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UNHS Staff at Montezuma Creek Community Health Center responds to incident at elementary school...Medically Speaking-Volume One, Number Six 12/12/13

Carbon monoxide poisoning affects students, teachers & staff

Last month, medical providers and staff at the Utah Navajo Health System's Montezuma Creek Community Health Center, played a pivotal role in helping those affected by carbon monoxide poisoning at Montezuma Creek Elementary School.

When students and staff arrived at Montezuma Creek Elementary on the morning of November 18, everything seemed normal. School Principal Boyd Silversmith explained that the morning began with a weekly assembly in the school's cafeteria. According to Silversmith, this is a time when awards are handed out, there are drawings for prizes and different items are discussed. During these assemblies, one class does a presentation. On this particular day, the second grade wanted to do a presentation and have a discussion on tattling. He said he was asked to get a certain You-Tube video ready to be shown for the presentation. On Sunday night, while at home, Silversmith said he checked the site and made sure the video would work, which it did. However, on Monday morning, when he tried to access the video on You Tube during the assembly, he wasn't able to find it. He said he tried three different times without success.

"You can always get You Tube to work, but on that morning it was not available. I thought, 'it's not going to work today, so let's move to Plan B, which was to do the drawings and talk about lunch room expectations. We were done by 8:10 a.m. and we excused the kids to class," Silversmith explained.

But soon after, students began feeling sleepy and nauseated, and complaining about headaches. By 8:30 a.m., two students had been received at UNHS's Montezuma Creek Community Health Center, just down the street from the school. DNP, Chris Singer, a provider at the UNHS clinic, treated the first student. Then, when the second student came in with the same symptoms, UNHS staff became suspicious. Clinical Nursing Director, Sylvia Ben, sent two staff members over to the school to evaluate the situation. UNHS officials reported that shortly after, a call was received from Boyd Silversmith, asking for a medical provider to come to the school because, "he had students who were sick to their stomach, falling asleep and passing out." Chris Singer and his assistant, Travis Whitehorse, were dispatched to the school immediately with facemasks. When they arrived they found children and school staff in varying levels of sickness with some passed out, some throwing up and some holding their heads. A local San Juan County ambulance was at the door, having been summoned by Silversmith.

Singer asked the school maintenance man if he had a meter to measure the Carbon Monoxide levels in the air. The meter measured more than 300 ppm (anything over 35 ppm is dangerous to an adult). Singer ran back to the clinic and notified the clinical nursing director, administration and staff, of the Carbon Monoxide poisoning at the school. He requested all the staff support that was available, along with blankets and all the oxygen that could be found. Singer returned to the school and did a walkthrough to make sure all students and staff were evacuated. Children were lying on the grass and on the ground outside the building. Some were unconscious, some semi-conscious, and some were fading in and out of consciousness. Others were complaining of stomach pains and headaches.

A San Juan County ambulance loaded an unconscious teacher and child to be transported via air to a hospital. Three patients were eventually taken by life flight to Cortez, Colorado and Farmington, New Mexico. The UNHS ambulances (a new EMS service in San Juan County) were approved by the State of Utah for utilization in this emergency, and arrived along with the San Juan County ambulance from Bluff. As UNHS staff arrived on scene, they were assigned to stay with the sickest children.

With the help of R.T. Nielson, assistant Superintendent of the San Juan School District, the victims were assigned into groups: red, yellow and green, with green being the least affected

victims. Children were shivering because of the cold temperatures that morning, and Nielson arranged for a bus to take the least affected children to Whitehorse High School, where they could be warm while waiting to be medically evaluated. There were other School District administration and staff members at Montezuma Creek Elementary School that morning, but they did not assist, just observed.

Under the direction of Sylvia Ben and Chris Singer, UNHS staff began arriving with oxygen and

blankets for the children. Dr. Casey McCullough, of UNHS, joined Ben and Singer, and 23 other UNHS staff members, who assisted with the school children and staff at the school site. Additional staff, located at the UNHS Montezuma Creek Clinic, worked tirelessly throughout the day to take care of 84 patients at the clinic, who had been exposed to the Carbon Monoxide. This was in addition to 66 children and school staff who were triaged on site at the elementary school and at Whitehorse High School. A total of 153 patients were triaged and treated, or transferred to Blue Mountain Hospital, in Blanding, and other nearby hospitals.

