As temperatures drop, the number of visits to emergency rooms across the country tends to spike in the opposite direction.
From tumbles off of ladders while decorating and holiday baking burns, to icy falls and omnipresent flu germs, the “most wonderful time of the year” doesn’t always live up to its moniker. Yet, there’s one seasonal threat that we tend to forget about until a tragic story hits the news: carbon monoxide (CO), often dubbed the “invisible killer” or “silent killer.”
However, when the Emergency Medicine and Hyperbaric Medicine teams at the Hospital of the University of Pennsylvania (HUP) were recently confronted with a patient with a critical case of CO poisoning, they were able to smoothly coordinate a care plan while racing against the clock, ultimately saving a life and emphasizing the vital roles that quick-thinking and clear communication play in patient care.
Carbon monoxide is an odorless, colorless, and extremely toxic gas that is produced any time a fossil fuel is burned, as in the case of household appliances, water heaters, portable generators, fireplaces, and oil-burning furnaces. In the fall and winter, heating our homes becomes a priority, but issues like poor ventilation, blocked chimneys, or malfunctioning appliances can cause a largely unnoticeable buildup in CO. As it is breathed in, CO hijacks hemoglobin molecules and takes the place of the oxygen in blood, depriving the body of the oxygen it needs to function. This initially causes seemingly benign, “flu-like” symptoms, such as headaches, nausea, and dizziness, but as oxygen levels continue to drop, the exposure can cause confusion, vision problems, weakness, a loss of consciousness, and if left untreated, death. The extra terrifying part: this can all happen in a matter of minutes depending on the concentration. Even if you are treated, overexposure in both acute cases and over a long period of time can lead to cognitive impairment and severe cardiac damage.
According to the U.S. Centers for Disease Control and Prevention, more than 400 people die annually from unintentional CO poisoning unrelated to fires, and more than 20,000 Americans visit the emergency room as a result of exposure. In the case of HUP’s patient, she was found in her New Jersey home by the EMS team unresponsive, immobile, and requiring intubation because she was unable to breathe on her own – the result of a faulty HVAC system. The team immediately contacted their medical director to brief them on the situation, and the director made the correct call to transfer the patient to Penn Medicine so she could be given hyperbaric oxygen therapy as quickly as possible. To expedite the process, she was transported via helicopter, and because there were regular updates between each player, HUP’s Emergency Medicine team was ready and waiting.
“Carbon monoxide poisoning is not an infrequent occurrence at this time of year, but given her condition when she arrived, we were fairly convinced that she would have a poor outcome,” said Josh Glick, MD, a fourth-year resident in Emergency Medicine. “It’s really a testament to how well this team works together that that was fortunately not the case.”
Prior to the patient’s arrival, the ED team notified Hyperbaric Medicine to let them know there was likely a patient on the way who would require their services. They had limited information about the patient, but they knew it was important to start preparing just in case. This decision was critical. The process of getting a patient into a hyperbaric chamber can often take many hours because it’s necessary to call in hyperbaric-certified (“dive-certified”) respiratory therapists and nurses prior to the transfer, but even without knowing all of the details, the Hyperbaric Medicine team triggered their response protocol and began organizing their staff.
“You read about situations like these on tests, and you think, ‘Well, obviously the answer is C, just send her to hyperbarics,’ but in the moment, everything is happening very quickly, and it can be challenging as a lot of things need to happen at once,” said Stephen Hallisey, MD, a third-year resident in Emergency Medicine. “But our whole team came together. Michael (Gunter) Krauthamer, MD, [a third-year resident in Emergency Medicine] definitely deserves credit for starting her care.”
While the Hyperbaric Medicine team began preparing, the patient’s care team in the ED was focused on supporting her heart, which had nearly stopped beating. Not only does carbon monoxide starve blood of its oxygen, but it can cause direct damage to the heart muscle, which reduces its pumping capacity and can permanently impair cardiac function even after the CO has been eliminated. A healthy heart’s left ventricle pumps out between 50 and 70 percent of blood with each beat to deliver an adequate supply to the brain and body. In contrast, the patient’s heart was pumping between 5 and 10 percent – so, you know, not ideal. They administered epinephrine to increase her blood pressure and were ultimately able to stabilize her for her next transfer.
“In the ED, we’re really proud to be such effective team players,” Glick said. “From the get-go, everyone involved was able to coordinate pretty much flawlessly. There were no delays or errors in communication, and we were able to work together with the nurses and respiratory therapists to balance stabilizing the patient with keeping contact with the Hyperbaric Medicine team.”
If exposed to low levels of carbon monoxide and removed from the affected location and into fresh air, it takes between four and six hours to exhale about half of the CO in their blood. However, in a hyperbaric chamber,
a patient is able to breathe 100 percent oxygen at an elevated ambient pressure, which means they are taking in nearly 20 times the amount of oxygen we normally inhale. This allows oxygen to surge through the bloodstream, promoting healing and fighting infection from issues like non-healing diabetic wounds, radiation injuries, and decompression sickness. In the case of CO poisoning, spending a few hours in the chamber helps to reverse the carbon monoxide takeover and to restore the patient’s oxygen level as quickly as possible.
“We’re the only health system to offer hyperbaric oxygen therapy in the region, with the next closest locations being in Maryland and New York. This case really highlights how well the system works, and for this patient, the quick communication and the correct calls being made between states was lifesaving,” said David S. Lambert, MD, an assistant professor of Clinical Emergency Medicine and Hyperbaric Medicine. “The transfer to the hyperbaric chamber can take hours, but this patient was able to get in quickly because we had the notice to prepare. Carbon monoxide poisoning can cause neurological deficits, but getting into the chamber quickly can help and even prevent those issues.”
The next day, Glick and Hallisey swung by the ICU for a visit and found their patient – who had been nearly comatose not 24 hours prior – not only sitting up, but smiling and cracking jokes on her whiteboard. “She looked great!” Hallisey said. “When people come in that sick, they don’t typically get better that quickly, and here she was already being funny.”
Two days later, she was discharged with her heart pumping effectively and lungs breathing deeply, all because of the seamless coordination of her care teams. Like a well-oiled machine, each component moved quickly, effectively, and without mistakes: from the New Jersey paramedics who managed her breathing and kept her heart beating while determining the best course of action, to the flight team who expedited the time-sensitive transfer, to our own ED and Hyperbaric Medicine teams who were already dedicated to providing her with the highest quality of care before she even arrived on Penn’s campus.
“We see so many people coming in and out, but every once in a while, you encounter a patient who you can look at and think, ‘We really made a life-changing difference here,” and you can sort of hang your hat on that knowledge,” Glick said. “This was definitely an example of that. This was my ‘case of the year.’”