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NY Website looks at Hospital Quality

You've got to see this website hosted by the NYS Department of Health. Interesting data on hospital quality and comparative data. Although there is no data pertaining to preparedness activity, the site explains the quality points that we as a community should be looking at.

Prevention Quality Indicators
is a great site to consider.


NIMS: By any other name

Just when you thought it was safe to respond to an emergency, DHS has announced NIMS refit and updates in a recent press release. So, now that you've competed all those on-line annoying classes and taken all those ICS classes, you're ready to respond and manage disaster events! Maybe not. We'll have to wait and see, but I'll bet we'll all be sitting and/or tabbing through a series of "new and improved" NIMS classes. As if we don't have anything else to do.

Anyway, according to the press release...

"...NIMS expands on the original version released in March 2004 by clarifying existing NIMS concepts, better incorporating preparedness and planning and improving the overall readability of the document. The revised document also differentiates between the purposes of NIMS and the National Response Framework (NRF) by identifying how NIMS provides the action template for the management of incidents, while the NRF provides the policy structure and mechanisms for national-level policy for incident management."


"...The basic tenets of NIMS remain the same. There have been several improvements to the revised NIMS document which will aid in readability and usefulness of preparing, preventing, and responding to incidents. For example, the revised document places greater emphasis on the role of preparedness and has reorganized its components to mirror the progression of an incident. Recognizing the importance of private sector partners and NGOs in incident response, FEMA has ensured that those entities have been more fully integrated throughout NIMS. The new document is consistent with the NRF, and together they provide a single, comprehensive approach to incident management."

Get the new NIMS document here and make sure you tune into Mitigation Journal: The All Hazards Podcast. We'll be reviewing this in detail on shows in the very near future.


Elders and Pharm - A Must Read

This article from CNN is a must read for every emergency responder. We've been talking about the dangerous combination of prescription medication and over-the-counter supplements in classes for quite some time. The growth of supplement use among all age ranges in the Untied States has been increasing steadily since the 1980's.

"...One in 25 people in the study, or about 2.2 million people, were taking a potentially risky combination of medications. That number jumped to one in 10 among men who were 75 to 85 years old."

With particular attention to the elder population, we have to be aware that; as the number of prescription medication rises, so will the chance of an adverse medication reaction. Adverse medication reactions account for thousands of hospital admissions and requests for emergency medical service. In many cases, traditional pre-hospital education is lacking in the area of medication awareness and getting a medication profile. Responders must take into account patient medication and potential interactions with OTC supplements as a contributing factor.

Tune in to my podcast, Mitigation Journal: The All-Hazards Podcast, we'll be talking more about this issue in the near future.


Need Triage Training...turn on the Wii

Check out this article in Government Technology - ( just in time for the holidays, too. You can hone your triage skills with a video game!

I'm not sure that this training will ever replace live, functional exercises, but it may help keep skills up between trainings and drills. Still, the best way to learn triage skills is with live, dynamic participants and role-play of victims in scenario based training. I know that is a lot to ask...but it is the best way to learn.


Anniversary and Goals

Goals are good things to review this time of year. And as this year of 2008 comes to an end I am reviewing the intent and goals of Mitigation Journal. Both the blog and the podcast have seen an explosion of readers/listeners. Mitigation Journal The All Hazards Podcast continues to be ranked in the top 3 on iTunes in the Local organizations and government category. I'm simply humbled by the response from the community and the number of people who I've come to rely on to get this stuff done.

I almost forgot to mention this topic, but as the calendar is down to just one page, I thought it would be nice. The blog has been going for three-years (since November 2005) with over 140 posts and several feature articles, and the podcast has just turned two-years old with 92 weekly editions, numerous in-service training sessions...and thousands of listeners.

So a simple "thank you" is in order to everyone who has helped make this effort worth it. We'll be moving in several new directions for 2009 and I'll be looking forward to your continued support!

Please contact me with your insight, thoughts and comments. If you have an idea about what you'd like to hear, read, or see us do in 2009, I'd love to hear from you! You can reach me at anytime by email, calling our voice mail line at 585-672-7844.
I'll be posting our Year in Review segment here and on the podcast shortly after 1/1/2009. Please join us!


As It Happens - Plane Crash

I'd like to direct everyone over to Eric Holdemans blog; Disaster Zone. Besides the fact that I follow his blog closely, there is a wealth of insight posted there. Eric was kind enough to speak with me on Mitigation Journal a few weeks back on the topic of technology in disasters (see #86). One of the items we discussed was the use of social networking sites, YouTube, and services like Twitter; the ability to get real-time data from forward observers (those actually at the incident site).

