Friday, November 17, 2017

Carbon Monoxide 2017

Carbon Monoxide

Carbon monoxide (hereafter referred by its chemical symbol CO)
This post could save your life. How many of you own a carbon monoxide alarm? If you do, good for you. Make sure that it is in good working order. The units do not last forever. IN some of the older units, batteries need to be changed annually (at least) and some units suggest that you vacuum the cover monthly to remove accumulated dust. If you are one of the many who do not yet own one, please remedy that immediately. It has been the law since January, 2013, with few exceptions.

Homes with a fireplace, attached, garage, or any gas appliances are at higher risk, but there are many different factors that can cause an elevated level. A friend of mine is a lawyer who was involved in a heartbreaking case where a guest at a Bay Area hotel sustained long term health impairment from an exposure. The victim’s room was above the hotel pool and a faulty boiler used to heat the pool vented carbon monoxide into his room. When he didn't show up for dinner, his friends found him unresponsive. It was a very alert physician in the emergency room who figured out the cause. It was only at that point that the hotel was evacuated. This is not an isolated incident. As a result, my lawyer friend takes a portable detector along with him on all of his travels!

Because heaters and fireplaces are often involved, exposure is usually higher during the winter months.

Carbon monoxide is a colorless, odorless and tasteless poison gas that can be fatal when inhaled. CO binds to hemoglobin with much greater affinity than oxygen, forming carboxyhemoglobin (COHb). It is hundreds of times more efficient than oxygen at attaching to the cells, so even small amounts can deprive our bodies of vital oxygen. In severe cases, for folks who survive an exposure, it can cause irreversible brain damage by starving the brain of oxygen.

Normally if someone is deprived of oxygen they may look pale or cyanotic (bluish); in the case of CO poisoning, the color will remain nice and pink. A standard pulse oximeter may not be an accurate indicator of where or not there is a problem. If carbon monoxide exposure is suspected a blood test can be done to check the carboxyhemoglobin level.

One of our local ER docs who allowed me to pick his brain added that one of the tricky things about CO poisoning is that the symptoms are very vague and nonspecific. A faster than normal heart rate (tachycardia) is the only really reliable physical exam finding.

Mild exposure might cause slight headache, nausea, vomiting and fatigue. This can easily be mistaken for flu or viral syndrome. Medium exposure symptoms would be a throbbing headache, drowsiness, confusion and a rapid heart rate. Extreme exposure will lead to unconsciousness, seizures, and cardio-respiratory failure that usually is fatal.

The effects of exposure can vary greatly from person to person depending on age, overall health, and the concentration and length of exposure. Young children and pets are thought to be especially vulnerable. Pregnant women should also be especially careful because the fetus can be seriously impacted.

A carbon monoxide alarm is similar to a smoke detector because it monitors the air in your home and sounds a loud alarm to alert you of trouble. However, the way you respond to a CO alarm is very different than a smoke detector. When a smoke detector goes off, it is pretty easy to to judge the level of danger. You can see or smell the smoke. On the other hand, because CO is completely undetectable to your senses, you are dependent on the alarm to let you know there is a problem. If the alarm sounds:

  • Operate the test/reset button
  • Call 911
  • Immediately move to fresh air (make sure that everyone in the household is accounted for.)
  • Do not go back in until you have the all clear from the emergency responders.

Concentrations of CO between 1 and 30 ppm can often occur in normal, everyday conditions. See the chart below for CO levels and corresponding symptoms.

If your unit is coming to the end of it’s life it may give off multiple chirps to notify you that you need to replace the device or change the batteries. Newer alarms might be good for as long as 10 years. Ours has a digital display that will signal when it is time to replace it.

Last year my daughter Alana had her CO alarm go off in her apartment in Michigan. She knew enough to get outside and call 911 immediately. After the fact she recounted her conversation with the fireman who had responded:

“I am worried about my cats, can you help get them out?”
“What do they look like?
“They are CATS, they are furry, have 4 feet and tails!”

