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Wednesday

Don’t worry, its only pepper spray.

An intentional release of pepper spray caused twenty students from a Urbana, Illinois middle school to be transported to a hospital. According to the report published in The News-Gazette, a 14-year-old student discharged pepper spray into two occupied school hallways.

Students in the affected area were moved to the gymnasium where another burst of pepper spray was released. According to the report (link: http://www.news-gazette.com/news/2006/12/22/14-year-old_arrested_in_pepper_spray_incident) school officials quickly identified the material as pepper spray and called the fire department. Twenty students complained of irritation and respiratory symptoms common to riot control agents; fifteen of those were triaged as “green” or minimal. The triage status or condition of the remaining five students is not in the article. The kids, who are described as “frightened and panicked” were not exposed to the elements.

I have numerous questions about this incident. And while it’s clear we don’t have all the facts, I think it is important to look at the actions and attitudes portrayed in this event. My first concern is the statement about school officials recognizing the agent as pepper spray. How did they know it was just pepper spray? I doubt that any detection devices were utilized to identify or narrow a list of possible agents. In fact, devices designed to detect or confirm riot control agents are not often available to responders. It is realistic to assume that a container or dispersal device was found lending clues to the agent. However, we should never assume that the obvious agent is the only agent. Responders should be aware of signs and symptoms as well as dispersal patterns and physical properties when attempting to narrow a list of possible agents. Identification of the agent is important for patient care, decontamination, and provider safety.

Another, and perhaps more menacing issue, is that of intent. In this case, the perpetrator discharged another spray after students had been moved to the gym. I have two concerns; did the perpetrator have prior knowledge of evacuation plans and collection areas and plan a secondary strike, and was any measure taken to prevent the perpetrator from getting into the gym? Both of these issues are difficult to address, yet both were components in the Columbine massacre.


We must be reminded, also, that although riot control agents are considered “less-than-lethal” they possess the potential to create multiple patients, decontamination issues, and hazards to the responders. Although not deadly, riot control agents can exacerbate a variety of respiratory and cardiovascular medical conditions and cause hypoxia resulting in critical patients.

My recommendations:
Never assume the obvious threat is the only threat; other potentials should be ruled-out to a reasonable extent.

Take the time to pre-plan for a incidents at schools. Collaborative planning and training efforts between traditional and non-traditional responders (ie: EMS/Fire and school officials) will pay big dividends during crisis.

Be sure your response plans are tested, practiced and revised. Tabletop exercises are a great low-cost way of doing this. Plans should be general in scope with annexes for specific threats. Planning for school events must include accounting for weather, media, dispersal of victims prior to arrival and site security. Don’t forget to build in communication with local hospitals.

Recent concern over too much school security has made news lately asserting that school security measures are a result of paranoia and not actual potential (for more on school security, see School Security Should Go Over the Top, Mitigation Journal (December 2006 http://mitigationjournal.blogspot.com/2006/12/school-security-should-go-over-top.html). My stance is that schools are facilities of critical infrastructure by virtue of occupancy and potential impact of an attack/event. A natural disaster such as an earthquake or a Columbine-like attack will yield panic and disruption in any community. We cannot simply dismiss an event, any event, involving schools. They are soft targets and should be hardened and protected.

These providers saved lives…at risk of their own.

The Chicago Sun-Times reported that five paramedics and one paramedic student were overcome by chemical fumes after responding to what they thought was an asthma attack.

As reported in the Sun-Times; a man had been attempting to open a clogged household drain for several days using a variety of “consumer-level hazardous materials” (consumer-level hazardous materials or CLHM, is my phrase for the chemical products available at grocery stores, drug stores, Home Depot, Lowes…ect. that if used property are no big deal, but used improperly or mixed create a hazard..)

It seems that the homeowner died from the fumes emitted by mixing several consumer-level hazardous materials; Liquid-Plumr, chlorine bleach, and Rooto. The Liquid-Plumr was used first and after several days – he started adding the other products – resulting in the “consumer-level hazardous materials event. (A Consumer-Level Haz Mat would be an event created by improper use or mixing of this type of chemical and typically found in the single or multi-occupant residential setting or resident/institutional setting…a nursing home or school dorm.)

EMS was dispatched for an asthma attack and found the homeowner dead, his wife and adult son overcome and incapacitated. The paramedics rescued the victims from the house…becoming exposed to the fumes and requiring hospitalization. The article states that “The paramedics didn’t wear masks when they went in because they thought they were there for an asthma attack.”

Some important issues for discussion:
“Consumer-Level Hazardous Materials” or CLHMs contain a legitimate danger even if used properly. You should note that Liquid-Plumr contains Sodium Hypochlorite (NaClo = sodium hydroxide + Chlorine, A.K.A. bleach) and Lye as a stabilizer. Lye is also known as caustic soda and causes defatting/sapofacation…liquefaction of the tissues. This is considered worse than an acid burn and from what I can read, the other products (Commet and Rooto) contain sulphuric acid (H2SO4)

When you mix this stuff together, you’re going to get nasty results. In general, BLEACH + Acid yields CHLORINE GAS, BLEACH + AMMONIA yield Chloramines. This reaction can be violent, especially if the reaction takes place in a confined container or builds pressure as chlorine gas and oxygen are liberated.

These chemicals can (and are) used to create Homemade Chemical Bombs or HCB’s. For more on HCB’s see Homemade Chemical Bombs: A Legitimate Threat to Responders, Mitigation Journal (August 2006) Link: http://mitigationjournal.blogspot.com/2006/08/homemade-chemical-bombs-legitimate.html

It is reasonable to assume that this EMS service did not carry SCBA and therefore, any masks they could have used would be of the infection control type. HEPA masks, N95 masks and the like will provide no protection from chemical exposure. None whatsoever, remember that. The best you may be able to do is identify the situation and call for appropriate resources.

This scenario once again proves my point for the all-hazards approach to planning and training. This was not a terrorist event yet, the dangers are similar as are the ancillary concerns of responder safety, decontamination, receiving at the hospital, multi-agency integration (NIMS, anyone?) and mitigation.

Do yourself and your partners a favor; the next time you’re in the store, take a look at the chemicals in these consumer-level hazardous materials and do some simple research.