A recent posting on Disaster Zone highlights this potential...and Eric puts the topic in focus.
( A passenger on board the plane that skidded off the runway recently. Here is the direct link to the Twitter page from this passenger.

Holiday Gift Cards

They are better than a tie...a gift card for health care! Check out the story from a Rochester, NY news station

I think this is a great idea and may go hand-in-hand with the use of retail health care clinics. Keep an eye on this one.

I've also talked about this on Mitigation Journal podcast #92
Check out this link to Ready Illinois. They have a guide published "Emergency Preparedness Tips for those with Functional Needs".

I'll be reading it later this week and I've added it to my shared items under Emergency Service News in the sidebar. Let me know what you think.

Stretching Vaccine Supply

Stretching Vaccine Supply is an important issue for those involved with pandemic planning. The supply of anti-viral agents, both oral and injected, is a major issue among planners at all levels. In fact, the limits of anti-viral agents have pushed the need for non-pharmacological interventions such as face masks or other protective clothing.

Here is a story from MSNBC outlining the results of a recent study suggesting that flu vaccine given at half-strength can be effective.

Let's not get carried away...this is not an indication that we have all the vaccine we could need, nor should we abandon our non-pharm efforts. The fact still remains that, while this vaccine may be effective at half strengths levels, we still need to match the H's and N's of the circulating strain. Additionally, we will continue to contend with all the logistical issues of ineluctable and oral anti-viral agents.


Keeping pets safe from holiday hazards

Keeping pets safe from holiday hazards can become a full-time job. Given the possibilities that could cause serious illness or death of the family pet, heightened vigilance during the holiday season will be worth the effort.

CNN is reporting on the little know dangers to pets from everyday foods and provides a list of surprising items that can cause serious illness or death to domestic animals such as dogs and cats.

Don't miss my latest series "Pets in Disasters" on Mitigation Journal podcast for more information on protecting pets in crisis and evacuation situations. The series starts with edition number 89.


Holiday Food Safety

The Wisconsin Department of Health is offering tips for safe food handling during the holidays ( They site some common sense tips for keeping you and your family safe from foodborne disease...just good practice for all seasons.

The holiday recommendations and the Home Safety Tips both start off with...clean hands and clean surfaces!

This material would make a great health and safety topic for all personnel.


Hospitals, Hotels, Malls - Soft Targets

We've been reading about the terrorist attacks in India and the relationship to soft targets. I talked about the need to identify and plan for attacks on soft targets in all communities on Mitigation Journal podcast this week. MSNBC has a nice article on the topic as well (

A hard target is one that has some level of security protection that reduces the chances of an intentional fire service terms; fire alarm systems "harden" a location against fire. Soft targets are locations that lack the deterrent from such events. Can you imagine if terrorist were to attack hospitals or hotels in the United States in the same fashion as in India?

It's important to understand that open structures with multiple access/egress points, isolated utility and services corridors and large crowds are potential target hazards for multi-patient, mass casualty events. Remember, we're not just talking terrorism here...gang activity can cause collateral damage as well as structural collapse, fires, panic situations, and of course, intentional events.

If you have MCI plans; do they reflect differences between an MCI occurring as a result of a bus crash on the highway and a multiple shooting at a movie theater? Everyone should take the time to review response plans and understand the needs of the location will necessitate alteration in your response plan.

Smallpox Vaccine Lasts Longer

According to a new study as reported in Medical News Today, ( the smallpox vaccine may last longer than we thought. Smallpox vaccine was thought to have little or no protective benefit after twenty or thirty years. According to this study, people vaccinated over 40 years ago have antibodies and may not even need a booster. You may recall that several trials of smallpox vaccination were stopped after adverse effects and deaths.

Keeping in mind that the last case of smallpox occurred in the late 1970's and routine vaccination stopped around the same time; anti-terrorism experts have been concerned that we humans lack any ability to protect ourselves and that vaccine stockpiles will not be adequate. Although this is only one is still good news.


Sick? Stay Home!

If you're sick, stay home! Sounds like good advice, but how many of us actually do it? How many employers outwardly condone employees staying home if they are sick? This article from Medical News Today is specific with suggestions for Norovirus, but the lesson still makes sense...if you're sick, stay home. The point that has to be considered is that emergency responders may bring disease home with them, contribute to coworker illness, or even be unknowing partners in spreading community disease.