Happily the kitties were all safely brought out of the apartment.

The best guess for what set off the alarm was something faulty with the air conditioning system. It went off several times with no clear source identified, which prompted her to move.

You may not think that your home is at risk, but there is NO downside for investing in an alarm (plus you are complying with the law.) They are inexpensive. If you are renting and there is not a unit in your apartment, call your landlord immediately and get that remedied. in January of 2017, in the Bay area, there was the tragic instance of a young couple and their pets all found dead with no obvious cause. It turned out that it was CO exposure from a malfunctioning 3D printer. A functioning alarm would have saved their lives. Don’t mess around with this. Please make sure you are protected.

Saturday, November 11, 2017

RSV 2017

November is often considered the start of RSV season. It has yet to arrive with a vengeance, but I know it is coming. The local emergency rooms may have started to see some cases. Here is the RSV post, updated for the 2017/18 season.

What is severe RSV disease?
Respiratory syncytial (sin-SI-shul) virus, or RSV, is a common, seasonal, and easily spread virus. In fact, nearly all children will get their first RSV infection by age 2. Like most viruses it ranges in its severity from case to case.

Severe RSV disease is the number one reason babies under 12 months old have to be admitted to hospitals in the US. You know the wretched colds that knock you flat and stand out in your memory? These are the colds that come with runny noses, sniffling and sneezing, harsh cough and fever. That illness might well be RSV. I actually can almost diagnose it over the phone when I hear the patients coughing. The cough sounds like it hurts. Generally the first signs are runny nose and decreased appetite. The cough follows a few days later.

There is a test that we can do in the office (a swab to the nose) to see if it is RSV or not, but unless your child is looking really sick we might not bother. It doesn't necessarily change the approach. We often do nebulizer treatments for our wheezers, but with RSV they don't always help all that much. This is a virus and antibiotics would not be appropriate.

Time usually fixes this and all that we can offer is often the same symptomatic treatment and supportive care that we would do for any bad cold and cough. Treat the fever as needed  
To clear the nose, squirt some saline or breast milk in each nostril and then suck it back out with either a Nose Frida/ aspirator or theNeil Med Naspira. I think those are much easier to use than the standard bulb aspirators.
Another available product that some parents like is the Oogie bear.This is a safe little scoop that can safely get into the nostril and removed the more stubborn boogies.

If your child is having trouble eating because of all the congestion, try doing some clearing about ten minutes before a feeding. It is also helpful to keep their heads elevated. They may need to spend the night in a safe infant seat or you can try to raise the mattress a bit. For older kids, add an extra pillow. Let them sit in a steamy bathroom, and use a humidifier at night. Increase fluids during the day.

RSV can cause ear infections and pneumonia. In fact some studies show that somewhere between 25-40% of young infants with the RSV virus will have bronchiolitis or pneumonia. Severe RSV disease symptoms include:

Coughing or wheezing that does not stop
Fast or troubled breathing
A bluish color around the mouth or fingernails
Spread-out nostrils and/or a caved-in chest when trying to breathe
Gasping for breath

If your child is having trouble breathing, or significant trouble feeding, they may need to be hospitalized for a night or two for fluids, oxygen and observation. I would say that we have several kids routinely hospitalized for this every year (not just young babies.) There is no other real treatment for RSV other that close observation, but for certain high risk patients, there is a medication that is given monthly that significantly protects them. This medication is called Synagis.

If your child was premature, or has cardiac or pulmonary issues, they may qualify. Talk to your doctor's office ASAP to find out if your child fits into the guidelines. Alas the guidelines are quite restrictive. Much to the dismay of most sensible practitioners, they became even tougher last year. We used to be able to get it for preemies who were born before 35 weeks. The new rules moved that to 30 weeks. So far I don’t have any candidates this season. I hope it stays that way. In California the official RSV season starts on November 1st. (I don't think that RSV knows that it has a season, but that is when the insurance companies will start shipping the medication.)