The first ambulance on the scene was the San Juan County ambulance from Bluff. Other ambulances responding included, San Juan County's Montezuma Creek ambulances; the new ambulances from UNHS that were approved by the state of Utah to be used for the emergency; and Navajo Nation ambulances from Red Mesa. The ambulances were used to transfer patients in the Red and Yellow groups to hospitals for needed care. In addition to the three patients transferred by life flight to Cortez, Colorado and Farmington, New Mexico, four patients were taken to Northern Navajo Medical Center, in Shiprock, New Mexico; 12 patients were taken by bus to Southwest Memorial Hospital, in Cortez, Colorado; 28 patients were taken to Blue Mountain Hospital, in Blanding, Utah; and 16 patients were taken to Four Corners Health Center, in Red Mesa, Arizona. Three children and one EMT with a broken leg were transported to San Juan Hospital, in Monticello, when officials at Blue Mountain Hospital felt that, in view of the number of patients already being treated there, it might be better to transfer the four to the Monticello facility.

"The truth of the matter is we were beyond full," explained Blue Mountain Hospital's Emergency Manager Cari Spillman. "Yes, we could have handled those four patients, but were they going to get the best care, with as full as we were? So, the decision was made to divert them to San Juan Hospital because there's an Orthopedist in Monticello and we would have had to transfer the EMT with the broken leg anyway. Also, those patients were already in an ambulance, so we decided to send them to Monticello."

One of the patients flown to Southwest Memorial, in Cortez, was ultimately flown to LDS Hospital in Salt Lake City because that facility has the only Hyperberic Chamber in the State that does Carbon Monoxide treatments. She received three CO treatments there.

Resolute Energy Company provided its safety officer for the incident. The safety officer established a command center to assist with communications and coordination of services. This was beneficial to the UNHS providers and ambulance services.

As soon as the Red and Yellow groups of patients were triaged and being transferred, Singer and McCullough went to Whitehorse High School to triage the green group of patients. Many had left before they arrived, but most of those had been taken by parents to the UNHS clinic for care. The UNHS Montezuma Creek Clinic was completely full when the providers returned. Each exam room had two patients, and the lobby was filled with patients waiting to be seen. Singer and McCullough, along with P.A. Martin Neubert and Dr. Kimberly Fairly, provided health care to 153 patients including those who were triaged at the school sites.

An investigation revealed that the carbon monoxide poisoning was the result of a broken vent on a hot water heater in the kitchen area, releasing the gas over the weekend.

"The highest CO concentration was in the cafeteria where we have our assemblies," Silversmith said. "I'm just glad the video didn't work that day, and we didn't have the video, and the discussion after it. It would have taken a good 15 minutes added on to the other stuff we were doing. How strange is that?" When asked if he believes in coincidences, Silversmith said, "No. I believe in miracles, and I think that's what happened that morning. I told a couple of families in the community that I think their kids were part of a miracle that Monday morning. I think we've got a special bunch of kids here at this school."

Silversmith reported that all those affected by the CO incident were doing well. He said the day after the incident only a small number of students were back in school. By Wednesday 70% of the students had returned and 90% were back in class on Thursday. By Friday, he said, nearly all the students were back in school with the exception of a half-dozen students that Silversmith did home visits with to make sure they were okay. In the days following the incident, Silversmith said students talked about what had happened, but several students were most excited about seeing Montezuma Creek Elementary School on television as part of the news coverage of the carbon monoxide incident.

Silversmith also reported that by Monday afternoon CO levels in the school were back to zero, and CO monitors had been installed in the school. He said in the days following the incident, teams of inspectors from the State Risk Management office, District employees and the State Fire Marshall were investigating the incident and doing inspections of the school. He also said the problem with the hot water heater had been fixed. He said the response to the incident was very good from medical providers at UNHS and other emergency services personnel.

The response from local residents to last month's incident raised the question of student and staff safety, as well as appropriate upkeep and safety checks on the part of the school district. There were also lessons learned, regarding the importance of safety monitors and regular maintenance checks on all wiring, piping and conduits.

UNHS CEO Donna Singer said the incident provided an opportunity for UNHS providers and staff to work together with emergency service providers from throughout the county, and established a more collaborative support system for future situations that might develop.

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