Generator Dangers

This story reminds us all of the dangers of carbon monoxide. In this situation, a generator was being used to heat and power a home and, due to improper use, created a situation of greater than 14,000 ppm of CO inside. The systemic effects of CO are underscored here as responders become overcome during the initial rescue operations.

Link to video:

View Video:


Should Emergency Plans be open to the public?

I came upon this brief in Medical News Today ( talking about communicating emergency plans to the public. It seems that not all states have been able to make their plans available upon request. There also seems to be a disconnect in the communications area...few plans have a contingency communicating with the public.

This is an important topic for many reasons, two for sure; communication and public access. Communications are a vital part of any plan. We know that a solid community response can make or break the government response. That said, we have to ensure the public knows what to do, why they have to do it, and what we're going to do as emergency responders. On an entirely different point, we need to consider that the public may want to actually read our emergency plans. I don't think that anyone in the public will take action based on what they read in some plan...I think they are more likely to take action based upon the communication they receive from emergency personnel. However, we have to acknowledge that plans should be available in some form. Obviously there are parts of our plans that should be kept private.

I'd like to hear your thoughts to this.


Just in time for the holidays

Just in time for the holiday shopping season, gang-related shooting at a local Mall. MSNBC is reporting ( that a shooting in a Washington State Mall has resulted in at least two wounded.

Lets remember that this kind of attack can happen in any public venue and in any location. This is a good time to revisit (or create) your pre-incident plan to a multiple shooting or other MCI in public places such as malls and shopping centers.

Would you go to the Clinic at Wal Mart?

We've talked about in-store health care clinics on MJ in the recent past. These clinics are making the news again as some think these clinics, operated by Big Box stores, may be the next wave of health care solutions and relief of hospital over crowding.

MSNBC has done another story on them ( But the question is...would you go to one?

Check out the poll on the side-bar


Extrication: A Thing of the Past

How long will it be before the evolution of hybrid and alternate fuel vehicles changes the way we open vehicles and extricate trapped occupants? Will the cutting and tearing, muscle and sweat of hydralic tools become a thing of the past?

Interesting questions: no clear answers. The point, though, is that hybrid and alternate power vehicles have construction features and hidden hazards that will make traditional methods of disentanglement obsolete if not a potentaly harmful to the rescurer.

We shouldn't be suprised by this prediction...after all, we've seen changes in automobile construction that spured tactical changes before. You may remember at time when you could cut into a vehicle, gain a purchase point and move metal with some predictability. Perhaps those cars build prior the the 1980's fit here. After 1980, cars seemed to scale down and we saw less steel and more plastic. Frame construction changed as well as location of fuel lines. Plastic replaced steel in dashboards and crumple zones became an industy standard. Not long into the 80's traditional bumbers evolved (disapeared) and the airbag with its deployment system began to evolve.

From metal to plastic, frame to unibody, bumper to airgag, responders have adjusted thier extrication tactics and tecniques to fit the situation. Hybrind and alternate fuel vehicles represent the next generation of chage. The adjustment, however, will need to factor in hazards associated with the vehicle in evreyday conditions...not just in crash situations.

Perhaps the bigest concern is the use of high voltage electrical systems througout hybrind and alternalt fuel vehicles. These electrical systems are often hidden within the vehicle structure and rescures are advised not to cut into them. The charge and discharge time of an electrical system varries widly with vehicle manufacturer and the rescuer should consider the system "live" during extrication efforts. The location and potential hazard of high voltage cables have created "no cut zones" and limit the use of traditional operations such as roof removal and a dash roll-up. Even lifting a stearing colum may have to be avoided. Vehicle stabilization operations may also have to change as electrical system components become exposed during collision. The simple act of box cribbing under hybrind vehicles could expose rescures to damaged, live electrical conduting systems.

While we'll see less petrolium (gasoline) product, larger battery systems, high voltagae converters, additional acids, and fuels such as hydrogen will add another dynamic to controling hazards.


Graduation Time!

Lee (at left) is one of the most senior medics in our he is talking with one of our regions seniors who just became a medic (Rick Roach). Rick is also a former ILS student of mine.

Dr. Shah (right) and I solving the world problems...

Honored to be the Emcee for the event, I'm getting ready to open the evening with one of my special one-liners...

At left, Amy Ruffo takes the stage and salutes her class

Members of the junior paramedic class, Kate and Nikki, attended the graduation. They now belong to the SENIOR paramedic class of 2009! Best of luck!

Boys will be boys...and we'll leave it at that.

Mr. B looks on as the festivities begin. Peter is the lead instructor for the Monroe Community College Paramedic Program.

Mr. B gives his address and salute to the sixteenth graduating class of paramedics from Monroe Community College.