Since most of our children can not get protected with Synagis, please take precautions to prevent the spread of this nasty virus, especially for the youngest most vulnerable babies.

Wash your hands before touching your child. Make sure others wash up, too. Clean toys, crib rails, and any other surfaces your baby might touch. Try to keep your baby away from crowds. Avoid anyone with a cold or fever. Don't let anyone smoke near your baby. Tobacco smoke exposure can increase the risk of severe RSV disease.

Sadly it takes multiple exposures before you develop immunity. Most folks get RSV about 8 times until they finally seem to be not as vulnerable! It spikes again in older folks when the immunity tends to wane and it can sweep through retirement communities, so be cautious for the older adults in your life as well.

If your child is unfortunate enough to get a nasty case of RSV during the season it takes a long time for the lungs to calm down. In my experience it is not uncommon for these kids to have a tough winter. Every new cold seems to re-trigger the wheeze. This does NOT necessarily mean they have asthma. For repeat wheezers, if the nebulized medications bring relief it might be worth owning a machine. We rent them out of the office for $5/ day, but you can purchase them for less than $100 from Walgreen's. Having a nebulizer safely tucked away in the bottom of the closet may save you from a nighttime or weekend trip to the emergency room.

Halloween Safety tips 2017

Halloween Safety tips 2017

Halloween can be such a fun holiday, but as you can imagine, as advice nurses we tend to hear about some of the misfortunes that can along as part of the festivities.

Carving a pumpkin can be a very fun tradition. Please make sure that your child's level of participation is consistent with their age and ability. Watch out for the sharp implements and make sure you assign your younger child to the safer tasks (young kids can draw on the pumpkin rather than carving.)
Clean up the mess. Pumpkin flesh is slippery and can cause falls and injuries when dropped on the floor. Layer newspaper or old cloths under your carving work space and clean up spills right away so no one slips or trips. Skip the candles, which may cause fires. A burning candle in a pumpkin may become a blazing fire if left unattended. Instead, use a glow stick (available in many colors) or flame-less candle to safely illuminate your jack-o'-lantern.

Choosing a costume
Children are more than twice as likely to be hit by a car on Halloween than on any other day of the year!

Decorate costumes and bags with reflective tape or stickers and, if possible, choose light colors.
Have kids use glow sticks or flashlights to help them see and be seen by drivers. Is your dog going along with the trick or treaters? Have them wear a glow in the dark collar!
When selecting a costume make sure it is the right size to prevent trips and falls.
Be sure to wear flame-resistant costumes. Remind your child that they need to pay very close attention to their surroundings and avoid walking near any candles or flames, especially if they have loose flowy costumes.
If a sword, cane, or stick is a part of the costume, make sure it is not sharp or too long. A child may be easily hurt by these accessories if he or she stumbles or trips.
make sure that no part of the costume is covering their ears solidly enough that their hearing might be impacted.
Since masks can sometimes obstruct a child's vision, try non-toxic face paint and makeup as another option. Face paints have been in the news lately. Some of them have some toxic ingredients like lead. Be familiar with the ingredients before you apply anything to your child’s skin.
Always test the makeup in a small area first. Always completely remove it before bedtime to prevent possible skin and eye irritation.
Make sure that your child doesn't have any latex sensitivity before you do too heavy of an exposure. Many masks are made of latex. We actually had a patient who had an allergic reaction to the hair tinsel. You may want to do a test run of the costume and make up a couple of days ahead of time to rule out any allergies.

Trick or treat rules
Children under the age of 12 should not be alone at night without adult supervision. If kids are mature enough to be out without supervision, remind them to stick to familiar areas that are well lit and trick-or-treat in groups. Never go into a strangers house without supervision.

Popular trick-or-treating hours are 5:30 p.m. to 9:30 p.m. so be especially alert for kids during that time if you are out driving.

A good meal prior to parties and trick-or-treating may discourage youngsters from filling up on Halloween treats.