Read the Chicago Sun-Times article here:
http://www.suntimes.com/news/metro/179079,CST-NWS-orland20.article

Sunday

Navigating the Atlantic Storm through the Dark Winter






Terrorist attacks using biological agents are potentially deadly beyond imagination. In 2001, the dissemination of engineered Anthrax struck panic with American civilians and emergency service responders resulting in exaggerated responses and near-ridiculous actions. Inhalational anthrax is fatal if not treated appropriately, but there is treatment. How would be as population fair if the biological agent was something more devastating than anthrax; an agent with no cure or treatment? Let’s use smallpox as an example.

In June of 2001, the Johns Hopkins Center for Civilian Biodefense Strategies along with the Center for Stategic and International Studies, the Analytic Services Institue for Homeland Defense held a senior-level tabletop exercise that simulated the effects of a covert biological attack on the United States. The dissemination of highly contagious smallpox as an act of terrorism became know as the “Dark Winter” scenario. This one-of-a-kind TTx examined the ability of senior-level policy makers to face the challenges of a bioterrorist attack with outbreaks of highly contagious diseases.

A similar event took place in January, 2005, this time among the international leadership community. Known as Atlantic Storm, this TTx continued on a larger scale from Dark Winter. Atlantic Storm simulated the heads of state and senior international governmental leaders attempting to manage a simultaneous smallpox bioterror attack on Istanbul, Frankfurt, Warsaw, Rotterdam, New York, and Los Angeles.

Both Dark Winter and Atlantic Storm focused on government leadership and ability to manage issues in public health, medical services, diplomacy, domestic response, and critical infrastructure. Both exercises were well developed and planned...they did, however, reached differing results. What follows is a comparison of the tabletop exercises Dark Winter (2001) and Atlantic Storm (2005). Despite commonalities in scenario and biological agent, glaring differences have emerged that leave those studying such material wondering and concerned. The opinions and concerns addressed herein are based upon study of documents, video where available, objective analysis of the scenarios themselves, of course, smallpox.

Comparison of Assumptions
Dark Winter focused on the United States as the only target in a “worst-case” scenario; Atlantic Storm targeted the international community with “best-case” circumstances. This primary difference may prove to be a single most perturbing factor when comparing the two exercises.

Although both scenarios simulated the use of smallpox as the agent with similar methods of dissemination, there were concerning differences in the projected infection rates, death rates, and person-to-person transmission potential. Dark Winter assumed a thirty percent fatality rate while deaths from smallpox were projected at twenty-five percent in Atlantic Storm. Atlantic Storm also assumed that there was residual immunity among the affected population with 300 million doses of vaccine available. Dark Winter was somewhat less optimistic; simulating a CDC stockpile of 15.4 million doses of vaccine and allowing for up to twenty percent of stockpile loss due to contamination or improper use.

Dark Winter hypothesized that 1g of smallpox could generate 100 infections when aerosolized resulting in 3000 first generation cases from 30gms of virus. There is no mention of virus quantity in Atlantic Storm; however, both scenarios disseminate the virus via an aerosolizing device under similar conditions. Dark Winter used 1:10 transmission rate (every one person with smallpox could infect ten others) as compared to Atlantic Storms rate of 1:3. Atlantic Storm also anticipated 1: 0.25 for second to third generation while no mention was made in the Dark Winter scenario of second to third generation transmission. Dark Winter planners integrated herd immunity of twenty percent into the scenario which was not accounted for in Atlantic Storm. I found the following excerpt from the Dark Winter scenario an interesting commentary on person-to-person transmission rate. A sidebar reads:

“…Given the low level of herd immunity to smallpox and the high likelihood of delayed diagnosis and public health intervention, the authors of this exercise used a 1:10 transmission rate for Dark Winter and judged that an exercise that used a lower rate of transmission would be unreasonably optimistic, might result in false planning assumptions, and, therefore, would be irresponsible. The authors of this exercise believe that a 1:10 transmission rate for a smallpox outbreak prior to public-health intervention may, in fact, be a conservative estimate, given that factors that continue to precipitate the emergence and reemergence of naturally occurring infectious diseases (e.g., the globalization of travel and trade, urban crowding, and deteriorating public health infrastructure) [26, 27] can be expected to exacerbate the transmission rate for smallpox in a bioterrorism event…”

In contrast, the Atlantic Storm best-case scenario planned for adequate disease control, compliance with public health “social distancing” (a.k.a. quarantine), available vaccine, higher herd immunity, residual protection granted by prior vaccination, and lower transmission rates. The wide range of transmission rates between the two exercises may account for the differences in total number of smallpox cases and deaths. Dark Winters worst-case predicted 1,000,000 deaths with 3,000,000 infections while the Atlantic Storm exercise predicted 660,000 cases and approximately 495,000 deaths.

Summary: Lessons or Recommendations?
Dark Winter summarized the exercise with a list of lessons and Atlantic Storm used the term recommendations to summarize. Below is a list of lessons from Dark Winter or recommendations from Atlantic Storm that seem to be common to both events despite being conducted years apart. Various excerpts from the text have been added to aid explanation.

  • Leaders are unfamiliar with the character of bioterrorist attacks, available policy options, and their consequences.
  • After a bioterrorist attack, leaders’ decisions would depend on data and expertise from the medical and public health sectors.
  • …they were given more information on locations and numbers of infected people than would likely be available in reality.” Statement concerning the amount of infromation given out in both TTx's.
  • …lack of information, critical for leaders’ situational awareness in Dark Winter, reflects the fact that few systems exist that can provide a rapid flow of the medical and public health information needed in a public health emergency.”
  • …it was difficult to quickly identify the locations of the original attacks…”
  • The lack of sufficient vaccine or drugs to prevent the spread of disease severely limited management options.
  • After a bioterrorist attack, leaders’ decisions would depend on data and expertise from the medical and public health sectors.

    … [This] reflects the fact that few systems exist that can provide a rapid flow of the medical and public health information needed in a public health emergency.”
    “What’s the worst case? To make decisions on how much risk to take…whether to use vaccines, whether to isolate people, whether to quarantine people…I’ve got to know what the worst case is” (Sam Nunn).