Laurie King (a former ILS student) receives her Paramedic Diploma.

Bob Breese getting ready to deliver the Paramedic Oath to the Class of 2008. Known for his trauma lectures and "bob-a-cology", Bob is a leader in and out of the classroom.

On a more serious note...

Best Wishes to the MCC Paramedic Class of 2008!


Great Guide

The Home Emergency Pocket Guide from Informed: Perfect for Preparedness at all levels!

I've been using Informed field guides for EMS for years and just recently received a copy of the Home Emergency Pocket Guide. Of all the guides and documents I've reviewed in the last few years, this one takes first place.

One of the most frequent questions I get when it comes to disaster preparedness is "where do I start!?" The problem is that those who actually take personal and family readiness seriously can be easily overwhelmed by the amount of material available...even the most motivated of people can find themselves spinning without clear direction. The Home Emergency Pocket Guide provides that clear direction in a easy-to-understand format that allows for reference and repetition as well as planning.

I read the guide cover to cover several times and found it easy to use and written so anyone, from citizen to CERT member to experienced responder can quickly get potential life saving information on everything from planning to first aid. Covering natural disasters, hazardous materials, terrorism and recovery, this guide takes the All-Hazards approach.

I was hooked by page 4: "...preparedness experts have cautioned civilians for decades to take the necessary precautions to help themselves in times of catastrophe. And yet, many of us do not. " We believe it will happen to someone else: we suffer from Optimism Bias - In fact recent data suggests that only 6-7% of the public has done any planning or preparation for disaster or crisis. The Home Emergency Pocket Guide walks you through in a logical direction, the path to being aware and prepared for numerous situations.

The section on first aid is formatted for quick reference and easy recall. ABC'S, CPR, medical emergencies and trauma situations are all covered. Some not-so-common situations are included as you may need to be self reliant in disaster or survival situations. There is even guides for biological agents such as smallpox, botulism, cholera, and anthrax.

The first rule in any emergency is to stop and think. The Home Emergency Pocket Guide provides the foundation for your preparedness efforts. The more prepared the public...the better the responders can help! Even the most experianced responder can benefit from this guide, giving piece of mind that your family knows what to do while you're responding to crisis

Check out my commentary on the Home Emergency Pocket Guide on the June 16, 2008 edition of Mitigation Journal: The All Hazards Podcast. Watch for a special offer from Informed and Mitigation Journal soon!

Thinking about Ambulance Safety

While at a recent emergency services exhibit, I noticed one of the most interesting ambulance designs...
This ambulance from the Premier Line was set up for a side loading gurney. Rather than the traditional rear load, this ambulance has two side doors and can load the gurney from each side. The patient rides across the width of the vehicle while the crew is seated in either front or rear facing seats. You can check out the full description on the North Eastern Rescue Vehicles here.
Below are a few shots I took of this ambulance as well as a few video clips from the NHTSA. I don't have any proof or test data that shows this side load configuration is any safer than the tradition design, but after watching the videos...I'll try anything. I'd be interested to hear what you think.

This is the passenger side of the ambulance. Notice that the crew member is in a forward facing seat.

Again, from the passenger side; notice the sliding door on the drivers side and the gurney loading track in the middle.

These video clips are from YouTube...certainly something to think about!

In Search of Preparedness in America

We've seen devastating examples of natural disasters all over the world. Here in the United States the number and severity of storms has seemed to increase along with the the death toll. In fact, the National Oceanic and Atmospheric Administration (NOAA) is reporting that 2008 is shaping up to be one of the worst years for severe weather. Given the combination of terrorist attacks and natural disasters like Hurricane Katrina as well as other storms around the world you'd think we (the public) would be paying attention. In fact, with all the dollars spent on domestic preparedness/homeland security, you'd think we would be ready for anything.

Don't believe everything you think.

A number of recent studies have indicated that the public is not prepared to provide self-help in times of crisis or natural disaster. In fact, the data suggests that much of our population is hanging onto the "it can't happen to me" mentality or, worse, is misinformed as to the potential life threatening situations that they may face.

From volcanoes in Hawaii to storms chewing up the mid-west, we've seen Mother Nature dish out some of the worst conditions since Katrina. Mainstream media has brought cataclysmic earthquakes in China into our living rooms and we watch with some disbelief...yet, it can't happen to us. The unfortunate fact is that "it" can happen to us and all the funding in the world can't buy a preparedness mindset.

