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Protecting At-Risk Populations

Protecting At-Risk Populations: Here is a great story...perhaps the best way to better hold off the spread of  H1N1 or any other disease. CNN is reporting on a crew of volunteers going out to the streets to vaccinate homeless persons against H1N1. Taking the vaccine to the streets, along with any type of treatments, will almost certainly keep the infection rates down and may prevent spread of the disease.

Lets remember that the homeless population includes many who have issues with addiction or mental illness in addition to co-existing medical conditions. This situation clearly makes the homeless population at greater risk.


Air Terror Attack

I've suspected something of this nature would be happening and have been following events the mainstream media has not been covering. Tonight, 12/25/09 we have striking developments from Detroit...
MSNBC is reporting that a Nigerian man attempted to detonate or ignite a powdery material on a Northwest airlines flight today.

At the same time, CNN is reporting that this incident took place at the end of the flight from the Netherlands to Detroit and involved fireworks or fire crackers of some type.

While the latest Reuters report out of Washington and being carried locally here in Rochester, NY,  has the White House confirming a more serious event...calling it an act of terrorism.

Interestingly, we've been talking about several instances occurring on commercial airliners in the last few weeks. These events seemed to involve threatening or hostile-like actions on the part of passengers appearing of Middle-Eastern dissent. I've called them "probing" events - those events used to test our response to and actions during an event and just talked about them in MJ#140 on the podcast. They have received scant media coverage and what has been covered has received a glossy political correct finish. While supposed eye-witness accounts and the "official" airline accounts differ in degree of severity, its important to note that seemingly everything that can be done to discredit those concerned (civilians) who bring this issue up.  The National Terror Alert is linking to an article published by the American Thinker that you should read. They do a nice job of piecing the commonalities together.

While all the details are yet to be known, we have to ask what type of explosive or device could get past TSA? We'll be increasing our security for sure. More to follow.


Cardiac Arrest Survival: Thirty Years of Change without any Changes

Cardiac Arrest Survival: Thirty Years of Change without any Changes...Yes, you guessed it. I going to take yet another shot at the American Heart Association. UPI is reporting on a study by the University of Michigan that states cardiac arrest survival rates have not changed in thirty-years. This despite all the CPR and ACLS cards issued to and paid for by emergency service responders.

The study concluded the chance of surviving an out-of-hospital cardiac arrest has not improved since the 1950s. As quoted from the original UPI article:
"Increasing bystander CPR rates, increasing the awareness and use of devices to shock the heart and keeping paramedics on scene until they restore a person's pulse needs to occur if we are ever going to change our dismal survival rate," Dr. Comilla Sasson, the study's lead author, said in a statement.
Now lets take a look many CPR changes have we seen...all with a new book ($$) and another class (more $$)...and can someone tell me why we have to PAY for CPR training? How about all the "research" that causes us to change the procedures we do (advanced airway, for example) or the medication changes we have to endure. High dose Epi, Vasopressin, Amiodarone, Verapamil, bicarb or not, Lido or what order...and don't forget...the research (sarcasm) will tell you that everything you know and have been doing will be totally wrong and deadly tomorrow! So run out and take another class and buy another book. Because you can see the results of all the cardiac arrests we saving.

Too many systems still gauge effectiveness based on cardiac resuscitation rates. Nothing could set us up for failure more than this unrealistic expectation. Why do we expect responders to show up and correct decades or a lifetime of disease that caused the cardiac arrest? We'll work on a cardiac arrest victim for a while with limited resources in the field and then turn them over to the ED. Yet, if they don't walk out of the hospital...we didn't "save" them. How can this make any sense?  A majority of what Paramedics carry in terms of medications and equipment is aimed at the cardiac arrest patient.

And despite what we know and do, we're not making much of a difference.


Air Medical. At What Cost?

I have the deepest respect for my colleagues who work in the air medical arena. I also have little doubt that air medical transport with helicopter and fixed-wing aircraft have saved untold numbers of lives throughout the Country. In general I support air medical, albeit with some reservation on the use of helicopters.