Bring plenty of water along when you go trick or treating. Just trust me on this one.

Make sure that your children know that after trick or treating, the grown up needs to pick through trick or treat bag and toss anything that looks suspicious. There is a warning out in Colorado this year about "pot laced" treats. That could happen here just as easily. Anything that looks like it has been tampered with should get tossed. Some candies are real choking hazards. If you have a younger child in the house, make sure they don't have access to the stash.
If you have a child with nut allergies (I am sure this is NOT your favorite holiday) make sure that they turn over ALL the candy so that you can separate out anything that might cause trouble. My favorite allergist adds another piece of advice. Most of the time nuts may be just one of the ingredients, but as a general rule, kids who are allergic to nuts should also be able to identify the nuts that they are allergic to. If it is peanuts, make sure they know what an actual peanut looks like.

Expecting trick-or-treaters or party guests?
Consider purchasing non-food treats for those who visit your home, such as coloring books, stickers or tattoos. Provide healthier treats for trick-or-treaters such as low-calorie treats and drinks.(Okay, fine...maybe you don't want to be "that" house, but I had to put it on the list.) Be sure walking areas and stairs are well-lit and free of obstacles that could result in falls. Keep candle-lit jack o'lanterns and luminaries away from doorsteps, walkways, landings, and curtains. Place them on sturdy tables, keep them out of the reach of pets and small children, and never leave them unattended.

Now what do we do with all this candy!!!
Make a plan about how much candy they can eat at one time. It is okay to be a little more liberal than usual for a day or two, but come to an agreement about a reasonable candy intake over the next few weeks. Some dentists and orthodontists have buy back programs, where they will give your child a reward for turning in their candy. Check with your dentist to see if they participate

Bibi, one of our mom's, doesn't bother with the dentist and has instituted her own buyback program. Her kids can exchange candy of new lego pieces.

You may need to be extra vigilant with teeth brushing this season.

Remember that candy freezes (and some of it is actually better that way; frozen snickers bars, yum!) My daughter Lauren was about 6 when she caught on that mom and dad were pilfering through her trick or trick bag and stealing all the good stuff. After that she guarded her stash more carefully.

Here are some tips that some wise mamas have added to this post over the years:

"Once Cleo was out of the stroller and walking, we put glow stick bracelets and necklaces on her so we could see her more easily when out and about in crowded spaces in the dark (we do this at things like the Dia de Los Muertos parade, too.) Cliff's sells them in a big 100-stick bulk container. Not terribly eco, but gives a little extra "eyes on" help when navigating the crowds."

My little patient Franny, bent a glow stick in order to activate it and it broke.
Some squirted in her mouth. While, you do want to avoid unnecessary contact with the insides of a Glow sticks, they are non toxic

Here are some Halloween activities

Friday, October 20, 2017

Eczema/updated treatment options

October is national eczema month...who knew there was such a thing!!!
I did a recent rash post that focused on when to worry about a rash. This one is about how to manage and treat eczema.

The term eczema is broadly applied to a range of persistent skin conditions.
Options for treated have increased since I did this post a couple of years ago

Some babies have buttery soft skin. Others are not so lucky. The very dry skin is prone to all sorts of rashes. This is one of those topics that we routinely get calls about year round. It doesn’t have a season. Understanding some basic facts about the skin can help you understand what is going on and how to deal with it.

Eczema actually comes from the Greek word for “eruption”. You may also hear it referred to as Atopic Dermatitis. The top layer of the skin is called the epidermis and the top layer of the epidermis is called the stratum corneum (SC). The SC is incredibly thin but it is the main barrier of the skin. It keeps chemicals that come in contact with the skin from being absorbed into the body, and it keeps fluid inside the skin from leaching out. The SC contains 3 types of lipids that have different chemical compositions and functions; ceramides, cholesterol and free fatty acids. But it gets even more complicated. There are nine different types of ceramides in the SC, conveniently named ceramide 1 through ceramide 9, and they account for 40-50% of the lipids in this outermost layer. Scientists are doing a lot of research on the important function that ceramides play. What they are now discovering is that people with eczema have significantly fewer ceramides in the SC than folks with healthy skin. (Don’t worry there won’t be a test on this.)