  • The lack of sufficient vaccine or drugs to prevent the spread of disease severely limited management options.
  • The US health care system lacks the surge capacity to deal with mass casualties.
  • The numbers of people flooding into hospitals across the country included people with common illnesses who feared they had smallpox and people who were well but worried.”
    “…[the challenges]of distinguishing the sick from the well and rationing scarce resources, combined with shortages of health care staff, who were themselves worried about becoming infected or bringing infection home to their families, imposed a huge burden on the health care system.”
  • To end a disease outbreak after a bioterrorist attack, decision makers will require ongoing expert advice from senior public health and medical leaders.
    “…the imposition of geographic quarantines around affected areas, but the implications of these measures (e.g., interruption of the normal flow of medicines, food and energy supplies, and other critical needs) were not clearly understood at first. In the end, it is not clear whether such draconian measures would have led to a more effective interruption of disease spread.”
    “A complete quarantine would isolate people so that they would not be able to be fed, and they would not have medical [care].…So we can’t have a complete quarantine. We are, in effect, asking the governors to restrict travel from their states that would be nonessential. We can’t slam down the entire society” (Sam Nunn).
  • Federal and state priorities may be unclear, differ, or conflict; authorities may be uncertain; and constitutional issues may arise.

    “My fellow governors are not going to permit you to make our states leper colonies. We’ll determine the nature and extent of the isolation of our citizens…You’re going to say that people can’t gather. That’s not your [the federal government’s] function. (Frank Keating).

    “…worried that it would not be possible to forcibly impose vaccination or travel restrictions on large groups of the population without their general cooperation."

    “The federal government has to have the cooperation from the American people. There is no federal force out there that can require 300,000,000 people to take steps they don’t want to take” (Sam Nunn).

    “…Atlantic Storm showed that even experienced politicians have unrealistic notions of what WHO would be able to deliver in a crisis, given its current budgetary, political, and organizational limits.”

    “In Atlantic Storm, leaders viewed border closings and travel bans as an unattractive option for controlling the spread of disease, but, given the lack of vaccine or any other mechanism to control disease, they were forced to consider these measures.


“…leaders were provided with far more situational awareness than they would have had in a real crisis. They were given the locations and numbers of reported smallpox cases in almost real time, and they were constantly updated as information changed. If this had been a real bioattack or epidemic affecting cities in multiple countries, leaders would have had a great deal of trouble getting even this level of basic information.”

My list of Questions:
In the end it would appear that we are not much closer to answering (or instituting) the questions posed by these two exercises. The results of the two events, despite being years apart, have come to similar end points…without resolution. Since Dark Winter, we have seen the 9-11 attacks, dealt with WNV, witnessed SARS, and begun preparing for H5N1. Yet, these questions continue to be re-invented.

Given the time frame of the two exercises, one being pre-9-11 and the other post-9-11, is there any expectation change in the “post-9-11 mindset”?
Can any correlation be drawn between the expectations of national leaders towards international cooperation and state/local leaders towards cooperation with the Federal government?

Will the American public respond differently to a biological attack that threatens only the United States in contrast to an attack threatening the U.S. as well as other nations?
How will we approach issues of evacuation, quarantine, mandatory vaccination, and loss of freedoms? Will compliance be better or worse based on the events of Katrina?

Can we compare the expectations of FEMA during Katrina to the expectations of the CDC during a biological terrorist attack?

Why are we not closer to resolving the issues mentioned in these exercises? So many of the Atlantic Storm recommendations are strikingly similar to the lessons of Dark Winter that one has to ask if the organizers have even read the Dark Winter scenario!

Tuesday

Homemade Chemical Bombs: A Legitimate Threat to Responders.

The recent arrest of 21 people in Great Britain plotting to use liquid explosives to destroy at least ten airliners puts the treat of terrorism back into focus. Although exact ingredients and chemical products have not been released, we know that the plan to destroy numerous passenger aircraft involved the use of liquid explosives, possibly common civilian chemicals. In 2003, the FBI arrested an Algerian man for planning to blow up an airliner with a bomb hidden in a baby bottle.
The FBI conducted tests, involving a 7-ounce mixture of potassium chlorate, sulfur, sugar, and baby powder, demonstrated the bottle bombs could be exploded in a car or plane. The FBI stated that the explosion could tear apart nearby passenger seats and puncture a plane’s fuselage. One FBI agent testified that such a bomb “would likely cause significant damage to the aircraft and cause injury or death to the persons on board.” He said it also could “cause catastrophic failure” of a pressurized aircraft if exploded at high altitude.

Although the possibility of facing a terrorist attack aboard a commercial airliner is remote for most emergency responders; the possibility of a “household chemical bomb” scenario may not be as low as one would assume. The “All-Hazards Approach” to emergency response demands that firefighters and emergency medical technicians understand the lethality of common chemicals that can be turned into Homemade Chemical Bombs or HCBs.

Discussion:
Homemade Chemical Bombs (HCBs) are easily constructed out of every-day materials and chemicals. The internet is loaded with video clips and instructions for such activity. HCBs are also known as MacGyver bombs, bottle bombs, “the works” bomb or acid bombs, are explosive devices created by mixing volatile household chemicals, usually in some type of pressure vessel. Toilet bowl cleaner or drain cleaner and tin foil mixed in a capped soda pop bottle are among the most common, and perhaps the most toxic, combination of materials. The mixture of isopropyl alcohol and chlorine or dry-ice and warm water and mixed in a capped water bottle yield a similar result. Regardless of the combination, the products are mixed together and placed in a soda pop bottle or other container suitable to containing pressure. The container eventually ruptures violently resulting in overpressure, fragmentation, shrapnel, and often times hazardous materials.

Indicators:
Callers to 9-1-1 reporting HCB events often report an “explosion”, “fireworks”, or “shot gun fire”. Surveillance data from various sources provide a fairly descriptive profile for HCBs. The chemicals most often used are sodium hypochlorite, sodium hydroxide, and hydrochloric acid. A majority of events occur on school property; such as local schools, college or university settings. HCB events have been reported in public places and residential areas. A majority of events occur during the summer or during after-school hours. There is however, no formal data base for this type of activity and numerous events may go unreported or unrecognized.