Recent surveys indicate that our population is overwhelmingly complacent towards preparedness...lacking preparedness plans, survival food and water, or a basic awareness about the potential hazards in their region. Governments seem to have lacked the stamina to keep up with preparedness as well. Even those regions who have planed and practiced for disaster situations will find themselves fighting an uphill battle. One report cited 93% of Americans are not prepared to be self-sufficient for any crisis. How can any response community expect to assist a population where only 6-7% of a population has any capability to help themselves? Here's an everyday example: Your car is low on gas; what do you do? By looking at your cars gas gauge, you can estimate when and how much fuel you'll need. You simply drive to the gas station and fill up...that's taking care of yourself. What if we were to apply the "it won't happen to me" mindset or what I call Optimism Bias to the situation. Simply put, no need for a gas car won't run out of fuel...and if it does, someone will come and fill it up for me.

The idea that "someone" will come to the rescue is a far cry from the Cold War mentality of bomb shelters and Civil Defense. Although rescue may come, it may not be for days. The idea is for every community to encourage residents to establish their own self sufficiency plan.

Helicopters and Hospitals

Landing helicopters on top of hospitals is not a good idea.

Landing a medical helicopter on a hospital landing pad can be a dangerous proposition under the best of conditions. Having a landing pad on top of your trauma center is flashy and exciting. All the TV shows do it! As we see in this story from the AP, when something goes wrong the outcome can be disastrous.

According to CNN, AP, and the local media coverage, Butterworth/Spectrum hospital in Grand Rapids, Michigan, endured a crash of a medical helicopter on the rooftop landing pad resulting in thick smoke and fire. According to the media reports several patient care floors had to be evacuated and power to the building had to be shut off. Surrounding roads and ground traffic were closed due to the threat of falling debris. According to available information at the time of this posting, there were no fatalities as a result of the helicopter crash. (Photo credit

Hospital trauma centers around the Nation utilize hundreds of air medical helicopter flights each bring trauma victims from emergency scenes to the trauma centers. There is little doubt that the appropriate use of air medical helicopters and trauma centers save lives that might otherwise be lost. Hospitals that have a need for air medical services can and should have designated landing pads (I think helispot is the correct term for those of you playing the NIMS home-game).

However, landing a helicopter ON TOP of a hospital is not a good never has been. This practice is flashy and dramatic, but not without risk. The crash at the Spectrum Hospital in Grand Rapids is a reminder of what can happen. As a result of this crash -several patient floors had to be evacuated -power to the hospital was disrupted -debris, smoke, and burning aviation fuel caused contamination and secondary hazard concerns, and roads were closed stopping surface traffic in the area. Beyond those issues, the "ripple effect" on a city or region include a drain on emergency response, surge issues on other hospitals as the Spectrum ED was closed (they are also the only level-one trauma center). Let's not forget that many major cities have hospitals in the in close proximity to other buildings and in the heart of the city.

Use air medical helicopters....yes, fly patients from rural areas to urban trauma centers...certainly, land the helicopter on the way. Landing in safe proximity to the hospital in a designated location is safer and can be nearly as efficient.

Consider the potential outcomes in the Grand Rapids crash and do a realistic risk/benefit analysis. The outcomes could have been much worse...and can be avoided.


To Live or Die in Disaster

The Associated Press is reporting on a panel of physicians who have made recommendations regarding who would and wouldn't get health care during times of disaster or catastrophe. The list is developed with the idea that health resources will be scarce or not readily available in times of crisis and the need for a more consistent method of triaging those resources. On the surface the idea has merit. The context and list-like approach are troubling.

The report recommends that each hospital have a team assigned in times of crisis to triage health care resources...note: resources is used synonymously with treatment. The triage team would have the sole responsibility of performing triage and utilizing the triage model...not a easy job when you consider those people meeting certain criteria (high risk of death) may not receive access to those resources. According to the list, you would not recieve treatment (ie: access to health care resources) if you have a high risk of death and a slim chance of long term survival. The following list is offered to define high risk of death and a slim chance of long term survival:
People greater than 85 yeas of age
severely burned patients greater than 60 years
Those with mental impairment...Alzheimers's disease
Those with chronic disease...heart failure, lung disease, or poorly controlled diabetes...

So, if you meet the above criteria or you have one of those conditions, there may be no care for you in a disaster. What do you think about that?

Although I totally agree that health care resources will be limited (if available at all) and a disaster situation will require health care rationing of some sort, I think this report is short sighted and not grounding in reality. Here's what I mean...

This scheme is not too distant from current triage modalities with one major triage we always base our decisions on the situation and a set of triage priorities. It is safe to say that those we choose not to work on in a triage situation are not conscious and those that are will be treated as expectant...note that I said treated here.