The obvious focus is to try to rebalance and add back some of those deficient ceramides. Thus, the key to treating basic eczema is moisturizing! There are some very good products that can make a big difference. Dr Lawrence Cheung is my go to dermatologist who sees a lot of our patients. He lists the following products as some of his favorites:

Aveeno Eczema Therapy
Cetaphil Restoraderm
Cerave Hydrating Cleanser and Moisturizing Cream

Eucerin and Vaniply are a few other good brands. Read the labels and make sure that ceramides are on the list of ingredients.

If you like home remedies, my sister-in-law Barbara swears by coconut oil mixed with a bit of tea tree oil.

Well lubricated skin does not get as itchy and doesn’t break down as easily. It is important to moisturize at least once a day, but there is no downside to greasing up your kid more often than that. It is really important to break that itch cycle. Aside from causing misery, scratching can tear the skin, and an infection can occur.

There does seem to be a hereditary component to this condition so it is pretty common for eczema to run in families. My patients with this diagnosis generally have fairly dry skin with rough patches. These kids (and adults) seem to be much more sensitive to various foods and other environmental factors. Something that is making the skin reactive is referred to as a trigger. Triggers can range from changes in temperature, a new detergent, teething or a new food. Acidic foods seem to be big culprit for some kids.

Every year when it is “easy peel” tangerine season, I start getting loads of calls about patients whose eczema is flaring up like crazy. Other kids seem to react to dairy. My daughter Lauren got horrible eczema when she first switched to cow's milk. I stopped it for a while; when we retried it several months later she was fine with it. Sometimes you just need to do some trial and error experiments.

When food sensitivity is to blame you will often see chapped cheeks and a red ring around the anal area.

People used to recommend infrequent bathing, but it turns out that this is a myth. If your child likes their bath, you can give one as often as you like. Baths are fine, but sitting in soapy water for extended periods is not such a good idea. Let them do their “fun in the tub” session for most of the bath first and then do the actual washing and rinsing with gentle soap and shampoo right before getting out. Bubble baths and harsh soaps are pretty high on my list of suspects when I am sleuthing around for the cause of a rash.

Some folks find that adding a splash of apple cider vinegar to the bath water (about ¼-½ cup for a big tub) is soothing and may even prevent some rashes. If the eczema is severe, believe it or not, a bleach bath is often recommended by many dermatologists.

Here are important steps for giving a bleach bath:

1.     Use regular strength – 6 percent – bleach for the bath. Do not use concentrated bleach. And use plain bleach; avoid those with various scents added.

2.     Use a measuring cup or measuring spoon to add the bleach to the bath. Adding too much bleach to the bath can irritate your children’s skin. Adding too little bleach may not help.

3.     Measure the amount of bleach before adding it to the bath water. For a full bathtub of water, use a half cup of bleach. For a half-full tub of water, add a quarter cup of bleach. For a baby or toddler bathtub, add one teaspoon of bleach per gallon of water. Obviously these are approximate measurements since baths will have varying amounts of water.

4.     Never apply bleach directly to your child’s eczema. While the tub is filling, pour the bleach into the water. Be sure to wait until the bath is fully drawn and bleach is poured before your child enters the tub.

5.     Talk with your dermatologist about how long your child should soak in the tub. Most dermatologists recommend a five- to 10-minute soak.

All baths should be followed up immediately with some lotion!!!

Dr Jessica advocates the “greased pajama” method. Put the jammies on right after applying the moisturizer. The pajamas will be a little greasy. As long as they stay clean otherwise, wear those for several nights in a row.