HCBs are particularly dangerous because once the chemicals are mixed there is no timing device… the chemical reaction dictates when the device will go off and is unpredictable… HCBs have been known to detonate within seconds to hours after mixing.HCBs can be constructed using a variety of chemical mixes and any container capable of allowing pressure build-up. Common containers are plastic soda pop bottles, sports drink bottles, and water bottles of all sizes. These containers have a screw-on cap and expand to allow for containment of greater pressure prior to detonation. The liquid inside the container may be green, bluish, or clear, depending on the chemical and may have tin foil rolled into balls or folded into strips inside the liquid. Regardless of the type of material; the liquid may be fuming as the chemical reaction takes place.

As the reaction progresses the container will begin to bulge or expand. Due to the variable amount of chemicals, each HCB should be considered unique and unpredictable. Containers that are bulging should be considered volatile and may detonate at anytime. It is possible that a pressure within a container will build-up to the point of expansion, yet not rupture. Any movement of a container in this condition may cause it to detonate.

Containers may be wrapped with nails or placed inside of a garbage can to produce shrapnel and fragmentation. Responders should be alert for bulging discarded containers.

Once a HCB has detonated, the residue varies with the chemicals used. The use of cleaning solutions and tin foil usually produces a foaming blue or green liquid (depending on the manufacturer of the cleaning product). HCBs made with alcohol and chlorine may leave only the smell and a cloud of the product. Dry-ice and water will totally disintegrate. In either case, the remains of the container may be the only indicator or evidence a HCB has gone off.

Injury Patterns:
Assuming that the HCB is a simple act of vandalism is a serious mistake. These devices meet both the National Fire Academy (NFA) and National Fire Protection Association (NFPA) definition of an explosive device. All of the chemical combinations used for HCBs are capable of causing deflagration and result in an overpressure situation. Although unlikely to cause serious structural damage or fire, HCB situations may result in primary and secondary blast injuries. Primary blast injuries result directly from the sudden overpressure changes caused by the blast. This overpressure is most likely to effect hollow structures such as the lungs, gut, and ears. HCB events often occur in open areas resulting in limited overpressure; rupture of the ear drums may be the most common of the primary injuries. It is important to remember that overpressure events are magnified by confined or enclosed spaces and an HCB detonated in confined areas should make one suspicious for other primary overpressure injuries. Responders should be aware that as little as 1.0 - 5.0 psi overpressure is sufficient to break windows and rupture tympanic membranes.

Secondary blast injuries are those injuries resulting from flying debris or shrapnel. HCBs are capable of scattering shrapnel and producing secondary injury. Mechanical and thermal injury may also result from the device going off as it is picked up by a responder or civilian. Keep in mind the person making the bomb may become an unintended victim.

HCBs are particularly dangerous because once the chemicals are mixed there is no timing device. The lack of fuses or timers means the chemical reaction dictates when the device will go off and is unpredictable. HCBs have been known to detonate within seconds to hours after mixing. Sodium hypochlorite is a frequently used chemical in making an HCB; however, other hazardous materials (ammonia, liquid nitrogen, and dry ice) may also be used (CDC unpublished data, 2003). Low to medium exposure to sodium hypochlorite, as found in household bleach, can cause irritation of the eyes, skin, and respiratory system. High levels can result in severe corrosive damage to the eyes, skin, and respiratory system and may be fatal. Exposure to other HCB products, such as hydrochloric acid can cause mucous membrane irritation laryngeal spasm and pulmonary edema.

Patient care should be dictated by injury severity, signs and symptoms, and local hazardous materials protocol. Responders should be anticipating the possibility of numerous patients, and thus be ready to undertake triage actions. There may also be need for gross decontamination at the scene prior to transport of any patient. Persons exposed the products of HCBs may also self-refer to local hospitals. Hospitals should be alerted whenever a HCB event is discovered in effort to prevent self-referring patients from contaminating the emergency department. Fire departments should be prepared to respond to local emergency departments in anticipation of decontaminating self-referring patients. Decontamination of patients prior to transport and prior to entering the emergency department is vital to preventing secondary contamination of the hospital. This role should be assigned to fire service personnel with training in decontamination or hazardous materials teams.

Summary:
Homemade chemical bombs (HCBs), also known as acid bombs, MacGyver bombs, bottle bombs, or “the works” bombs, are capable of creating chemical, thermal, and mechanical injuries. HCBs are unpredictable and may go off within minutes to hours after mixing. When deployed in public places, HCBs may create multiple patient – hazardous materials events resulting in the need for mass casualty gross decontamination both at the scene, and at the hospital. Patients must undergo decontamination prior to transport, but exposed persons may leave the scene prior to arrival of fire or EMS units. Fire departments must be ready to deploy to local emergency departments anticipating self-referring exposed individuals and preventing secondary contamination of the emergency department.

In addition to suitable personal protection, responders must be ready for hazardous materials and cautious of secondary events.

Underestimating HCBs as an act of vandalism can be deadly. These devices are capable of spreading shrapnel and fragmentation; turning a soda pop or water bottle into a deadly device. The unpredictable nature of HCBs, relative ease of construction, and combination of hazardous materials makes homemade chemical bomb events a true threat to responders and a challenge to successful patient care.

Implementing the All-Hazards Approach to training, pre-planning, and incident management will assist traditional response agencies with identification and successful mitigation of this type of event.

Selected Case Studies:
Rhode Island, May 2000. Two students were making bottle bombs on an elementary school playground using hydrochloric acid. The two students sustained eye irritation from the detonation of one of the bombs. Both were transported to a hospital for treatment and released. The school was evacuated for one-hour while a hazardous materials team conducted decontamination and debris removal.

Rhode Island, October 2001. A high school student placed a chemical bomb in a vacant classroom. The bomb, made with sodium hypochlorite, released chlorine gas on explosion. A total of twenty-three persons in the vicinity of the explosion sustained respiratory irritation and were transported to a hospital for treatment and released. The school was evacuated, and a HazMat team conducted decontamination and debris removal.

New York, June 2002. A sixteen-year-old sustained chemical burns after detonating a bottle bomb made from sodium hypochlorite in a friend’s front yard. The juvenile was transported to a hospital for treatment and released.

Rochester, NY, April 2004. Several persons, including emergency responders were contaminated with by-product acid as an acid bomb detonated while a suspect was being taken into custody.



