Jedidiah Ballard, D.O.

I call it the winter ninja: Carbon Monoxide (CO) is a colorless, odorless, lethal gas formed in the break down of carbon. So lethal in fact that it is currently the worldwide leader in deaths due to a toxin. Far more deaths occur in winter months as CO is emitted by home heating units, but vehicles that have catalytic converters also give it off. As CO is a part of our everyday lives, its prevalence is the cause of its deadly impact. As a 10-year-old boy I gained unwelcome first hand knowledge of the dangers of CO, story to follow.

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Please understand this next portion is in no way a slam on my parents. I did grow up somewhat unique by modern American standards, but am forever thankful for the combination of love, support, hard work and risk that made me who I am. Both my older brother and I went on to serve in U.S. Special Operations and are among the two most successful people to hail from Lima our hometown of 200 people nestled on the eastern slope of the Montana Rocky Mountains. Some descriptive memories include getting kicked out of bed at 3 a.m. to get firewood off the forestry land under the cover of darkness before school (good for the forest, still illegal); chasing our pet wolf miles through the forest when it would chew through its metal cable and escape; and regularly riding in the back of my dad's 1970 -ton red Ford pickup. It was the back of the truck that came within minutes and miles of ending my story prematurely.

Just before a long drive to look at houses to rent, my dad put a camper on the back of his truck. Though we were used to riding in the back of the tuck, the open air had previously diluted the CO to safe levels. My dad was big on mission planning to avoid backtracking, so the drive out was split up between stops to get out and explore the land, with the longest stretch on the way home. Midway through the ride back, my brother and sister had fallen asleep at the end near the tailgate and I was near the cab awake, but developing a headache.

The author (in a purple tank) with his family around the time when he was poisoned.

We stopped at McDonald's to reward a long day of good behavior, a rare treat at the time due to my parents financial constraints and health consciousness. Walking through the restaurant we stumbled onto other tables, our parents getting agitated thinking we were clowning. We didnt feel well, but no chance we were not going to indulge in the chicken nugget luxury before us. For a reason I cannon remember after McDonald's I was moved to the cab for the rest of the trip home and promptly threw up in my lap once the truck started moving. Maternal instincts now alerted, my mother figured it out and immediately had my dad stop to pack my brother and sister into the cab. As funny as it sounds chicken nuggets saved my life. Without the uncharacteristic McDonald's stop to break up the home stretch I am certain my siblings and I wouldnt be here. That's why CO is so dangerous. Here's how to stay safe.

How Carbon Monoxide Kills

In your blood, the hemoglobin molecules are like little boxcars, each with four seats to carry oxygen to the tissues where it is needed to facilitate life in your cells. CO is structurally similar enough to oxygen that your body will let it race in and fill these seats, and it is 200 times better at it than oxygen! Thus the blood train takes off full like its supposed to circulating to feed the tissues, but there is far less oxygen on board than your body was hoping.

Normal blood levels of CO range from 2 to 3 percent, cigarette smokers are generally in the 6 to 10 percent range, and regular Hookah smokers go up to about 15 percent. Poisoning symptoms will occur around 20 percent and over 25 percent carries a significant risk for permanent damage to your most heavily oxygen dependent tissues like the brain and heart. Beyond just the initial hypoxic insult, CO also sets off a severe inflammatory response, which continues to attack the tissues well after normal oxygen levels are restored and can lead to permanent brain damage weeks to months after the event.

What to Look Out For

CO toxicity makes you feel like you have the flu. Headache and fatigue will be standout symptoms and look for muscle aches, nausea, vomiting, and loss of balance. Due to the heart's high oxygen demand chest pain, shortness of breath, and passing out also occur. CO is a gas that spreads throughout the immediate environment, so be very concerned if multiple people in the same house develop flu symptoms at the same time. Further, all mammals have similar CO physiology, so the dog also acting sick is a huge red flag. Because CO is essentially invisible this is why it's critical to have working CO alarms (such as the <a href="https://www.amazon.com/Nest-Protect-smoke-carbon-monoxide/dp/B00XV1RCRY/ref=as_li_ss_tl?creativeASIN=B00XV1RCRY&amp;imprToken=QHyCz6XA8f9Vigvb3kHbEw&amp;slotNum=0&amp;&amp;imprToken=H4flLXV0c7paZBgTf9zyYA&amp;slotNum=1&amp;s=hi&amp;ie=UTF8&amp;qid=1464884131&amp;sr=1-1&amp;keywords=nest+protect&amp;th=1&amp;linkCode=w61&amp;tag=safewicom-20&amp;linkId=37c574039201b2767315a4ae29009082&amp;sp_asc_r=1" id="96275ee7-b510-369d-ae66-705b13c003da"> Nest Protect </a> dual smoke and CO alarm) in your house: Within 10 feet of the internal door to your garage (if it is attached), at the top of the basement stairs, and on every level.