As I already mentioned, we want to minimize itching. If your child is doing a lot of scratching we may end up recommending an antihistamine. Zyrtec (cetirizine) and Benadryl (diphenhydramine) are the two main brands that we tend to use. Benadryl is shorter acting. Most of the time it makes the kids sleepy, but once in awhile it has the opposite effect (not something you want to find out at night.) Zyrtec is longer lasting and doesn’t tend to cause either the sleepiness or the jitters.

Although the label will warn you to check with your MD if you child is under 2 years, Dr. Kaplan has no hesitation giving the Zyrtec as young as 6 months if necessary. It comes in a liquid form. She would start with ½ teaspoon at bedtime.

Hydro-cortisone creams or ointments can also be used to spot treat especially itchy areas. I would start with the weaker over-the-counter strength. If that isn’t helping, it would be a good idea to have a doctor take a look. We have options of different prescription strength ointments, creams and oils that we might try. Most of the time simple eczema can be handled by your pediatricians office. Once in awhile complicated cases that are not responding to treatment may end up at the dermatologist.

If the eczema is mild to moderate and not responding to simple moisturizing and OTC hydrocortisone, one of the options is a fairly new product on the market called Eucrisa that is looking very promising. This is a non steroidal option that can be used all over the body, including the face. As they say on the television commercials,‘nose to toes’. It is safe for long term use and has been approved for children as young as 2 years of age. Some dermatologists may use it for younger patients, off label. It is likely safe but it hasn’t been tested and will NOT be covered by insurance.

With many new medications the prices are jaw dropping. The company for Eucrisa has some excellent introductory pricing. There are copay cards available that can get a tube for a reasonable price. The most you will pay with one of the copay cards is $70 if you pay cash and have no insurance assistance. On most plans you will pay less.

One drawback with the Eucrisa is that it might sting, but that is supposed to go away over time. Applying a thin layer of aquaphor or other moisturizer on the skin prior to applying the Eucrisa might help.

In the trial only 18 patients out of 1522 stopped because of the stinging.
Generally it takes at least 2 weeks before you might see results. But some people report seeing quicker improvement.

For adults with moderate to severe atopic dermatitis there is a brand new option called Dupixent which is an injectable medication. This is info for the grown ups out there; it is not approved for folks under 18 as of yet.

For patients of all ages, Dr. Cheung shared that more and more of his patients are getting excellent results from photo-therapy. He has the safe, narrow band option at his office. The photo-therapy is done 2-3 times a week for 3 months. Often patients who have been dealing with this chronic condition for years go into remission.

If you like to think out of the box, I have seen some patients have a big improvement in their skin from some treatments from the folks at Advanced Allergy solutions. They are not the magic wand for everyone, but have been very helpful for many of my patients.

In summary

  • Keep your child moisturized daily with one of the recommended lotions or creams
  • Make sure your kids nails are kept short. Infants can have little mittens on their hands at night if they are doing a lot of scratching.
  • See if you can figure out what the triggers are and avoid them. Sometimes it is simply cutting out berries.
  • Zyrtec and Benedryl are fine for itching but don’t treat the underlying cause.

Take advantage of the new treatment options if the basic home treatment isn’t doing the trick.

Friday, October 13, 2017

Fires/smoke and air quality alerts

The Bay Area Air Quality Management District ( has issued a Health Advisory and Spare the Air Alert this week. Very unhealthy air quality from the wildfires in the North Bay is causing unprecedented levels of air pollution throughout the Bay Area. Due to active wildfires and changing wind patterns, air quality could be impacted for many days to come. Outside of the active fire areas, air quality will be variable and unpredictable. Air quality may improve at times or get worse, very quickly.

For those of you who are reading this and are not in the Bay Area, go outside and take a deep breath of fresh air. Now take another one and savor it. We tend to take so much for granted, Including breathable air, until we are faced with situations like this.