References:
1. Agency for Toxic and Disease Registry, Hazardous Substances Emergency Events Surveillance System biennial report, 1999-2000. Atlanta, Georgia: U.S. Department of Health and Human Services, Agency for Toxic Substances and Disease Registry, 2001. http://www.atsdr.cdc.gov/HS/HSEES
2. CDC NIOSH, U.S. Department of Health and Human Services, CDC, 1997. http://www.cdc.gov/niosh/npg/npg.html
3. New Jersery Department of Community Affairs, Division of Fire Safety. Bottle Bombs, Trenton, New Jersey, 2003. http://www.state.nj.us/dca/dfs/bombs.htm
4. R. Russotti. Blast, Crush and Overpressure Injuries, April, 2003. rrussotti@frontiernet.net, http://mitigationjournal.blogspot.com/

Keywords:
1. Bottle Bomb
2. Baby Bottle Bomb
3. MacGyver Bomb
4. Acid Bomb
5. “The Works” Bomb
6. Homemade Chemical Bomb

Friday

Play Your Position, Please.

The EMS News network is sadly reporting the deaths of two Paramedics in British Columbia, Canada.

As reported in the Vancouver Sun: “two paramedics -- Kim Weitzel, 35, and Shawn Currier, 21 responded for some type of mine accident - When a mining contractor mysteriously disappeared at Teck Cominco's Sullivan mine, a second man was sent to look for him.”
He found the contractor's body.
The man led two other rescuers to the body.
All three died.
Early unconfirmed reports indicate the possibility of an oxygen deficient atmosphere and exposure to hydrogen sulfide contributing to the deaths of the contractor and the Paramedics.

Know your district, know your limitations.
EMS personnel typically do not have respiratory protection to enter an immediately dangerous to life/health (IDLH) atmosphere. The best, and in many cases only protection, for EMS personnel is to have situational awareness and understand the potential hazards of any given response area. Complacency kills.

EMS has a vital role in rescue operations. EMS services that are not associated with fire/rescue services may respond to find situations to be different than reported. Failing to recognize the hazards and taking appropriate self-protective measures can be devastating. When arriving to find a previously unreported hazard, the EMS crew first on scene can provide vital information and should call for appropriate response.

Our thoughts and prayers are with those in B.C. Canada.

This Plan is Your Plan; This Plan is My Plan.

We’ve been looking down the barrel of a loaded “pandemic gun” all winter. We’ve been meaning to do something abut biological preparedness since West Nile Virus, Anthrax, and SARS (what I have no idea). So, here comes spring and were guided ever so gently by the media away from flu (avian or otherwise) and pointed towards gas prices, immigration, and the ‘who’s who’ list of ex-Bush team members. Although not without good reason and some value, we’ve forgotten about the “pandemic gun” or maybe just because the weather is warm here we figure that gun is no longer loaded.

Its spring; Do You Know Where Your Plans Are?
Just because we’re out of the typical flu season is no rationale whatsoever to put planning and training for such an event on the back burner. Numerous updates have surfaced in the last few weeks. Perhaps the most striking (if only in volume) is the Pandemic Influenza Implementation Plan published by the Department of Homeland Security in early May, 2006. The object of this plan is to outline the governments effort to prepare for pandemic influenza and identify the critical roles of state and local authorities, private sector, and communities to address the threat of a pandemic. I’ll be conducting a review of the DHS plan shortly. You may recall the Department of Health and Human Services issued their own Pandemic Plan in November, 2005. Please see Mitigation Journal archives for November 2005 for my review of the HHS plan.

I’ve been asked a number of questions recently pertaining to planning, preparedness and response capabilities. There is no easy way to address many of the questions. The sad fact is; that despite effort and dollars; most plans in most jurisdictions fall short of reality. The overtone seems to be that the health care community and public health are going in one direction and traditional response groups are not going anywhere at all when it comes to planning for a biological event.

Each of the plans I’ve reviewed share a number of pitfalls. These plans assume:

1. The ability to communicate will not be disrupted and accurate/factual information will flow
2. Power and transportation will be readily available
3. Personnel will be healthy enough and willing to report to work
4. Civil obedience will be maintained both in the community and at health care facilities
5. Patients will be able to be evacuated to neighboring facilities or regions.

In addition, these plans do not mention the fact that every-day emergencies will continue to come to hospitals expecting treatment.

Let’s take a look at each one of these at its own context.

Communications.

Each plan assumes that there’s going to be the ability to communicate. And further, the ability to communicate will be undisturbed throughout any given event regardless of the length or scope of that event. It is reality however; the day-to-day communication is difficult to maintain even under ideal conditions. Case studies of numerous large scale events in history of all services indicate the communications will be among the first piece of infrastructure to be compromised. Further, the ability to rely on information from any given point must be questioned. When communication systems have failed or are compromised alternate means of communication will spring up; and it is these alternate means of communications that will lend a false sense of communications security and ultimately yield unreliable and inaccurate information on which decisions will be made.

Emergency plans also indicate their reliance on power and transportation with little or no mention of alternate means of supplying electricity, light, heat, or a means of moving people from place to place. The reliance on public energy and public transportation are critical weak link in the disaster and emergency planning process. Power in transportation are linked together in the disaster planning setting; in any given instance if we have and reliable and hardened power infrastructure capable of producing climate control, light, and maintaining critical operations in a given facility we can reasonably assume that facility will remain habitable and functional during crisis. If the power supply is threatened or lost we will no longer be capable of sheltering in place throughout the crisis in decisions will have to be made concerning evacuations and alternative sheltering. Should the need arise to evacuate a given facility, especially a Healthcare facility such as nursing home or hospital, there will be our reliance on emergency medical service transportation to effect such an evacuation. EMS transportation vehicles may or may not be available in such a situation. One must understand that all traditional response groups, including emergency medical services, will have their resources stretched to capacity and beyond. Air and ground transportation units will be subject to the same problems of fuel, power, and communications disruptions as fixed facilities. Alternate means for power supplies and shelter in-place needs must be addressed by fixed facilities in addition to evacuation contingency planning.

