BY WILLIAM SHOULDIS
Like most fire departments, Philadelphia faces many challenges in providing fire protection, emergency medical services, and technical rescue services. Runs for unknown fumes have increased. One of the culprits is carbon monoxide. Responders cannot see it, taste it, or smell it. It is nonirritating. There are few visible warnings of this hidden hazard. Carbon monoxide (CO) exposure is often considered a silent killer. Speak with any “front line” firefighter or paramedic; they can share a story of a “near miss” with CO. Examine the U.S. Fire Administration (USFA) Fire Fatality Report on the death of Firefighter Kevin Whitely from the Emmett City (ID) Fire Department. His unit responded to a natural gas leak that resulted in a carbon monoxide exposure. He collapsed while walking back to the apparatus. Resuscitation efforts failed. Fire department leaders should evaluate these “high-risk fume” responses. Trends have been identified, and specific steps should be taken to create an awareness program and purchase the proper protective equipment before a national headline is the result of a local nightmare.
“STROKE” RESPONSE
On March 5, 2003, around 2300 hours, the Philadelphia (PA) Dispatch Center received a phone call from a distressed person. The caller claimed his wife was showing symptoms of a stroke. An advanced life support (ALS) ambulance was dispatched to the private home; it arrived within three minutes. The front door of the tiny two-story house was closed. Paramedics knocked on the door. A 19-year-old male greeted them. The medics were informed that the boy’s parents were in the front room on the second floor. The mother was sick and bedridden. Medics performed a rapid patient assessment and determined that the large woman needed immediate hospital treatment. Because of the patient’s weight and overall size, an additional unit was requested for a “lift-assist.” The paramedics began to clear a path between the bedroom and the stairs. All furniture was moved, and a portable fan had to be shut off. No windows were open at this time.
Within five minutes, Engine Company 2 arrived with three EMTs. The crew’s supervisor noticed that the occupants were acting in a strange manner. They appeared dizzy, disoriented, and uncooperative. They were rearranging the furniture and blocking access to the patient. Lieutenant Edward Manko ordered the family members to a first-floor location. Even the paramedics were exhibiting physical symptoms. One medic complained of a frontal headache. The other had nausea.
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After a brief conversation with the paramedics, the company officer suspected that this was no ordinary medical response. Manko suspected and acted on the hints of an elevated carbon monoxide level. The company officer instructed the firefighter/EMTs to ventilate the building by opening windows. He went to the thermostat and tried to lower it. Attempts to shut off the heating system failed. An emergency evacuation of the ambulatory occupants and first responders was ordered.
The Dispatch Center was alerted to send a full first-alarm assignment. Shortly, four engine companies, two ladder companies, two ALS medic units, and a chief officer were en route. As the incoming units assembled, a triage group was established to provide oxygen and medically monitor the occupants and fire department members. Arriving crews donned SCBA and removed the nonambulatory victims. A combustible gas indicator (CGI) determined the dangerous level of carbon monoxide in the structure. A CO reading of 830 ppm (parts per million; the U.S. Environmental Protection Agency has established that residential levels are not to exceed 9 ppm over an eight-hour average) was detected in the basement. After search, evacuation, and ventilation tasks were completed, the battalion chief placed the incident under control. Investigators from the gas company and fire department determined that a blocked flue and an old, poorly maintained heater caused the CO gas to leak and build up inside the home.
Philadelphia Fire Department ambulances transported the three civilians to a hospital with a hyperbaric chamber. Two were listed in critical condition. Five emergency responders were hospitalized and given 100 percent oxygen for three to six hours before being released.
CRITIQUE AND LESSONS LEARNED AND REINFORCED
On March 10, 2003, a formal post-incident analysis of the Waterloo Street incident was conducted. Field personnel, Safety Division, and Emergency Medical Control officers attended to compare the current operational policies with a retrospective review of the run report. The objective was to improve first responder safety and training. A strong recommendation was submitted to the fire chief that all 40 fire department medic units be equipped with a durable, reliable, and easy-to-read carbon monoxide meter. Research had determined that the cost would be about $250 per unit.
A Safety/Training Awareness Bulletin (STAB) was issued to provide technical information on signs/symptoms and evacuation considerations. Because training is never a “one-time deal,” an article was written for the Philadelphia Fire Department’s newsletter to emphasis size-up factors for responders to consider during medical care operations.
