Toxicologists break down what went right in Pa. day care carbon monoxide response

By Leif Greiss
The Morning Call

ALLENTOWN, Pa. — The children and adults exposed to carbon monoxide at Happy Smiles Learning Center were lucky to make it out with no deaths and likely no long-term effects following a mass carbon monoxide poisoning event, Dr. Kenneth Katz said.

Katz, an emergency room toxicologist with Lehigh Valley Health Network, said things turned out as well as they did because of the coordinated response by everyone involved.

From the immediate actions taken by adults at the Allentown day care, as well as firefighters and emergency medical personnel, to the way doctors, nurses and other hospital staff at LVHN, St. Luke’s University Health Network and University of Pennsylvania Health System pivoted to meet the influx of patients, those responsible for saving lives met the moment, he said.

In total, 27 children and eight adults were evacuated from Happy Smiles Learning Center, 471 Wabash St., and 32 adults and children were hospitalized Tuesday.

All patients treated by LVHN and St. Luke’s have been discharged, network spokespeople confirmed. Penn Medicine did not respond to inquiries about patients who were taken to the University of Pennsylvania Hospital and Children’s Hospital of Pennsylvania for more intensive treatment.

The mass poisoning incident was caused by a malfunctioning heating unit and a blocked ventilation system, an investigation by UGI Utilities found. UGI spokesperson Michael Swope said the company did not know the root causes behind the malfunction or blockage.

Genesis Ortega, a spokesperson for Allentown, said because of the incident, Happy Smiles’ operating license was suspended by the city Tuesday. The facility passed a safety inspection in July.

Ortega said the day care’s operators need to file for a permit to repair the building’s boiler unit, and then city inspectors will have to approve the facility to reopen.

Jesenia Gautreaux, the owner of the day care, previously told The Morning Call she was working to reopen as soon as possible and planned to install carbon monoxide detectors, which the building lacks. Under an amended city ordinance, childcare facilities in Allentown have to install detectors by Oct. 27.

What you need to know about carbon monoxide poisoning

Carbon monoxide is a colorless, odorless gas and is undetectable without specialty equipment. Early symptoms include headache, dizziness, nausea, chest pain and loss of coordination and motor control that results in something similar to a drunken stupor, called ataxia.

Katz said what makes the compound particularly dangerous is how good it is at binding to hemoglobin, the part of red blood cells that carries oxygen throughout the body. Carbon monoxide is about 250 times better at binding to hemoglobin than oxygen, thereby decreasing the amount of hemoglobin available to carry oxygen, asphyxiating the person exposed.

Pets and small children are especially sensitive to carbon monoxide poisoning and the children who were at Happy Smiles ranged from several months to 10 years old. One of the first reported signs something was wrong was when one boy got up from his seat and then collapsed mid-stride. The seriousness of the situation became even more apparent when napping children didn’t wake up. Katz said the sheer number of children affected probably played a key role in the timely response by adults at Happy Smiles.

Testing for carbon monoxide showed the gas was present in a concentration of 700 parts per million, more than three times the threshold that can kill.

When someone is being poisoned by carbon monoxide it is important to waste no time removing them from the exposure area. Once the poisoned person is removed, their condition usually begins to slowly improve. Katz said patients should have high levels of oxygen directly administered, which cuts the half-life of carbon monoxide in the body to an average of 90 minutes, compared with about five hours otherwise.

FIRST RESPONDERS

Katz said a “mass casualty” situation like this can be particularly unsettling to the professionals responding for a number of reasons.

“When you’re dealing with not only a lot of patients, but you are also dealing with a lot of kids, or kids that are months old, toddler age, etc., it just adds even more angst,” he said. “It just amplifies the unsettling nature of the mass casualties on top of what it would normally be.”

Dr. Chase Jones, another emergency room toxicologist for LVHN, said everyone kept their cool and the coordination of the response was impressive from the get-go.

The firefighters and EMS workers who tested for carbon monoxide at the outset were key to identifying the cause of the incident and ensuring patients got the immediate treatment they needed. He added the first responders worked fast to break the patients into groups based on who needed the most immediate care.

Katz has been a toxicologist for nearly 20 years and Jones for about six, but neither had dealt with a mass poisoning event like this one. Some major challenges presented to care providers. Jones said one of the first barriers was that a significant number of patients spoke Spanish as their first language, and spoke little or no English. He said LVHN mobilized its in-house translators and interpreters.

Early on, hospital staff also had difficulty getting in touch with parents, grandparents or other caretakers and guardians, which made getting information like age and medical history difficult. Even so, Jones said, they identified existing congenital heart disease in one pediatric patient.

Most hospitals face staffing shortages, especially in their emergency departments, and incidents like this further strain their resources.

“We have other patients, too, it’s not just those patients,” Katz said. “You have other adults and children that are there for unrelated reasons, so the hospital has to operate around it, it has to absorb it and keep moving forward.”

Jones said challenges like these are why training and preparedness are crucial.

“In both medical school, residency and even beyond that, Lehigh Valley Health Network will regularly set up simulated mass casualty incidents,” Jones said. “I was in the Marine Corps prior to being a physician and what you want to see is a circumstance where people that are put into a high-stress, high-risk situation continue to perform their jobs as if it was a training exercise and that’s what I saw.”

Despite the fast and overall smooth response from professionals, some patients needed more advanced care. Several patients were transferred to the University of Pennsylvania Hospital and Children’s Hospital of Pennsylvania for hyperbaric treatment, which involves breathing pure oxygen in a pressurized environment.

But the vast majority of patients are known to have left the hospital. Though some of the patients were reported as collapsing and passing out, Jones said he is not aware of any patients LVHN treated who suffered physical trauma from the incident. Carbon monoxide is also associated with brain damage, though researchers and scientists have difficulty studying the phenomenon due to practical and ethical reasons. At this point, Jones and Katz said no patients have shown signs of permanent damage.

Carbon monoxide poisoning can occur at any time of year but Jones said it happens more often during fall and winter. The most common cause of carbon monoxide poisoning is the indoor use of unvented, combustible fuel-based space heaters, which many people use to keep warm while saving on electricity. But, he added, carbon monoxide poisoning can occur outside, including while boating.

Jones said it is important that people know that carbon monoxide poisoning is almost entirely preventable, by having detectors indoors as well as ensuring adequate ventilation when alternative heating sources are used.

But he added when situations like this do happen, it’s important that those who respond know exactly what to do.

“Thank your nurses and thank your EMS workers and firefighters because they made all this possible,” Jones said. “They made sure that all those kids and these adults got out of there safely and got to the right place for treatment.”

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