Another fatal flaw in emergency planning is the assumption that personnel will in fact report to work. This consideration must be taken without regard to the status of roadways and transportation. A survey study conducted by Columbia University in September, 2005 demonstrates possibility of personnel, who are otherwise unaffected by crisis, refusing to report to work. In this study, health care workers were asked to indicate if they would be able to report for work or willing to report for work in the event of a mass casualty incident. 81% said that they would be able to go to work if there was an environmental disaster, yet only 69% said they would be able to go to work during a small pox epidemic. The study goes on to note that the willingness to report for work would only be 48% of health care workers during a SARS outbreak. Further, only 57% of health care workers would return to work in the setting of a radiological event. The fallacy in this stage of planning is to assume that Healthcare workers who have a perceived obligation to respond will, in fact report to work. Numerous sources have noted that the willingness to report for work in any situation may be impacted by concerns for the safety of the responder’s family. It is important for employers of public and private organizations to understand that the family care can be as vital as responder care. Workers fears will impact their willingness to work and administrators and company leaders must talk to their workers about these concerns regarding exposure and contamination and reassure them by planning to assure family and dependent safety. An example of such contingency planning would be the setting of avian flu or H5N1 pandemic. It is estimated in such a situation that nearly 30 to 40% of the American workforce would become stricken or ill and unable to report for work of any kind. And that percentage the number of persons engaged in critical infrastructure duties such as police, fire department, EMS, or other critical infrastructure positions failing to report for work and any given crisis situation can then be expected to be magnified.

In the above mentioned settings simple failures in the supply chain for routine maintenance can become catastrophic.

Another important point to consider is that of the lack of surge capacity in the concept of ripple effect deaths. Surge capacity is a specter of imagination as many Healthcare systems operate at or above capacity every-day. Just as the traditional response groups will continue to respond to the routine calls for service during a large scale event, routine requests for routine medical emergencies will continue to arrive at local hospitals. Lacking surge capacity will almost certainly cause some of these otherwise routine patients to destabilize and become critical or fatal. This can add to the death toll of any large scale event and further destabilize community infrastructure. Much attention has been given to triage in the appropriate use of medical resources such as ventilators. Triage of such medical procedures and devices is also unrealistic; consider that just a short time ago the health care community could not come to consensus on the triage of flu vaccine during a shortage and without the pressure of an actual event going on.

This Plan is Your Plan; This Plan is My Plan. Not.
Despite the fact that numerous of urgency service agencies and Healthcare systems have spent countless hours and dollars on the planning process few if any of these plans integrate with each other. There is little if any continuity between traditional response groups and Healthcare systems or any other community infrastructure for that matter. Failure of any agency or service to adopt or even recognize the existence of the national incident management system or NIMS will be the cornerstone of failure during a large scale event. Scant few services, either public or private, address, and planning needs or participate in any level of joint training. This unfortunate situation is perhaps the least expensive and easiest to implement, yet remains ignored.

What do we do now?
There are no clear-cut answers in any of these situations. However failure to acknowledge that such shortcomings exist in the planning process may themselves the largest obstacle to overcome. The setting of a biological vent weatherman made intentional or natural cannot be compared to acts of terrorism the American public has become familiar with. Any naturally occurring biologic event or intentional act of biological terrorism will force our change in perspective.
The good news is we have been dealing with biological events for quite some time. We have come to no and rely upon basic medical personnel protective equipment and procedures such as hand washing and respiratory etiquette. These protective measures which we employ every day will serve us well in the setting of a biologic event.

Never Mind Osama, Here's the Aryan Nation



I’ve been sitting on the sidelines for a bit longer than planned. My expected weekly publish date of April 26 has long gone by. Despite the word from some sources that my opinions are not well received; I continue to be asked when the Journal will be updated. There is no holding back since I've recently been called the “Super Wal-Mart of conspiracy theory and apocalyptic thinking”. Remember: My Blog; My Rule. (I still don't care about APA or MLA style. Stop telling me about it!) So, here's my view on a few topics...

No way in hell are we going to oust all or even a meaningful number of illegal immigrants, even if we logistically could, to what political and social end? Huge implications for U.S. diplomatic relations with South America (read: oil) FOR THE RECORD: I have not made a stance on deportation of illegal immigrants. I have a daily personal and professional struggle with this issue; and therefore will try to look objectively. Hold the hate mail, please.

Guest worker program = stop gap measure; polarization of government and society on this issue will grow exponentially (can you say Race War?)This will be compounded by a few factors: decline of the middle class and evaporation of health care. Sure; foreign aid, gas prices, and any other hurricane will play a role, too. Will there come a time when the only stable employment is held by "undocumented workers"?

Terrorism: forget about Osama et. al. I predict the social and economical implications of all this will put a torch to the domestic groups that have been so quiet in the last decade or so. Look for white supremacy groups, KKK, militia, anti-gov movements and the like to become vocal and active! (Can you imagine David Duke getting prime-time coverage?) Read the USA Today Story: http://www.usatoday.com/news/nation/2006-05-16-hate-immigration_x.htm

Sunday

Port Security

























I’d like to thank everyone who took a minute to participate in the Port Security study. The graphics represent totally unscientific results as collected over the past several days.

After seeing the results, I’d like to hear from you. What conclusions, if any, can we draw? Comments will be posted as they come in!

Thursday

Port Security Issues

Like many of you, I have my doubts about port security. My concerns have been heightened by the recent disclosure that a company owned by the Untied Arab Emirates (UAE) have been given management authority over several major United States ports.

I do, however, wish to keep and open mind and to that end am doing some research on the topic. There will be a opinion posted here soon. In the meantime, I'd like to hear from you. Please take the Port Security Servey at http://www.opinionpower.com/Surveys/587035284.html

If you have trouble with the survey, please email me directly. Feel free to forward the survey as well as Mitigation Journal to others who may be interested.

Monday

Tabletop Exercises for Effective Training

Do you remember Hurricane Pam? Despite having dumped 20 inches of rain with sustained winds of 120 mph and causing a storm surge that crumbled levees in New Orleans, virtually no one remembers Hurricane Pam despite the unfortunate fact that Pam has an eerie resemblance to Hurricane Katrina. How about the Dark Winter of 2002? That Dark Winter resulted in over three-million cases of smallpox and caused at least one-million deaths as the disease spread around the globe.

If you’ve ever wondered how your agency would respond under the most difficult of situations a tabletop exercise (TTX) is for you!
Chances are you’ve never heard of either of these disasters. You haven’t heard of them because they never happened…Hurricane Pam and Dark Winter were tabletop exercises designed to promote emergency and disaster preparedness.