I've written about the potentials of landing a helicopter at your emergency scene or on the roof of a hospital (a totally bad idea as far as I'm concerned) and you can read my comments in Mitigation Journal one persons opinion may be that helicopters and operating with lights and siren are the two biggest contributors to EMS LODD...maybe they should be avoided...and at all costs, keep your helicopters off of and away from your hospitals!

Todays posting is going to look at another, less deadly impact of air medical transport...cost. MSNBC is running an article with focus on the cost of emergency helicopter transport and the health care system. According to MSNBC, the cost of this service can be anywhere from $12,000 to $25,000 and that cost may not be covered by insurance. Sure, we can't put a price on a life...and I would certainly pay that amount and more for any of my family...gladly. I think what is at issue here is the fact that these flights are not always deemed appropriate. Even in the setting of trauma other alternatives to air medical transport my have provided the same outcome at a fraction of the cost.

Another issue is choice. Victims of trauma who are in serious condition may not have the capacity to provide informed consent for air transport. The public is trusting the emergency responders to make the best choice for their care. Transport mode should be a decision, like any other, made carefully and with the patients best interest in mind. In these cases the "customer" has little choice. And on that note, please remember we treat patients...not customers. Read my comments on the word "customer".

So let this one sink in a while. When is air medical helicopter really needed? How can this service be put to best use...when should it be avoided? Patient condition, injury severity, distance to definitive care, and weather conditions are just some of the points to ponder. Now we have to add in cost...or better stated; cost effectiveness. Will air medical transport make a difference in relation to the non-covered cost in relation to ground transport alternatives.  More to follow on this...and I welcome your opinion.


Finding Radiation in the Parking Lot

I happened to go out for a cup of coffee with a friend of mine this morning and found something unexpected in the parking lot. In the space next to mine was a pickup truck owned by a construction company with two containers in the back...labeled RADIOACTIVE. Barely secured with an old chain and skimpy padlock, these containers were just sitting in the open bed of the truck with nobody around.

I'm certain they were legitimate. But in today's society, just leaving them out in the open was a bit odd. Certainly, these materials could be used for some untoward event, like a dirty bomb, but more concerning is the number of possibilities that are more likely to happen.

Suppose this truck were to be involved in a collision, a roll-over or rear-end collision for instance. You find the containers after you approach, size-up and being patient care...or worse, you find the compromised containers only after patients have been taken to the hospital.

How about fire? You arrive to find this truck fully involved. Only after extinguishment you find the melted, compromised containers. Do you have radiation detection equipment available? Would you even think about getting it out?

Finally, what will the average citizen think of this? Two containers left out in the open and clearly marked radiation. Perhaps they'll call 9-1-1, how will you respond?


Bio-Event Ready or Die!

     ...or at least get sick. 3 Things to do today to prevent even that!

Biological events can be natural or intentional. The intentional kind is what you'll learn about in a weapons of mass destruction (WMD) training class and you read about in the papers. The naturally occurring kind...SARS or pandemic influenza, for example...are the kind that go on almost every year and we don't pay much attention to. One is intentional, one is natural. Both can be deadly, both have lessons to be learned. We've seen both types in the last ten years; SARS and West Nile Virus...naturally occurring, Anthrax, intentional. Again, both situations with lessons to teach. But did we learn anything?

Here we are in 2009 and many documents and memos are urging us to "get ready" for pandemic flu, H1N1 or otherwise. SARS hit the world back in 2003...what did we learn? It is way past time to be getting ready, we have to be ready. Its not as hard as you'd think and you don't need dozens of pages of plans, either.

Despite the intent, there are similarities between intentional and naturally occurring biological events that we can use to our preparedness advantage. Even the traditional WMD training can be translated to natural event readiness. Unfortunately, most of the WMD training has been a waste of time and preparedness dollars spent on big, shinny things and security cameras.

Traditional responders and the health care system is marginally better prepared today than it was on September 10, 2001. After Anthrax, after SARS.