Was there any concern for facility safety when establishing this list? How do you expect to handle a situation when a family member is denied treatment based on this list while others are given treatment? Let's put it this way: if health care resources are going to be short, it is likely that law enforcement will be in short supply as well. It is reasonable to expect that families will show up at a hospital or treatment center as a unit...with expectations and conscious.

Lists such as the one suggested by this report may violate age discrimination or disability discrimination laws...I guess its one thing to make a decision on who gets what during a crisis...yet another thing to put groups of people on a list ahead of time.

Finally, when the public outcry and debate over this occurs (and I surprised it hasn't yet) emergency managers and medical personnel alike will be required to justify these actions and this list. That is not to say the the proposed triage model is wrong...just the way the list is presented seems to be a sticking point. The fact is that triage and health care rationing will occur by default as there is no way our current health care systems will continue to function during disaster or crisis situations. Hurricane Katrina taught us that lesson...and we haven't done much about it yet.

The best approach to the situation of health care in disaster situations is to prepare. Simple to say, far more difficult to do. In all reality, those groups mentioned on the list will receive some level of treatment in a disaster. A better plan may be to prepare community resources outside the hospital systems and place emphasis on dealing with special needs populations including shelter-in-place actions.


Go Home, Everyone

I've recently had the pleasure of attending Courage to be Safe - So Everyone Goes Home. This program is offered by the National Fallen Firefighters Foundation and was delivered recently in my home town via the New York State Office of Fire Prevention and Control and was, simply put, one of the most meaningful presentations I've been at in the last twenty-four years.

This program, delivered by Mr. Paul Melfi, struck me at the core as a father, firefighter, and officer. I had the pleasure of interviewing Paul on the Courage to be Safe program while he was in Rochester. You can listen to the preview, my commentary and the interview with Paul on Mitigation Journal: The All-Hazards Podcast shows 60 and 61.Courage to be Safe - So everyone goes home is based on 16 Firefighter Life Safety Initiatives...everything from personal and organizational accountability for health and safety to apparatus design...are summed up in the 16 initiatives.

What are you prepared to do? Find your State Advocate here and request a class for your, do it now. Not a fire-based organization? Courage to be Safe easily translates to emergency medical service.

Of course I have a few of the 16 Firefighter Life Safety Initiatives that stand out and have special meaning for me. Among my favorite initiatives are #4 All firefighters must be empowered to stop unsafe practices this means that the newest probie to the most senior officer have to have the guts to get out of the old mindset "because we've always done it that way" ...and that will take guts. This also means that we have to adjust our egos, actions and policy to reflect innovative safe thinking. When it comes to empowering your personnel to look for and stop unsafe practices, we have to think in the long term...a cultural change.

If your a chief officer or department offical - find your state advocate and request a class, if your a firefighter - forward this info to your chief and push this class to your brothers and sisters. It may be the best thing you can do to save a life.


Meth Labs and Propane Cylinders

A recent warning from the National Propane Gas Association highlights additional dangers from the production of methamphetamine.

Anhydrous ammonia is a common ingredient in the production of methamphetamine and adds to the growing list of hazards found at incidents involving meth labs. According to a release (no pun intended) by the National Propane Gas Association, anhydrous ammonia has been found to be stored and pressurized in consumer-grade propane tanks. The safety alert notes that anhydrous will corrode a
nd deteriorate the brass service valves of a propane tank. The brass turns to a blue-green stain after exposure to anhydrous ammonia. There is no mention of time frame to failure/or quantity/concentration of anhydrous ammonia that will cause deterioration or failure of the service valve. It is noted that if the valve shows evidence of exposure to anhydrous ammonia it can't be trusted and it may be dangerous to move the cylinder. Valve failure may result in a violent discharge of the valve...resulting in injuries.

Many responders have been made aware of the dangers of meth lab incidents. We know to consider the chemical hazards as well and physical hazards at
these locations and to be mindful that meth labs exist in nearly every jurisdiction, even on the highway. We also know to consider ammonia of various types in refrigeration and fertilizing operations, as well as in the residential setting as used for cleaning and disinfection in the commercial setting.

The issue of improper storage of anhydrous ammonia and the potential for service valve failure is just the tip of the iceberg. Propane tanks that have had anhydrous ammonia stored in them may be found in retail centers, craft stores, or any other location that offers a trade-in circulation for consumer-grade propane cylinders. This situation has to be added to your pre-planning and situational awareness.

