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$4.45 devices prevent oxygen/smoking deaths. Why aren’t they mandated?

.45 devices prevent oxygen/smoking deaths. Why aren’t they mandated?

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It seems obvious that smoking while on oxygen can result in grave injury or death. Hearing about such a horrific case, many people reflexively default to victim blaming: It’s sad, but they should have known better.

But experts say that victim blaming doesn’t solve a widespread problem that could be prevented in many cases with a simple, inexpensive device that cuts off oxygen flow when exposed to flames.

And yet those devices are not mandated by many government agencies despite overwhelming evidence that they could save lives − not just of those who die or are injured smoking while on oxygen, but those of innocent family members also hurt or killed when oxygen explodes or flashes.

Oxygen, smoking equals horrific tragedy: Hanover firefighters show what can happen

More: Careless smoking resulted in explosion, fire that killed two: York County Coroner

In York County alone since the beginning of this year, there have been three deaths − including a child killed collaterally − resulting from smoking while on oxygen in three separate incidents:

  • On Jan. 8, two people — including a 4-year-old child — died in a horrific West Manheim Township fire that was determined by officials to be due to “careless smoking” while on home oxygen. In that case, the fire was described by officials on the scene as “entirely preventable.”
  • Just weeks later, firefighters successfully rescued a couple from a burning home in Shrewsbury Township after an oxygen cylinder exploded while one of the two was smoking on home oxygen.
  • Tragedy struck in York County again later that month with a 71-year-old woman dying in a Jackson Township fire that officials said was caused by smoking while on home oxygen. There, firefighters who forced entry into a soot-covered mobile home discovered the victim’s body inside, a cigarette still clutched between her fingers.

The death toll from these incidents continues to climb. In 2019, a study by a medical manufacturer found that on average someone dies from a home oxygen fire every four days in the United States.

The real number may be much higher, with safety advocates tracking over 863 home oxygen-involved fires since 2019, sounding the alarm on what is likely an under-reporting of the fires and fatalities caused by these incidents.

Despite the death toll, safety advocates nationwide say that the federal government and medical product manufacturers have been slow to implement additional safety measures for home oxygen use, including many that have been commonplace in Europe and the Veterans Affairs health system for years.

Advocates say $4.45 thermal fuses that shut off the supply of oxygen when a fire ignites could dramatically lower the deaths and suffering inflicted by these incidents.

A problem caused by a solution

Dr. Mark Fisher, director of the Johns Hopkins Bayview Burn Center in Baltimore, Maryland, has been treating burn patients for over 20 years − and he said oxygen-related cases are common.

“We see them every week,” Fisher said. “I’m never surprised when they come in.”

All too often, Fisher said, those burned in these incidents are among the community’s most vulnerable.

It’s a fatal combination that stems from the very nature of those who need home oxygen therapy — individuals with significant lung illness often caused by an addiction to smoking in the first place.

Most often, Fisher says, oxygen treatment is provided to individuals suffering from various types of lung disease. “It can be challenging to those patients to just get the oxygen from the air into their bloodstreams,” he said.

Such patients are not capable of absorbing enough oxygen from the air into their body due to the damage to their lungs.

Normally, about 20 to 21 percent of air is composed of oxygen, Fisher said. With oxygen therapy, patients are provided 100% oxygen through a nasal cannula — a device on the end of plastic tubing that slips over the patient’s ears and flows oxygen into the nose.

“If you increase the oxygen content in the air that they breathe, they can achieve relatively normal oxygen levels in the tissues of their body,” Fisher notes.

Home oxygen therapy provides these patients with the oxygen they need while in the comfort of their own home, and according to the American Thoracic Society, more than 1.5 million people use home oxygen therapy to treat their chronic conditions.

Hanover Area Fire & Rescue Fire Chief Tony Clousher has been a professional firefighter in southcentral Pennsylvania for almost 40 years, including many years as an instructor, and he’s been involved in the fire service since he was just 16 years old.

“Typically, but not all the time, people who are on supplemental oxygen have a respiratory problem, such as COPD, caused by smoking in the first place,” Clousher said.

A 2020 study in the Journal of Burn Care & Research conducted at a burn center in North Carolina estimated that up to 52 percent of home oxygen users continue to smoke despite the risks.

“Smoking is not an easy thing to give up,” said Clousher. “It’s very addictive. You smoke, you get COPD, you end up on oxygen, and now you’re still smoking. Everything’s cyclic.”

A difficult prognosis

When the sequence of events demonstrated by firefighters happens on a human victim, the results are predictably catastrophic.

