04, 2012, 10:30 AM
• FRANKENLUST TWP. — The Coast Guard Auxiliary is offering a
boating safety class at Delta College on March 10.
• Topics include:
• Boating Problems - Hypothermia; boating accidents and rescues;
man overboard recovery; capsizing; running aground; river hazards;
strainers: emergency radio calls; engine problems; equipment
failures; carbon monoxide (CO); other boating and PWC problems.

43. Dangerous 'teak surfing' prohibited in Nevada,
California
Jeff Munson
September 29, 2004
SOUTH LAKE TAHOE - A dangerous boat activity called teak surfing will be banned by the Nevada
Department of Wildlife and made illegal in the state of California.
The Nevada ban and California law, to take effect next year, are intended to save lives after a series
of accidents and fatalities over the past decade, officials said Tuesday.
On May 28, 2003, an 11-year-old El Dorado Hills boy died behind the boat his father was driving at
Folsom Lake.
An autopsy revealed Anthony Farr had 63 percent of his bloodstream filled with carbon monoxide,
which was emitted from the boat's engine into the boys lungs as he surfed hanging onto the step at
the back of the boat.
"Had I known this was dangerous, had I heard of the dangers of doing this, I would never have put
my son or myself at risk," said Mike Farr, Anthony's father, who convinced Sacramento lawmakers
to support the legislation.
The Nevada ban on teak surfing was agreed to Sept. 12 by the Board of Wildlife commissioners, the
body that regulates boating safety in the Silver State.
"We are extremely pleased the Wildlife Commission has stepped up to address this very serious
issues," said Fred Messmann, the boating law administrator for Nevada. "We have had a hard time
quantifying the exact number of deaths each year because of this activity, but the specific examples
show how dangerous teak surfing can be."
KATU 2 News - Portland, Oregon
www.katu.com
Come 2006, teak surfing will be illegal in Oregon
- SALEM, Ore. - A summertime water sport popular with teens and
young adults will become illegal in Oregon beginning in 2006.
Teak surfing, also known as platform dragging, is when a person hangs
onto the rear of the boat to be pulled through the water until the boat's
wake builds enough to allow body surfing.
Senate Bill 56, which Gov. Ted Kulongoski is expected to sign, would
make teak surfing illegal.
There are a number of dangers associated with teak surfing.
An obvious danger is the swimmer's proximity to the boat propeller.
Another not so obvious danger is carbon monoxide poisoning.
In addition to these dangers, teak surfing is usually done without a life
jacket because it inhibits body surfing.
(Copyright 2005 by The Associated Press. All Rights Reserved.)
Legislation

44. Regulation:
Monitoring Air quality, Lake Havasu

45. ABYC STANDARDS
• ABYC Standard A-24 requires a CO detection
system to be installed on all boats with an
enclosed accommodation compartment(s) and a
gasoline generator or an inboard gasoline
propulsion engine.
• ABYC Standard P-1 now includes a section on
the installation of a vertical stack exhaust system
for houseboats.

46. National Park Service Memorandum
January 30, 2012
This memorandum outlines new requirements for
concession boat rental and marina operations to help
control the potential for carbon monoxide (CO)
poisoning
• Retrofit all houseboats with vertical stack exhaust
systems
• Convert outboard, stern drive/inboards and generators
to catalyzed low CO emitting units
• Concessioner must provide signs about the dangers of
CO and how to prevent poisoning on vessels and
around the marina.
• CO poisoning must be addressed in all motor boat
safety briefings

47. • Comprehensive EPA and CARB regulations
affecting all marine engines.
• As of January 1, 2011 marine engine
manufacturers could no longer legally sell non-
catalyzed engines in the United States unless the
company had built up EPA clean-air credits.
– A company must roughly sell five catalyzed engines to
get enough credit to sell one non-catalyzed engine.
• Spark-ignition marine generators
• Stern-drive and inboard engines
• Outboard and PWC
Regulatory actions

48. Vertical Stacks:Vertical Stacks:
Moving Generator Exhaust to a Safer LocationMoving Generator Exhaust to a Safer Location

49. Generator Exhaust
Configurations--Stack
Removable stack
for easier transport
(Sampled on center of swim platform)
Time, (Hours:Min:Sec)
10:30:00 10:40:00 10:50:00 11:00:00 11:10:00
CarbonMonoxideConcentration,ppm
0
200
400
600
800
1000
1200
1400
With Stack
Without Stack
Generator On Main Engines & Gen. On
(NIOSH Ceiling = 200 ppm)

50. Low CO Emission Generators
• Westerbeke Safe-
COTM
Generator
– 14-kW and 20-kW
generators
evaluated
• Kohler Generator
Testing
– 15-kW Generator
evaluated
Catalyst

51. Houseboat Generator
• Stack reduced CO concentrations on lower rear
deck by 50% (vs. side) and 99% (vs. rear
exhaust)
– The dry stack is a simple and effective control that has
performed well under multiple evaluations.
• The Westerbeke Safe-COTM
and Kohler
generators resulted in low CO emissions
– CO concentrations reduced by 99% from exhaust

52. Control at the Source – Inboard Engines
“It’s the right thing to do,” ….

53. Ski Boats—Propulsion Engines
• At idle, the Indmar new catalytic
technology resulted in an average
92% reduction of CO emissions
(measured directly into the exhaust
opening)
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
11,000
12,000
13,000
14,000
15,000
0 20 40 60 80 100 120 140
Time (sec)
COConcentrations(ppm)
NO-CAT
CAT
SKI Boat With/Without CatalystSKI Boat With/Without Catalyst

54. Propulsion engines
NIOSH researchers worked with various engine manufacturers to
assist in evaluation and development of low-CO marine propulsion
engines that are now on the market.

55. Prevent it !
Engineering controlsEngineering controls
EducationEducation
Legislation/Legislation/RegulationRegulation

56. Those who contributed the most,Those who contributed the most,
the victims and their familiesthe victims and their families
• The Double Angel Foundation
http://www.doubleangel.org
• The CO Action Group
http://www.coactiongroup.org/index.html
• Ken Kidder Memorial Fund
• The families of Stacy Beckett, Anthony
Farr, Mark Tostado, Joel Martin, Kathryn
Reese, Jena Jones, Chad Ethington, Skip
Bauer and over one hundred more……

57. Prevention
through Public
Awareness
One example of many:

58. We only see what we look for,
and
we only look for what we know
Now you know it so let’s prevent it!