Recently, the Centers for Disease Control and Prevention (CDC) has predicted that 40% of the United States population will become sick with 2009 H1N1 Swine Flu. That's 40% of the average population. Not to mention those in health care, emergency response, and those with risk factors. And considering the disease as it is today...not accounting for any antigenic drift. Keep in mind H5N1 or Avian Flu continues to lurk and there has been a strain of H3N2 found to be undergoing change.

By way of review, the H's and N's stand for proteins on the influenza type A virus. There are several types H's and N's that, in combination add up to tricky business for vaccine procedures. Influenza vaccine has to match the H and N combination. If not, the vaccine is not effective.

My top three things to do to Be Ready for a natural or intentional biological event:
  1. Train your people on infection control and personal protective equipment (PPE) more than once a year. This is the time to develop good habits for regular cleaning and disinfection of our vehicles. Also, several studies have pointed to practice with masks...getting proper fit and know how to put them on being more important than annual fit-testing. By the way, numerous sources have also indicated that the N95 mask may be no better standard surgical masks for protection against viruses.
  2. Promote the safety and health of responders and their families. That means getting appropriate vaccine or other medications available for your personnel and at-risk family. Identify those who can't get vaccinated or take medications and take steps to isolate them from infection. Numerous self-report surveys have concluded that one key to keeping your personnel coming to work in a biological event is provide for the safely of the family.
  3. Prepare a Can't Go Home Plan. Stock you stations and facilities with food, water, hygiene products and ready additional bunk areas to keep personnel in-house during extended operational periods.
As always, I look forward to comment and debate. If you have something you'd like to add to the me at


It's Only Pepper Spray!

Just a reminder here that those non-lethal or less-than-lethal weapons can cause serious issues. Recently, an REI store had to be evacuated due to bear-spray release. Check out the details of the story here:

We've been lulled, perhaps by the name, that non-lethal weapons like pepper spray are not serious concerns.


Even when deployed for legitimate reasons and in proper fashion, pepper spray, mace, and other such products can cause a variety of situations. These materials stress the respiratory and cardiovascular systems and precipitate brochospasm. There is also the potential for multiple people to be exposed and in need of treatment. Saturation and prolonged skin contact can cause burns...especially in those hard to reach, moist areas of the body.

Perhaps most important for the responder; remember the need for decontamination. Victims exposed to mace or pepper spray need to be cleaned prior to being placed in a treatment area or in the back of an ambulance. Appropriate removal of outer clothing and water wash should do the trick in many cases. Understand that failing to do so puts the responder at risk of exposure to the material. And just like any other hazardous material event, no patient should be transported to a hospital without being evaluated for need for decontamination.

Lastly, don't forget the psychological impact of these situations. The "worried-well" can clog a system and deplete response resources at a faster rate than actual victims do!


Two Chemical Events...Many Lessons!

Once again proving the point that you don't have to wait for a terrorist attack...

The articles linked below highlight the need for all of us to be familiar with chemical event potential. As I've been saying for years, we don't have to wait for a terrorist attack with a chemical agent to utilize the knowledge/training that we have. When I say "we"...I mean traditional and non-traditional responders...EMS, fire, police, and hospital personnel.

Note to the American Fire Service...I don't buy into the idea the fire department will be too busy to support hospital decontamination/protection efforts in large-scale events. Fire departments must be involved in planning, training, and implementing protective measures at hospitals...even if only one fire officer, to help direct mutual aid companies. Hospitals are critical infrastructure.

The first two links below relate to a chemical event at refuge company. I'm getting the impression that something got mixed in the trash and reacted, releasing an unknown chemical vapor resulting in three critical patients, numerous contaminated, many transported...119 total. The underlying situation is that one hospital was ready with decon...they had drilled for such an event with the fire department. Also, EMS didn't send contaminated patients to the hospital and on-scene decon worked. These articles are preliminary, but I'm thinking this will be an interesting case to follow.

The last link is to an article that is much more disturbing; a situation using a chemical dispersal device, chlorine and an incendiary device were deployed...with intent...with a specific target. The mainstream media is calling this a hate crime. I'm looking at it as an act of domestic terrorism.