Click here for the Safety Alerts page of the National Propane Gas Association. All photos courtesy of the National Propane Gas Association.

Suicide by Blood Agent

A teen age girl in Japan committed suicide by creating deadly hydrogen sulphide gas in her apartment. The instructions for creating the chemical mixture was found on a computer in the apartment...apparently there have been a number of suicides/attempts since the internet information has been published. About 100 residents in the apartment building had to be evaluated following exposure. Other residents complained of respiratory distress and irritation.

This tragic story is yet another example of the Consumer-Level Hazardous Materials Incident. These events are created when routine chemical products are combined, intentionally or accidentally, to generate harmful chemical events. With all the focus on terrorism...we tend to forget about the common items we see everyday...and the impact they can have on our response.

In this case, Hydrogen Sulphide (H2S) was created by a mixture of readily available products (note: I am not listing the chemicals in attempt to keep people from doing this...if you're a responder and would like the information, please email me). H2S is a blood agent, meaning that it prevents the hemoglobin from functioning. Carbon Monoxide and Cyanide are other examples of blood agents. As an interesting note: cyanide is described as one of the least toxic blood agents. H2S poisoning follows the toxidrome of mucous membrane dryness, gasping, air hunger, respiratory failure, tachycardia and CV collapse.

In addition, H2S and a variety of other chemicals and acids can be produced by homemade chemical bombs. These types of events, intentional or accidental, can produce deadly outcomes. They can create the instant MCI and include worried well as well as actual exposure patients. Remember to consider decontamination of any patient exposed to a chemical liquid or gas.

More to follow.


Sudden Blizzard Causes MCI in Rochester, NY

Sudden blizzard-like conditions on Route 390 caused a forty-seven car pile up just outside of Rochester, NY. Details are still comming in, but at last count there were 27 patients transported, one surgical cardiac arrest.

All initial reports from those on scene indicate scene control and managment along with triage, treatment and transport were well done. The climate at the time of the event was 12 degrees F, with 20-30 mph winds.

Stay tunned to Mitigation Journal for more on this.

White Paper fails to make justification for FD-EMS

A review of the White paper - Prehospital 9-1-1 Emergency Medical Response
The Role of the United States Fire Service in Delivery and Coordination
shows shortsightedness on the part of some leaders.

This document points to the direction of emergency medical service in a fire service-based delivery model and highlights several benefits of that system. Although the document correctly notes the history and structure of the American Fire Service, it fails to achieve its self described mission; that “decision makers should recognize that the U.S. fire service is the most ideal prehospital 9-1-1 emergency response agency.” While this report makes several points many will find interesting, it lacks a comprehensive view of emergency medical service. Rather than accounting for the various aspects of EMS such as the provision of non-emergency and specialty care transport, the authors focus on only emergency response.

Emergency medical service is often considered as an ambulance only service. The public needs to understand the vital role of that first-response, non-transporting fire departments play in the total delivery of out-of-hospital care. Many fire departments provide both transport and first-response EMS with many of those being larger metropolitan areas staffed by career fire departments. However, with nearly 70% of fire departments being staffed by volunteer firefighters, the question is weather or not the fire service-based EMS transport model is sustainable. Numerous reports have indicated the need for more volunteers in any community.EMS has been cited as a drain on volunteer fire department resources and some departments only provide an emergency medical response to the most critical events.

The document also states that the fire service is the agency that first delivers on-scene health care services under the most true emergency situations and that “ [EMS] has become almost universally, a principal duty of the fire service as well” and “fire service-based EMS systems are strategically positioned to deliver time critical response.” Its true that most if not all communities have a fire station strategically placed, usually near the center, of the population or a high-hazard area. While the traditional fire station may meet the needs of fire protection, I’m not sure the same structure is efficient for ambulance service. As population shifts occur at various times of day, the needs of a geographic area will also change. Ambulance services have practiced strategic staging of ambulances to meet changing needs of an area. Reliance on a fixed facility as a singe base of operation may not meet the daily changing needs of a community.

The report suggests that it is the fire service that provides the majority of medical services during emergencies that occur out of the hospital. What about the rest of the patient care cycle? Is the care and treatment provided during transport to be considered in a minority? These statements imply that once care is delivered on-scene (by fire department personnel), the patient needs only a ride. We know that this couldn’t be further from the truth. Patient conditions can change at any time...that’s why we continually reassess and examine.