The patients admitted to Fisher’s burn center are commonly injured during that initial flash, with fire shooting up into the nasal airways. When the insides of the airway become burned, those airways can swell to the point that the patient asphyxiates, Fisher said. In those cases, while patients may appear initially relatively stable, they may suddenly crash as that swelling develops. For those patients, medical personnel have to intubate victims, placing a breathing tube into their trachea to ensure that their airway remains open despite the swelling.

Intubated patients then require a ventilator, Fisher said, which can be incredibly difficult to wean patients from when they have weakened lungs due to existing illness. That makes the prognosis “very much” life threatening in those cases, Fisher said.

“The time immediately after a burn can be really super critical,” Fisher said.

This urgency remains even with burns that don’t pose an immediate threat to life, Fisher explains. If, for example, a burn is deep in the hands or feet of a victim, the blood to those areas may be strangulated by the burn. When this happens, patients require surgery to release the pressure on these areas to avoid irreparable damage to quality of life.

Advocating for change

Chief Ray Reynolds, the director of Fire and EMS for the Public Safety Department of Nevada, Iowa, has been advocating for safety measures to prevent oxygen-fueled fires.

Reynolds was thrust into the issue after his community of roughly 7,000 people saw multiple fatal fires that stemmed from smoking while using home oxygen.

“In just the last 365 days, we pulled four people out of burning buildings related to home oxygen,” Reynolds said in a February interview. Those tragedies inspired him to search for a solution.

He was shocked by how easy it was to find: after a quick Google search, Reynolds learned of something that the Veterans Affairs health system and much of Europe already mandate: thermal fuses attached to the cannula and oxygen cylinders that are provided to home oxygen users.

“There’s a lot of education that needs to take place on this,” Reynolds said. “I’m embarrassed that, after 35 years, I didn’t even know (thermal fuses) existed.”

The concept is simple: thermal fuses are small attachments to oxygen tubing that upon being touched by fire break a fuse and shut off the flow of oxygen through the tubing. Each fuse costs $4.45, with standard practice calling for one fuse located at the cylinder side of the tube, and one fuse located at the cannula side of the tube, close to the patient’s face.

Combined, the two fuses cost around $9.

“It’s not a free pass to continue smoking,” Reynolds said, but the safety device can prevent catastrophes.

According to International Organization for Standardization (ISO) guidelines, oxygen concentrators and cylinders state that such devices should provide a thermal fuse to stop the propagation of fire. Despite that, the practice has not become commonplace outside of countries that require them.

While $9 doesn’t sound like much, many home medical equipment suppliers are already working under razor-thin margins, Reynolds said. These equipment suppliers may only get around $85 a month to visit patients at home and replace their oxygen supplies, often resulting in a profit of about $3 a month per patient.

Add nine additional dollars to the equation, and those suppliers are now operating at a loss, Reynolds said. He advocated for state reimbursements to cover the costs as a safety device.

Within months, Reynolds’ advocacy would spur the Iowa Department of Health and Human Services to become the first state in the nation to approve funding reimbursement for thermal fuses in November. There, thermal fuses are reimbursed under the same code for patient safety devices such as walkers and lift belts.

Now, Reynolds is leading an International Association of Fire Chiefs work group that is pushing to make these thermal fuses standard and reimbursable nationwide, instead of piecemealing the solution on a state-by-state basis.

The slow gears of government

Despite years of advocacy from various groups around the country, including 10 years of lobbying by the American Burn Association, the government has been slow to act on thermal fuses, Reynolds says.

While Veterans Affairs began including the fuses with home oxygen in 2018, almost six years later, the Centers for Medicare and Medicaid Services (CMS) still does not provide reimbursement.

“One federal agency approves it, the other doesn’t,” Reynolds said, “where’s the disconnect?”

“Sooner or later, CMS has got to see that this is the best practice,” said Reynolds.

Many of the victims of home oxygen fires are Medicare recipients, Reynolds said.

If Medicare implemented thermal fuses, Reynolds said, “we think that Medicare could single-handedly reduce our fire deaths in the country by 12%.”

In the United States between 2019 and 2021, Reynolds cited 152 deaths attributable to smoking on home oxygen. Comparatively, in the United Kingdom, where thermal fuses are already required, in a four-year span between 2013 and 2017, only one death was attributed to smoking on home oxygen.

Along with reducing fatalities, implementing the use of thermal fuses nationwide could save the healthcare industry millions, Reynolds said.

