Where There’s Smoke
People who smoke while using home medical oxygen pose a serious fire threat to emergency responders, neighbors and family, and themselves. So far, reducing that risk while honoring patient privacy has proven an elusive goal.  Where do we go from here?

NFPA Journal®, January/February 2009

By Marty Ahrens

In the past few years, I have heard from many people frustrated and frightened by individuals who smoke while using medical oxygen. While property managers, the fire service, and health care system workers are all assumed to be responsible for the safety of these people, none have the right combination of authority, resources, and power to quickly and effectively address the problem.

IMAGES / FIGURES Photo 1:  Two views of an exploded medical oxygen tank. AUDIO CLIPS   Marty Ahrens, NFPA's Manager Fire Anaylsis Service on the hazards of medical oxygen:  What makes medical oxygen so dangerous?  Who is potentially effected by this hazard?  A summary of oxygen burn statistics.  Why does smoking represent the greatest threat to someone using medical oxygen?  Is there a responsibility issue on the part of the medical community?  More audio files RELATED INFORMATION    National Statistics on Home Burns and Fire Associated with Medical Oxygen Use MORE RELATED INFORMATION  The full "Fires and Burns Involving Home Medical Oxygen" report (PDF, 224KB)  Printable fact sheet on home medical oxygen (PDF, 44KB)  More information on the major causes of home fires

Fires started by smoking in the presence of home medical oxygen are all too common in NFPA’s Fire Incident Database Organization. A few examples:

• In 2005, a 73-year-old Delaware woman was smoking in bed while on oxygen in an apartment building for seniors. Her cigarette ignited her pajamas. A sprinkler operated and extinguished the fire, but the unit remained smoky. The victim was able to get into her wheelchair and make her way to the stair tower, where she was found by firefighters. She died of her burns.
• Discarded smoking materials ignited paper in a wastebasket in an Arizona single-family home. When the occupant, a woman on oxygen, carried the wastebasket to the sink, fire burned through the oxygen system’s plastic tubing and spread to an upholstered stool and the oxygen generator in the living room. Two sprinklers extinguished the flames. Firefighters found the woman in the bathroom, dead of smoke inhalation. 
• In 2004, a fire/rescue company in Rhode Island responded to a house fire with medical oxygen present. They found heavy fire and a severely burned victim in the back yard. As they entered the structure, a medical oxygen cylinder ruptured. A rescue squad member, Greg Hitchcock, writing in the 1st Responder Newsletter, reported that the force “lifted the attack team off the porch back to the street. Had this cylinder and shrapnel from both the tank and cast metal base stand gone right instead of left, I probably would not be writing this today.” No firefighters were injured. The cylinder is shown in Photo 1.
• According to the Massachusetts’ Office of the State Fire Marshal, fires involving smoking and home oxygen systems have claimed 18 lives since 1997.  In one case, an eight-year-old girl died in a 2002 fire that started when her 56-year-old father dropped his cigarette while using home oxygen. The fire was intensified when an oxygen tank ruptured. In a 2004 fire, bedroom furniture was ignited by a cigarette in a home with medical oxygen in use. The fire claimed the life of the oxygen user’s roommate.

Added oxygen makes any fire that starts burn hotter and faster. When medical oxygen is present, skin oils, hair, clothing and bedding can ignite at lower temperatures. The resulting fires can progress so quickly that even the best fire protection may not be enough to prevent fatal injury, particularly to someone who is already in poor health. The risk to firefighters responding to a medical oxygen fire is also heightened, especially when they are unaware such cylinders are in use. In a 2001 technical investigation report published by the U.S. Fire Administration, John Lee Cook, Jr., wrote that the prospect of medical oxygen in the home is so hazardous that “firefighters should always assume, until proven otherwise, that any dwelling that houses an elderly or ill resident contains oxygen cylinders.” 

The incidence of such fires is comparatively small. The storage and use of medical oxygen is tightly regulated in health care environments such as hospitals, but to a great extent the safety of home oxygen use depends on the people in the home. As a result, ethical and practical issues abound for those who struggle to maintain a safe environment in the presence of home medical oxygen: health care providers, insurance companies, property managers, family members, neighbors, firefighters, and, most importantly, the patients themselves. It remains unclear how to reduce this risk without intruding into a patient’s privacy. The only way to begin addressing the question is for the various stakeholders in medical oxygen safety to begin working together to find real-world solutions. 