If you’ve ever wondered how your agency would respond under the most difficult of situations, with new leadership, working with a recently written or updated response plan, a tabletop exercise (TTX) is for you!

A tabletop exercise simulates an emergency situation in an informal, stress-free environment. The participants can be either people on a decision-making level, veterans of the organization, or new members, who gather around a table to discuss general problems and procedures in the context of an emergency scenario. The focus is on training and familiarization with roles, procedures, or responsibilities. No plan? No tools? No problem! A TTX is also a great way to build a response plan based on input from the exercise and can be accomplished with some basic preparation (just like a lesson plan) and without any special equipment.

The tabletop is largely a discussion guided by a facilitator (or sometimes two facilitators who share responsibilities). Its purpose is to solve problems as a group. There are no simulators and no attempts to arrange elaborate facilities or communications. One or two evaluators may be selected to observe proceedings and progress toward the objectives.

The success of a tabletop exercise is determined by feedback from participants and the impact this feedback has on the evaluation and revision of policies, plans, and procedures. In many respects, a tabletop exercise is like a problem-solving or brainstorming session where problems are tackled one at a time and talked through without stress.

Problems and Messages

A tabletop is not tightly structured, so problem statements can be handled in various ways. The facilitator or controller directs the flow of the TTX by adjusting time frames and messages. Messages or injects as they are often referred to, are statements used by the facilitator to simulate an event within the scenario, add a problem or situation, or put the TTX back on track as needed. A majority of messages or injects are created in advance and are built upon the scenario itself.

The purpose of tabletop exercises is usually resolving problems or making plans as a group. That means going after real solutions not superficialities.
The facilitator can verbally present general problems, which are then discussed one at a time by the group. Problems can be verbally addressed to individuals first and then opened to the group. Written detailed events (problems) and related discussion questions can be given to individuals to answer from the perspective of their own organization and role, and then discussed in the group.


Another approach is to deliver pre-scripted messages to players. The facilitator presents them, one at a time, to individual participants. The group then discusses the issues raised by the message, using the EOP or other operating plan for guidance. The group determines what, if any, additional information is needed and requests that information. They may take some action if appropriate.

Occasionally, players receiving messages handle them individually, making a decision for the organization they represent. Players then work together, seeking out information and coordinating decisions with each other.

Some facilitators like to combine approaches, beginning the exercise with general problems directed to key individuals and then passing out messages one at a time to the other players.

Group Problem Solving

The purpose of tabletop exercises is usually resolving problems or making plans as a group. That means going after real solutions not superficialities.

Some facilitators make the mistake of trying to move too fast through the scenario, believing that they have to meet all of the objectives and get through all of the messages. However, that is not a good approach if nothing gets settled.

Remember: If you spend all the time on one big problem, maintain interest among players, and reach consensus, then the tabletop is a success! Push the players past superficial solutions. A few carefully chosen, open-ended questions can keep the discussion going to its logical conclusion.

Designing a TTX is Simple!


There are eight simple steps you can use to design a TTX:

  1. Assess your needs
  2. Define the scope
  3. Write a statement of purpose
  4. Define TTX objectives
  5. Compose a narrative
  6. Write major and detailed messages
  7. List expected actions
  8. Prepare messages

Applying the Design Steps

The Narrative: The tabletop narrative is sometimes short. It is nearly always given to the players in printed form, although it can be presented on TV or radio. When the purpose of the tabletop is to discuss general responses, the narrative can be presented in parts, with a discussion of problems after each part.

Events: The events should be closely related to the objectives of the exercise. Most tabletop exercises require only a few major or detailed events, which then can easily be turned into problem statements.

Expected actions: A list of expected actions is useful for developing both problem statements and messages. It is always important to be clear about what you want people to do. However, in a tabletop, sometimes the “expected action” will be a discussion that will eventually result in consensus or ideas for change.

Messages: A tabletop can succeed with just a few carefully written messages or problem statements. As always, messages should be closely tied to objectives and should be planned to give all participants the opportunity to take part.
The messages might relate to a large problem (almost like an announcement of a major event) or a smaller problem, depending on the purpose of the exercise. Usually they are directed to a single person or organization, although others may be invited to join in the discussion.

Ex-FEMA Chief Makes the Case for the All-Hazards Approach

Michael Brown was the head of the Federal Emergency Management Agency. Was; that is, in the past. You’ll recall seeing him in front of cameras from CNN, NBC, ABC, FOX, CBS pleading his case about how “we (FEMA) are doing everything we can” to rescue the City of New Orleans. With the continual video footage of New Orleans residents stranded on rooftops, stories of emergency services breaking down, and chaos at the Superdome; we sat and wondered how this all got that bad.

And in the middle of it all Michael Brown was sent home to D.C. with his tail firmly between his legs. A few days later he resigned as FEMA’s Director.

The Congressional hearings and fact-finding started back in December of 2005 and Michael Brown came out swinging. His words should be the wake-up call for dumping the wasteland “terrorism preparedness” and “WMD training” have become. These terms and many others like them indicate the national focus of Homeland Security (another moronic term) and inappropriately shifted our focus away from big-picture preparedness; the All-Hazards Approach.

You see, as Brown stated in his testimony “if we’d confirmed that a terrorist had blown up the levee, then everybody would have jumped all over it trying to do everything they could” we are waiting for a terrorist to bring destruction to us. We’ve forgotten the Rule of Outcomes that states that certain commonalities exist among emergencies of small and large-scale and that those commonalities can be successfully planned for, trained for, and mitigated if the all-hazards approach is taken.

Brown suggests what I believe to be true; the current fixation on anti-terrorism played a major role in the outcome of Hurricane Katrina. Our over concentration on terrorism has made preparedness for disasters and emergencies other than terrorist events has made preparing for natural disasters, power failures, storms, floods, earthquakes, and more to become the forgotten stepchild of the Department of Homeland Security. The same terrorism blinded approach will continue to hamper efforts in warning, rescue, response, mitigation, and recovery of future events as well.

The Department of Homeland Security has done exactly what their name implies…worked on security. Unfortunately, security is only one piece of the all-hazards puzzle. Security is not synonymous with preparedness. The culture and mindset of a security force cannot embrace the inherent needs of preparing for emergencies and disasters whatever the cause.