In a case his department handled in August of 2023, two surviving burn victims of a home oxygen therapy fire were faced with $1.2 million in medical expenses.

As both victims were Medicare recipients, Reynolds noted that Medicare could have provided 269,000 thermal fuses across three states for the same cost as the healthcare expenses from a single home oxygen fire.

The invisible toll

While many are quick to blame the victims of these fires, the devastating toll affects more than just the smoker who starts off the catastrophic chain of events.

In many cases, such as the fire earlier this year that killed a 4-year-old child, family members of smokers are injured or killed.

Reynolds said family members of home oxygen fire victims often lament not knowing about thermal fuses sooner. “They say, if I had only known, I would have paid nine bucks,” said Reynolds.

For many on Reynolds’ work group, the issue is a personal one. Among those in the work group is fire Chief Scott Moore, of the Battlefield Fire Protection District in Missouri. Reynolds and Moore have seen firsthand the devastating impact that home oxygen fires have on families, including their own fire department families.

“This is becoming a firefighter safety issue,” said Reynolds.

Thanks to modern advances in fire safety and fire prevention, rural fire departments are rarely faced with rescuing victims trapped inside house fires, Moore said.

In the 35 and 30 years, respectively, that Reynolds and Moore have worked in the rural fire service, the pair has each only seen one successful rescue of a victim from a house fire. More often than not in their communities, occupants are found standing outside of their home by arriving firefighters.

But with the combination of victims in poor health and bad mobility, and the intensity of fires fanned by pure oxygen, many of the attempted rescues Moore and Reynolds see involve home oxygen therapy users, and most do not survive.

That takes a psychological toll on the responders who must go into these fires to attempt a rescue. Despite the intense fire conditions, in the fire service, the saying goes, “risk a little to save a little, risk a lot to save a lot.”

Often, those involved in affecting these rescues may be the newest, youngest members in a department. In April of 2022, Reynolds’ department responded to a house fire caused by an occupant smoking on home oxygen therapy. The victim was a patient his department was familiar with from countless medical calls to her home as she dealt with respiratory issues, Reynolds said.

Firefighters entered the home, pulling the woman from the fire with burns covering over 50% of her body. She would succumb to those injuries 24 hours later.

In the aftermath of this fire, Reynolds said, the young firefighters suffered an intense psychological impact, with one making an attempt to end his own life and another leaving the fire service altogether.

This fire was the catalyst for Reynolds’ involvement, making a promise to his department that he would try to find a way to prevent these incidents for the safety of the community and for the mental health of his firefighters.

In Pennsylvania, when a fatal home oxygen fire took the life of a 4-year-old boy and a 79-year-old man, two young volunteer firefighters, who had arrived on the scene in their personal vehicles, were sent to the hospital with smoke inhalation after climbing through a bedroom window without breathing apparatus in a last-ditch attempt to rescue the trapped child.

“Where are we going to find the next generation of firefighters who are willing to take on these risks?” asked Reynolds.

Engineered solutions to human problems

In the experiences of Reynolds and Moore, people are quick to blame the victim when these fires happen. However, blaming the victim won’t stop these fires from happening, they note.

“As a fire official, our goal is to eliminate fires, not judge people for medical issues,” Reynolds said.

In doing so, Reynolds’ work group has focused not on human intervention, but on an engineering solution to prevent these fires from occurring even when humans behave poorly.

“What we found is that you have to take the human intervention out of solving a problem, and that means engineered solutions,” Reynolds said.

“We can solve it,” Reynolds added, “we owe it as humankind to make a difference in the world.”

Moore echoed this thought, emphasizing the difficulty in changing addictive behavior. “People are going to be people,” Moore said, “they’re going to find their way. It’s not enough to regulate them; let’s regulate the device.”

Though the thermal fuses may not stop all injuries, such as the initial flash burns, and are not foolproof, they provide another layer of protection to quickly shut off the oxygen before it fuels a catastrophic fire, reducing the chance of a fatal injury.

While the working group advocates for making thermal fuses commonplace, Reynolds said he would like to see equipment manufacturers create cannulas and oxygen tubing that have the thermal fuses built into the tubing, removing another variable from the equation.

“It’s not a Pennsylvania problem, it’s not a Missouri problem, it’s not an Iowa problem, it’s a United States problem,” said Moore.

“It isn’t a cheap problem, but it’s a cheap solution,” he added.

Harrison Jones is a reporter for The Evening Sun in Hanover, Pennsylvania. Contact him at [email protected].