Addiction and Poor Health: A Dangerous Combination
Smoking is a powerful addiction. Almost all smokers have been advised for years to quit before requiring oxygen, and they are instructed that they must not smoke if they receive medical oxygen. However, information and good intentions are often not enough.  In a 2004 article in the British Medical Journal, Martin Jarvis reported that fewer than 3% of all attempts made by smokers to quit result in smoking cessation of a year or more. In a 2004 article in Respiration, Stamatis Katsenos and his colleagues noted that 26 percent of the patients in a home visit survey of long-term oxygen therapy patients in Greece were current smokers. In his 2006 article in the Danish Medical Bulletin, Thomas Ringbaek reported that records of Copenhagen patients receiving oxygen therapy for chronic obstructive pulmonary disease showed that, among the patients surveyed and tested, more than 21% exhibited indications of smoking.

Writing in Denmark for a 2001 article in Chest, Ringbaek, Lange, and Viskum point out that national guidelines state that current smokers cannot be considered candidates for long-term oxygen therapy, but that those guidelines provide no guidance to ensure this. The authors propose adding recommendations to the guidelines that would test prospective patients for carboxyhemoglobin in expired air or blood gases, the presence of which would indicate that the person is likely a smoker.

In a 2006 article in the Medical Journal of Australia, McDonald, Crockett, and Young described the position of the Thoracic Society of Australia and New Zealand on the subject: “Oxygen therapy is not indicated for patients…who continue to smoke cigarettes (owing to the increased fire risk and the probability that the poorer prognosis conferred by smoking will offset treatment benefit).”

In 2007, the Joint Commission on Accreditation of Healthcare Organizations added the medical oxygen issue to its annual Home Care National Patient Safety Goals. Those goals now require health care organizations to identify risks associated with long-term oxygen therapy such as home fires. Implementation expectations include home fire-safety risk assessments about the presence and functionality of smoke alarms, fire extinguishers, and fire-safety plans; fire prevention education to the patient and family; and assessment of the patient’s understanding and compliance with concerns reported to the patient’s doctor. 

Doctors want to be sure their patients get the care they need. To provide adequate care, physicians rely on their patients to be honest with them and to trust them. Policing behavior changes that dynamic, and doctors have little time and receive little reimbursement for lengthy discussions with patients. They can encourage smoking cessation programs for their patients who continue to smoke, or, if they feel the risk outweighs the benefits, they can choose not to prescribe or renew a prescription for medical oxygen.

Another group deeply affected by smokers using medical oxygen are property managers and nearby residents. Property managers may find themselves in a difficult position when tenants continue to smoke while on medical oxygen, since many managers do not want to find themselves in the position of evicting the ill and the aged. But many of the laws regarding health care, privacy, and tenancy do not mix well. In a 2006 retaliatory discharge case (Thomas E. Bright, Jr. v. MMS Knoxville, Inc.), the Nashville, Tennessee Court of Appeals upheld the right of a medical supply company to fire an employee who had violated company procedure. In that instance, the medical supply company employee encountered an oxygen-using customer who came to the door of her apartment holding a cigarette. The employee reminded a property manager that smoking in units with medical oxygen should not be allowed. Although the individual was not named, the manager knew which unit the medical supply employee had visited, and started eviction proceedings on the smoker, who in turn complained to the medical supply company that her privacy had been violated. The court noted that regulations on smoking while medical oxygen is in use apply to facility management, not the smoker.

Some groups are attempting to give the parties involved a clear path to follow. The Department of Veteran Affairs, in its VHA Directive 2006-021, requires that incidents in which patients on home oxygen fail to comply with its guidelines be documented and reported. If an oxygen patient’s continued smoking poses a potential safety concern, the VA uses a multidisciplinary review process or ethics consultation to decide if and how oxygen therapy will continue. 

But the issue is more complex than just cigarettes and oxygen cylinders. Although smoking materials were the leading heat sources in the incidents mentioned above, other heat sources such as cooking equipment, candles, and grinding equipment suggest that some patients were engaged in activities that would have been benign prior to the use of medical oxygen, but became dangerous with its use. Arcing was cited as the heat source in 5 percent of the reported fires and 18 percent of the associated deaths.