The use of NIMS, the National Incident Management System, is also indicated as another reason for the fire service to have the lead role in the provision of EMS. However, NIMS compliance among fire departments is not universal. Although most, if not all, fire departments have adopted NIMS or utilize some form of incident command many are not fully NIMS compliant. NIMS is far more than an incident management system and encompasses an agency philosophy of management. Unfortunately, too few EMS ambulance services have taken the initiative to become NIMS compliant and embrace the concept in service delivery.

Ambulance sub-specialties are mentioned in the report and the reader is cautioned that these services “must not be confused with 9-1-1 emergency response.” I think this is one of the most disturbing comments I’ve ever heard. I we’re going to look at the global needs of EMS delivery, we have to included specialty care units like critical care transport. To exclude the specialty services is to fail to address the needs of not only the patient but the health care system as well. The emergency-only approach to pre hospital care is self-limiting and will not fulfill the mission of the fire service, the public, or the health care system.

Perhaps the most disturbing question asked in this report is “...what does a non-fire based EMS crew do on the scene of a motor vehicle accident when the care is engulfed in flames and occupants are trapped inside, and fire crews were not dispatched?” When did dispatch error become a justification for the fire service to provide ambulance service? Crashes with cars on fire a occupants trapped and similar situations are dangerous threats to civilian life and responder safety. The threat exists regardless of the availability of personal protective equipment. So, to answer the question of what non-fire based crew should do in these situations...let’s answer play your position and get the proper resources to the scene.

And what if we were to ask the question in another way? “What does a fire service based crew do with all the structural firefighting personal protective equipment and apparatus at the scene of a heart attack?” The fact is, that if we were to apply this line of thinking towards an overwhelming majority EMS response the fire department “emergency only” service would seem like a large expenditure with limited return.

My conclusion is that the report Prehospital 9-1-1 Emergency Medical Response: the Role of the United States Fire Service in Delivery and Coordination fails to make a valid claim that the fire service is universally the best provider of EMS. As I’ve attempted to point out in this summary, the delivery model that best serves a community is the best delivery system and that is certainly not a one-size fits all situation. The fact is that there are several delivery forms that will meet the needs and expectations of a community. The job is to evaluate, study and choose the best option for our individual area.

(a link to the original document can be found at on the updates page)


Incident Safety Officers Crucial to Good Operations

Safety Officers Needed
Incident Safety Officers Crucial to Good Operations
Rick Russotti, CI/C, EMTP

The role of the incident safety officer or ISO is about to expand. Although some refuse to acknowledge the importance of the incident safety officer’s position, a competent and proactive safety officer plays a crucial role in emergency scene management. All to often the assignment as incident safety officer is seen as a lack-luster job without the real importance of other positions within the command structure. Some departments continue to relegate the position of safety officer to personnel who are considered “exterior” or support personnel while others dedicate those members on light-duty to the role. Failing to understand how a incident safety officer fits into the command structure and what he or she represents on the emergency scene or fire ground can be that first domino in less then successful events.

Incident Safety Officers are more then safety or equipment Nazis. While it is true that the ISO should be helping to ensure the proper use of PPE and observe for potentially unsafe situations or acts, he or she must undertake an active role in ensuring other important duties are accomplished. All to often the ISO is seen as a nitpicky nag that keeps “real firemen” from doing their job. Unfortunately, when personnel are assigned to the position of incident safety officer as a matter of default (they’re the last one on-scene or they’re on light duty), the role diminishes in credibility as those personnel finding themselves in this role by default may lack the training and background to be effective. This highlights the need for the incident safety officer to have the background practical experience combined with a depth of knowledge of fire ground operations. This combination of knowledge and experience equates to credibility on the part of the incident safety officer.

Experienced firefighters and officers can and do operate as effective incident safety officers…usually in those departments who’ve embraced the position and added some level of acknowledgement within the command structure. Although every person on the fire ground have a responsibility to act in a safety officer capacity, those assigned to the role should have demonstrated comprehensive knowledge of department standard operating procedures as well as established firefighting strategies and tactics. In short, the practice of assigning an incident safety officer by default shortchanges the members working at an incident and deprives the incident commander of an invaluable resource.

As other functional areas such as personnel accountability and responder rehabilitation continue to expand, they should fall under the direction of the incident safety officer in the command structure. This is not to suggest that the incident safety officer should actually perform the duties, rather he or she should ensure that they occur according to department procedure. Consequently as the complexity and geographical scope of an incident expands, so will the need for additional personnel to be assigned to the safety group and deployed so as to manage the incident safety officer roles within the given areas. Additionally, rehabilitation and accountability group leaders should be reporting to the Incident Safety Officer. Rehabilitation and accountability are just two of the functional areas that should be under the direction of the incident safety officer.