Hurricane Katrina killed nearly 2000 people and displaced hundreds of thousands of others. The storm caused physical damage with estimates in the tens of billions. Katrina’s visit nearly destroyed the City of New Orleans. A chemical or radiological attack on New Orleans could easily result in similar outcomes and response needs. Would there have been thousands stranded in New Orleans waiting for help after a chemical attack? Would there have been chaos and shortages at shelters after a nuclear event in New Orleans? Generically speaking, why would we mitigate differently?

Sunday

National Emergency Medicine Report Card



Mediocre: average; ordinary. That’s New York. That’s New York health care according to the American College of Emergency Physicians, anyway.

The American College of Emergency Physicians (ACEP) has recently released the National Report Card on the State of Emergency Medicine – Evaluating the Environment of Emergency Care Systems State by State. In this 129 page document, ACEP rated each state on access to emergency care, quality and patient safety, public health and injury prevention, and medical liability. An overall grade was calculated for each state as well as for the Nation as a whole.

“The results are sobering” says ACEP. “The National health care system is in serious condition, with many states in critical condition” the report says. ACEP concluded the emergency medicine system in the United Sates [as a whole] rates a C-…just above “D”. As for individual states; no state scored either an A or an F. I sense political correction here! After all, if some state were to receive an A; there would be no room for improvement. Conversely, can you imagine the fallout should a state rate an F? After reading the report I speculate that some state(s) in fact should have rated an F, but for fear of litigation, bad press, or whatever ACEP did not assign the grade. Perhaps the ACEP version of no child left behind…everyone passes. But don’t let my cynicism fool you.
Take a look at the grading criteria:
· States that reached at least 80% of the top state score received an A
· States that reached at least 70% of the top state score received a B
· States that reached at least 50% of the top state score received an C
· States that reached at least 30% of the top state score received an D
· States that fell below 30% of the top state score received an F


Let’s get back to New York.
New York State scored an overall grade of C+. Great, we’re just above the middle…mediocre. Access to emergency care rated a B-, quality and patient safety B-; under 70% for both.

Can anyone please tell me; since when can you score 50% on anything and get a C? In New York, EMT’s have to achieve a minimum of 70% to pass a written EMT or paramedic exam.

If I were in charge of NYS health care, I’d take away the PlayStation!

Public health and injury prevention leads the pack with a whopping A+…that is, a little better than an 80%. And bringing up the rear; Medical Liability Environment: D-.

The grades only tell half the story. New York ranked 49th for number of emergency departments per 1 million people and 43rd in percentage of population with access to enhanced 9-1-1 services. Yet, New York ranked near the top in annual Medicare fee-for-service (4th), annual Medicaid cost per person younger than 65 (7th), and annual per capita expenditure on hospital care (3rd).

There is little wonder why insurance costs in NYS are out of control. Insurance costs in Western NY are expected to jump between 12% and 16% in 2006
(for more information see the post: Spring Loaded in the Stupid Position http://mitigationjournal.blogspot.com/2005_11_01_mitigationjournal_archive.html)

The report cites overcrowding, medical liability concerns, poor access to care, and get this; inability to respond to public health emergencies or terrorist attacks as major shortfalls. The report attributed its findings to increased demands placed on the emergency medical system, and on budget cuts, which have lead to a steady decline in critical-care beds. The report noted that “the number of emergency departments has decreased by 14 percent since 1993. . .and hospitals are operating far fewer inpatient beds than they did a decade ago.” The report also found that there is a general association between the wealth of a state and emergency care, and a correlation between population density and a state’s overall grade.

FEMA, health care, disastrous events…is anyone adding this up?
Read the report: http://my.acep.org/site/DocServer/2006-NationalReportCard.pdf?docID=221

Monday

Get Rid of that Customer!

Here is my New Years resolution for 2006. This woke me up from a sound sleep the other night so, I have to just put this one out there and wait to hear what you think.

Get rid of the term “customer”. All-in-all the term customer is not a bad way to describe the people we serve as it embodies thoughts and accompanying behaviors that are most often positives in public service. Webster’s defines customer as a patron, clientele, or consumer. Rather than simply defining the term, let’s examine what a customer is…what actions do they take? What choices do they make?
The fact is that a customer or consumer makes a decision as to what services or goods they wish to consume along with the time of use and consumption. A majority of emergency service “consumers” don’t make those choices. They call when the need arises. In daily life, the consumer may also choose with whom they do business. Again, the majority of the folks calling 9-1-1 have no choice about who is going to show up to take care of them or put out their fire. So, in our “this is a business” mentality, the term customer is the first to go.
Let’s replace customer with citizen. A citizen deserves our care and attention. “Citizen” implies earned respect and comes with certain expectations. We’re not working behind the counter at Burger King and the citizens we serve are not customers! They are citizens of our communities.

The term “productivity” is another useless business term I won’t be using (or tolerating from others) in 2006. I just can’t stand it, the term as applied to emergency service lacks meaningful definition…even by the limp and leaderless that uses it!
I have had enough with supposed leaders spouting off about emergency services being a Business! Yes, I know the administration and management of any public service organization must be conducted in a business-like and professional manner. I also understand that the use of public funds such as tax dollars, require a level of justification and prudence. Agencies such as commercial ambulances certainly have to be managed as the business they are. But I’m not talking about commercial or for-profit services here. I’m strictly addressing tax-based organizations. The point that’s getting under my skin is that some leaders in public service agencies are starting to use the “this is a business” mentality and associated terminology and taking it way too seriously.
It seems that we have traded brothers for employees, leaders for managers, and a culture of family in service for a culture of corporate corruption and disposable people. Can you imagine the day when firefighters come to work as if it were “just a job”? Public emergency service is a calling, not just a job! Can we expect that our would-be leaders that are now managers in the “this is a business” mentality will continue to adopt other traits of the big business world? Perhaps we’ll be seen as more productive if they were to adopt a KODAK or ENRON mentality? Think of it…the disloyalty, dishonesty, and the corporate CEO corruption! Is this where emergency service leadership is heading?
Let’s get rid of the customer and go back to serving the citizen. Let’s understand that how a firefighter or EMT represents themselves in the public eye and what they are capable of doing is productive.