If any suspicion of CO poisoning at all the first step is to get out into the open and prevent further exposure. All toxins are dose dependent. It is then strongly recommended to go to your nearest ER to get checked out. The provider can order a simple blood test called co-oximetry looking for a carboxyhemoglobin level. Of note medical tradition is to get a painful arterial blood draw to test for this. It is more recently accepted that a standard venous blood draw is adequate and that's what I would request if getting checked.

The treatment for CO toxicity is oxygen, and based on your symptoms and levels this will range from a face mask called a non-rebreather all the way to a hyperbaric chamber, which is generally used in dive injuries and wound care. The half-life (time for the concentration of a substance to leave the body) of carboxyhemoglobin is 4 to 6 hours breathing room air, 1 hour on 100-percent oxygen through the non-rebreather mask, and 20 to 30 minutes at a standard pressure in a hyperbaric chamber. Even if your levels come out OK, it is also important to contact the gas company and get your house checked out.

The Silent Danger

How to Prevent Carbon Monoxide Poisoning

I'm writing about combat and civilian casualties because of my background. I was part of the Army <a href="https://www.menshealth.com/fitness/a18926146/army-ranger-workout-training/" id="6ef16ab3-ed53-346f-a59b-6f6fcdc9d462"> 75 </a> for five years. It's a light infantry special operations unit regarded as the Armys premier direct action raid force. Personally, Im partial to what our Afghan interpreter informed me the locals called us: "The men with the green eyes who come in the night," referencing the glow of our night vision goggles. Of my five years on active duty, two were spent full-throttle serving as a Battalion Surgeon in the 75 th Ranger Regiment.

What drew me to pursue serving as a surgeon with the Rangers? The unrelenting standards. Elsewhere in the special operations, the soldiers are split between operators, the bad asses coming out of the water in recruiting commercials, and "support" for which there are different training requirements. Not in the Rangers. Every soldier must uphold the minimum physical, marksmanship, and airborne standards regardless of rank and function. Prior to my arrival, my unit went for 18 months without a doctor because physicians go through the same selection process as other Ranger leaders and kept failing.

These standards are the reason Rangers are so good at saving lives on the battlefield. I'm now an <a href="https://www.menshealth.com/health/a25014497/emergency-room-doctor-hard-night/" id="ac264bf7-b344-3a42-a20c-be96b9afa488"> emergency room physician </a> and gave a lecture to the emergency physicians at a respected major trauma center and shared an unwelcome truth: If I got shot outside the hospital I would rather have a team of non-medical, high-school educated Rangers take care of me than any group of ER doctors. The reason? Rangers are drilled to be fast and efficient. I have clear memories of repeat training iterations well past midnight involving assessing, treating, and evacuating casualties using night vision in the midst of flash bang grenades, live machine gun fire, and rotor wash from nearby helicopters.

Between October 2001 and March 2010, the 75 th Ranger Regiment sustained 419 battlefield casualties during over 8,000 combat missions in Afghanistan and Iraq. In spite of overall greater injury severity, the Rangers had significantly better outcomes than the rest of the Department of Defense. Additionally, of the 32 combat deaths, none were considered preventable after action review, meaning that the Rangers life could not have been saved by any change in pre hospital medical care. These statistics were so impressive that they shifted the entire paradigm of American military trauma care.

Tactical Combat Casualty Care, or TCCC is the basis of this shift. Time counts in trauma and the focus of TCCC is on broadening out the responsibility of initial care beyond the few medical personnel out to everyone, and a huge number of lives have been saved because of it. Full training involves a multi-day intensive course, but simple scene safety and the three points below are absolutely enough to save a fellow human should you be unfortunate enough to have the option to act.

1) Stay Safe Yourself This is by far and away the most important principle. I want to reemphasize this: Do not add to the problem. Until the threat is neutralized, you need to maintain cover and do all you can to prevent being shot yourself. This is not just for yourself-if you become a casualty while attempting to do a great thing, you are further stressing the available medical resources and are decreasing the chance of others being treated in time.