Sunday evening in the middle of the night I woke up and thought I smelled smoke. I crept down to my kitchen to make sure that I hadn’t left on an appliance. There was nothing obvious. I poked my sleeping husband, “do you smell something?” He grunted “mmmph” which I took as a NO, so l went back to sleep. It turns out that many of the people I know had done some vestige of the middle-of-the- night sniffing around. Some had gone outside to make sure there was nothing burning in the immediate vicinity. When I turned on the news on Monday morning we had an answer. The news about the fire up in the north bay was devastating. So many homes, schools, and businesses are gone, including the home of one of my very best friends, where I was lucky enough to spend countless weekends in their little patch of heaven. It is heartbreaking.

An acquaintance of mine who is a reporter reached out and I got my 30 seconds of fame later that morning

Understandably the phones and emails have been nonstop for parents worried about the impact of the smoke.

It is not surprising that many people are experiencing some degree of irritation from the smoke. For those of you who are not local, we are talking about serious smoke. Here in SF we are almost 70 miles away from the actual flames but we are still impacted. There is ash on the cars. Have you ever been to a bonfire or campfire? You know how your clothes reek of smoke? That is how the air smells. The beautiful panoramic views that we get from our hilltops are clouded by a gray haze. Scratchy throat, stingy eyes, irritated sinuses, headaches are prevalent.

The most basic suggestion is common sense. Pay attention to local air quality reports. The link will give you information about how the air is improving or worsening:

Stay indoors and keep your indoor air as clean as possible. Keep windows and doors closed. Luckily it isn’t too hot this week, but if it gets warmer, run an air conditioner if you have one, ( most folks in SF don’t actually own one.) If you do have one, keep the fresh-air intake closed and the filter clean to prevent outdoor smoke from getting inside.

Do not add to indoor pollution. Don’t use anything that burns, such as candles or incense. Don’t vacuum unless you have a really good filtered machine. Normal vacuums stir up particles that are already inside your home. Don’t smoke tobacco or other products; the air is already polluted enough!!

Avoid any strenuous activity outside. It is fine to get to where you need to go. I just wouldn’t do any extra outdoor playing until things improve. I don’t think the bounce house birthday party in the park is a good idea this weekend.

Use an air filter
If you have a HEPA filter, use it. My patients reported that the local stores were completely out of the machines today. I would suggest that you take advantage of online shopping. It is probably not a bad investment even if the air is improved by the time you get it.
I am by no means an expert on Hepa filters and there is a lot of information online. I feel like consumers reports is a pretty good guide, so I am including that:

Keep in mind that the ionic filters that create ozone are not recommended and will not remove the particles that we are concerned about.

Do not rely on dust masks for protection. The only masks that will be at all protective are labeled N95 o N100. They don’t seal well on a young child, so your best bet is staying indoors.

In San Francisco with our blessed fog that comes and clears things out on a regular basis, we are accustomed to better than average air quality. It is important to keep in mind that there are populations around the world where the norm is very unhealthy air all of the time. For most healthy folks, a week or so of terrible air won’t have a lasting impact.

If you have a child with sensitive lungs absolutely keep an eye on them. Wheezing, shortness of breath, chest pain and/ or rapid heartbeat would be reason to get seen by the physician. If your child has a prescription for inhaled steroids, it might be a good idea to get those out and start using them at the first sign of any issues. Remember that if an inhaler hasn’t been used in over 2 weeks, it may need to be primed.

At this time, there has been no medical directive issued to leave the area . It is hard to say how long the fires and bad air will be an issue, and more information may be forthcoming from the Air Quality District in the next few days. There seems to be no good answer at this point as to when to go and how far folks would need to travel to be safe as there are wildfires all over southern California as well. Do what you feel is best for you and your family.

Your local municipalities should be able to provide you with information regarding air quality, safety precautions, evacuation and recommendations for local facilities that have filtered air.