In September 2003, after evaluating the plan, Fire Chief Harold Hairston approved the undertaking. Deputy Commissioner for Technical Services John McGrath implemented the nearly $30,000 project. Today, 100 percent of the front-line units (61 engine company, 30 ladder company. and 40 medic units) have been issued carbon monoxide meters. The meter is attached with a metal clip to the medical bag carried by every unit. The protective equipment has a distinctive alarm system. There is an audio warning at 35 ppm and a visual alarm at 100 ppm. Finally, the meter has a vibrating alert that activates on either danger signal. Training guidelines and an operational procedure were drafted to provide consistency for warning occupants and triggering a full evacuation of a structure.
The lessons from this potentially life-threatening incident should be a catalyst to examine existing equipment, improve dispatch protocols, and enhance the response team’s ability to interface with specialty hospitals. Firefighters to fire chiefs should share the following training tips to provide “front-line leadership” in an era of ever-expanding challenges:
- Fire officials and the media have informed the general public on the proper actions to take in a carbon monoxide emergency, but few fire departments have properly equipped initial responders with survey instruments or monitoring devices. Today’s dispatchers should follow a sequence of questions to prioritize calls. It is not recommended that an ambulance crew alone be sent to investigate fumes; yet, at times, early responders can unknowingly become implicated in an IDLH (immediately dangerous to life and health) atmosphere. Therefore, personnel assigned to any response team should be trained to the hazardous materials awareness level and have access to protective equipment. Pager-size meters can be purchased for a reasonable cost. Most are easy to wear on a belt. Some can be clipped to the medical/first-aid bag during the time of year when CO poisoning is prevalent.
- Carbon monoxide affects individuals in different ways. A person’s size and medical history are influencing factors. If more than one occupant is demonstrating similar symptoms, such as reduced muscle coordination, headache, nausea, disorientation, flu-like symptoms, or poor judgment, check for securely sealed windows. Look for condensation on the inside windows, moisture on walls, abnormal rusting on the top of a gas range from incomplete combustion, or a car running in the garage. Be aware that the smell of stale air is precipitated by insufficient ventilation because of tightly enclosed areas.
- Don’t expect to see the so-called classic cherry red coloration of a victim. Medical doctors who often treat carbon monoxide victims say this visible clue is subtle and is not commonly manifested. Patients may exhibit a bluish-purple appearance because of oxygen deprivation.
Benjamin Franklin, a founding father of this country and the first fire chief in the City of Philadelphia, once stated, “Those who hesitate are lost.” This message applies to all responders. We must be aware of the health hazards associated with carbon monoxide. The dangers are real and warrant quick actions. The death of Firefighter Whitely of Emmett, Idaho, and the narrow escape of the members of the Philadelphia Fire Department demonstrate the speed with which carbon monoxide can affect a rescuer. Education and engineering initiatives are needed to provide an acceptable level of personnel protection. Society has changed. Home improvements will continually focus on energy-efficient materials. Already, many property owners are switching to unvented gas appliances as alternative heating sources to lower heating costs. Along with these technological advancements comes the higher potential for CO poisoning during a nonfire response.
As the number of runs multiplies, first responders must guard against complacency. Regardless of the size of your community, the availability of resources, previous experience with hazardous materials, or liability concerns, having a knowledgeable workforce will increase the odds of a positive outcome.
The Federal Emergency Management Agency (FEMA)/U.S. Fire Administration (USFA) has joined with the U.S. Consumer Product Safety Commission (CPSC) in announcing a new document to help first responders to residential carbon monoxide incidents. The new document, “Responding to Residential Carbon Monoxide Incidents—Guidelines for Fire and Other Emergency Responders,” is available at www.cpsc.gov and www.usfa.fema.gov. It will help responders to ensure their protection against carbon monoxide when entering an occupancy, confirm whether a carbon monoxide hazard exists, make a preliminary assessment of potential sources of elevated carbon monoxide, advise occupants on how to prepare home for re-entry, and promote carbon monoxide awareness and safe practices throughout the community.
According to USFA Administrator R. David Paulison, “Carbon mon-oxide is a real threat to all of us, as events like generator use during the recent blackouts and now the need for winter heating have demonstrated.” The CPSC estimates that CO will kill approximately 200 people this year. Let’s make certain that none are the members of your emergency response team.
WILLIAM SHOULDIS is a deputy chief and a 30-plus-year veteran of the Philadelphia (PA) Fire Department. He is an adjunct instructor at the National Fire Academy and teaches courses on fireground operations, health and safety, and fire prevention. Shouldis has a bachelor’s degree in fire science administration and a master’s degree in public safety. He is a member of the Fire Engineering editorial advisory board and has spoken numerous times at the FDIC.