2) Stop the Bleeding Extremity wounds are the number one cause of preventable combat death. Extremity bleeding is stopped by use of a tourniquet rapidly applied painfully tight and as high up on the extremity as possible way above the actual wound. Bullets can track weird courses; think J.F.K.. The initial tourniquet should be put on rapidly, over the clothes and as near the torso as possible to keep the blood near vital organs. There are numerous effective products, but the CAT tourniquet is the best known and <a href="https://www.amazon.com/s/?ie=UTF8&amp;keywords=cat+tourniquet&amp;tag=googhydr-20&amp;index=aps&amp;hvadid=241922526156&amp;hvpos=1t1&amp;hvnetw=g&amp;hvrand=9335626877687212732&amp;hvpone=&amp;hvptwo=&amp;hvqmt=e&amp;hvdev=c&amp;hvdvcmdl=&amp;hvlocint=&amp;hvlocphy=9073479&amp;hvtargid=kwd-1559611408&amp;ref=pd_sl_1bjfwsz216_e" id="8d380b8b-48db-36f4-a449-cb2dfb22e6d8"> costs around $20 </a> on Amazon. I keep a few in my vehicle. A belt or whatever else you can tie around is secondary option, but has to be tight, like really tight. Do not worry about killing the limb with a tourniquet; hours can safely pass before any real damage occurs.

Treat shots in junctional areas-places you cant get a tourniquet on, but it's possible to compress, like the groin, armpit, and near the neck-with pressure. Focused pressure is the most effective, a finger tip where the bleeding is coming from is far better than a huge gob of bandages that slowly soak with large quantities of blood. I have gone un-sterile into the operating room with my hand inside my patients neck to prevent further blood loss from a slit throat.

Shots in the box (torso and abdomen) need a surgeon. Period. Your best care is to get them to a hospital ASAP. If there are a lot of people injured the ambulance service can be overwhelmed and going by private vehicle is totally appropriate and often life saving. In penetrating trauma, gunshots and stabs, you do not need to worry about preventing spinal injury, just get them to a vehicle and go.

2) Treat a Sucking Chest Wound. A penetrating injury to the chest or upper abdomen needs a simple plastic covering to prevent a rapidly fatal complication called a tension pneumothorax. This is where with each breath air gets sucked in through the wound and gets trapped in the chest cavity progressively raising the intrathoracic pressure and collapsing the lung and large veins returning to the heart. The dressing can be simple, a candy bar wrapper, zip lock bag, etc. held or duck taped over the wound.

3) Provide Warmth Keep the casualty warm with a blanket, ideally, but coats, the shirt off your back, or whatever else you have around will work. Blood loss and injury causes decreased body temperature even in really warm environments. This causes what textbook's describe as the coagulopathy of trauma. Basically, your bodys natural process to stop bleeding is dependent on enzymatic reactions that are slowed or stopped by cold. So you can drastically reduce the overall blood loss by keeping the casualty warm and allowing their body to do its part.

The simple steps in this article are absolutely enough to save a life without further medical training. If you want to take it a step further, <a href="https://citizenaid.us/" id="f29d2036-d602-3b51-a973-11bc1ebc8000"> Citizen Aid </a> has slimmed down the militarys casualty care training system for civilians. They focus on the initial life saving minutes before professional help arrives and offer a free what to do in a shooting phone app, trauma supply kits, and a one-hour $14 online training with a 1:1 matching incentive which trains a teacher.

Action is the first step to being a hero. Not long ago, in a state-of-the-art, fully resourced emergency room trauma bay, I was unable to bring back a healthy male in his early 20s with a simple gunshot to the leg. He bled to death in the middle of the day on a busy street full of good people. Literally just one person going up and taking action, either by putting a tourniquet on his thigh or even just jamming a shirt hard into the injury with a thumb, would have saved his life. Take action, my friends.

Throughout history, the battlefield has been key to civilian medical advancement- think vaccines, antibiotics, and the ambulance service, to name a few. In recent years, trauma care has dramatically improved through a few simple changes that, unfortunately, are now relevant in the civilian world. In 2018 alone, there were 323 mass shootings-defined as four or more people shot in the same location at roughly the same time-in the U.S. Last year also marked more school shootings than ever before...

How You Can Save A Victim of A Gunshot Wound

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Jedidiah Ballard, D.O.

Articles written by the author

How to Prevent Carbon Monoxide Poisoning

How You Can Save A Victim of A Gunshot Wound