A friend of mine who lives in Santa Barbara and has been through this a number of times, posted a very good list that is worth sharing:

Home Evacuation Checklist – How to Prepare for Evacuation:

Inside the House
  • Shut all windows and doors, leaving them unlocked.
  • Remove flammable window shades, curtains and close metal shutters.
  • Remove lightweight curtains.
  • Move flammable furniture to the center of the room, away from windows and doors.
  • Shut off gas at the meter; turn off pilot lights.
  • Leave your lights on so firefighters can see your house under smoky conditions.
  • Shut off the air conditioning

  • Gather up flammable items from the exterior of the house and bring them inside (patio furniture, children’s toys, door mats, trash cans, etc.) or place them in your pool.
  • Turn off propane tanks.
  • Move propane BBQ appliances away from structures.
  • Connect garden hoses to outside water valves or spigots for use by firefighters. Fill water buckets and place them around the house.
  • Don’t leave sprinklers on or water running, they can affect critical water pressure.
  • Leave exterior lights on so your home is visible to firefighters in the smoke or darkness of night.
  • Put your Emergency Supply Kit in your vehicle.
  • Back your car into the driveway with vehicle loaded and all doors and windows closed. Carry your car keys with you.
  • Have a ladder available and place it at the corner of the house for firefighters to quickly access your roof.
  • Seal attic and ground vents with pre-cut plywood or commercial seals.
  • Patrol your property and monitor the fire situation. Don’t wait for an evacuation order if you feel threatened.
  • Check on neighbors and make sure they are preparing to leave.

I also want to share some wisdom from Heather, a local mom who started a group called

As many of you know well, we have neighbors in need. 22 fires, many out of control, continue to rage in our backyard counties. In San Francisco, many miles away from the wildfires, we wake up daily to a visible, dense layer of smog and keep our stir-crazy kids and pets inside so they won’t breathe in what has become pretty horrible air quality. In the towns directly affected by this horrific and overnight destruction, hundreds of people have lost everything they have with thousands more forced to evacuate their homes, waiting in the wings to see what happens next. Some have lost or missing family members including precious animals. I cannot imagine what the air quality is closer to the destruction and active fire zone, nor how long it will take for kids to even be able to go back to school, much less what it will take to rebuild homes and businesses after the damage is done.

Because many of you, like me, feel lost in how to help, I have asked my friends directly affected by this tragedy what we can do from afar. There are many resources available out there; here are a few I found to be noteworthy:

1.   Donate to a credible monetary fund in the area who is directly helping victims in Napa. This is a good and relatively easy one to do remotely; the fund will use the money however it is best needed on a day by day basis:

2.   Help feed and nourish Santa Rosa and the Sonoma County community by providing healthy and nutritious meals to those in need; SAGmonkey is run by a friend and long-time resident of Sonoma County who is generously giving his time and energies to help to rebuild our community.

Your donations will go directly to the purchase of food and supplies to prepare and distribute fully cooked meals over the course of the next three months. By utilizing the resources of the Redwood Empire Food Bank and other local food pantries we will prepare and distribute meals for those in need. We want to make a difference in the lives of our neighbors and friends by providing this service. We have a commercial mobile kitchen trailer that is fully licensed by the State of California and the County of Sonoma.

3.   Consider volunteering to staff a shelter, donating food and other needed items, and helping pets:

Donation drop off points listed here for SF and East Bay residents to avoid tying up roads:

4.   If you know anyone who can host people or animals in need,the travel site HipCamp is connecting evacuees who cannot return to their homes with people who have available space to host them at ranches and rural properties, bed and breakfasts, and even RVs. Anyone who wants to be added to the list can contact HipCamp

5.   ADOPT-A-FAMILY! We were lucky enough to be able to take in dear friends who had to evacuate their home this week. We’re trying to turn a tragedy into a “Fun sleepover” for kids, dogs and adults. Since our friends who live in an affected area know many people affected directly, they recommend this as something folks really need right now. This is a difficult task if you don’t know anyone there but worth the ask as you check in with friends, colleagues and local businesses etc. who may have been affected.
Hoping the wind and weather helps us all see some relief soon…
In love and light,