Tune into Mitigation Journal Podcast for more details...look for edition 118 (expected release 8/5/09)

Unknown gas injuries in MA

Emergency Decon Drills Paid Off

Chemical Attack Hate Crime


NYS Nurses Association Opposes Mandates for Vaccine

Representing over 37,000 nurses, the NYS Nurses Association (NYSNA) has spoken out against a new regulation making flu vaccine mandatory for all people who care for patients in health care...including nurses. Under the new regulations, nurses would be mandated to get a seasonal flu shot as a condition of employment. No shot, no work.

My first thought was: how could anyone be against this?! But, after reading the testimony, I can understand it...moreover, there are a number of Ripple Effect points to consider. After reading all the material, I think NYSNA has a number of valid points.

The first point is: Can this be mandated when no current public health emergency exists? The NYSNA is clear that they fully support and encourage nurses to get flu vaccine. Most would agree that getting a flu shot is good preventative action. When working in health care, what rights do you give up? Consider all the issues the military had mandating Anthrax vaccine not too long ago. Keep in mind you can still decline to get a HBV series and work...

I'll be talking about this in detail on the next Mitigation Journal Podcast (Edition 118 expected release 8/3/09). In the meantime - I've talked about the three best things you can do - now - to prepare for biologic events now, without can hear my recommendations on Mitigation Journal Podcast Edition 117.

Below are the links to the NYS Nurses Association press release and testimony.
Medical News Today story:
NYS Nurses Association Press Release:
NYS Nurses Association full text of testimony delivered by Eileen Avery, MS, RN, Associate Director, NYSNA Education, Practice and Research Program to the State Hospital Review and Planning Council, July 23, 2009, New York, NY.


Paramedic Future

What role will technology play in the future delivery of out-of-hospital care? I once believed that an increased use of technology would increase the scope and duties of paramedics. Today I'm not so sure.

I'm now starting to believe that implementing technology may actually decrease the need for paramedic treatment and, dare I say, speed critical patients treatment.

I learned to read 12-lead EKG's over twenty years ago. It was not common for EMS to "do" a 12-lead and the technology wasn't there to support us doing so. Years later the technology became readily available and is in wide use today. Many seasoned paramedics looked down on the computer interpretation and some, including me, would not read the interpretation until after reading all the leads and making a diagnosis.

Luckily, the technology has grown and become far more trusted. That is trusted to a point where we can question if the middle-man is needed. That middle-man, of course, being the paramedic. I don't know how I feel about this; on one side, any EMT could attach the leads and obtain and transmit the readings to the hospital making 12-lead EKG readily available, sooner. But on the other hand, technology can't consider the patient as a whole and put all the assessment pieces together like a skilled paramedic can.

Like any other technology, once we become accustomed to it, we become dependent on it...try going a without your email or word editor and hand-write a few letters...get the point. In the case of EKG's I'm afraid we'll eventually decide we don't need to teach reading them any longer...what will we do when technology fails?

Anyway - here is a cool article on the use of Blackberrys and EKGs


Is there a Nuke in your neighborhood?

Is there a Nuke in your neighborhood? Check out Nukeometer at

Just enter your city and country to find out how many nukes are within range of your city! The breakdown is given by potentially offending country and by delivery...ICBM, submarines, short range missile...these guys thought of everything!

Here in Rochester, NY, we're in range of 6404 nuclear warheads...2347 from the USA and 3684 from Russia, 192 from UK, 121 from China. 2490 of those can be delivered from ICBM and 2771 by submarine with only 1143 available by bombers.

By contrast, Denver Colorado is within range of 8127 warheads and Washington DC 6404 warheads. Tune in and find out where your location stands...pleasant dreams.


When we fail to train together and understand the same goals and priorities...

ParamedicTV is powered by

ParamedicTV is powered by

Thanks, Mike for sending these in...


More Chemical Suicide

I've been made aware of a case of chemical suicide in Toronto via a memo on Toronto EMS letterhead. Although I've not been able to confirm the validity of the memo or find associated material on the event, it seems as if Toronto has had a case of chemical suicide. The chemicals listed in the Toronto EMS memo are among those on the list of potential chemicals for other events in Japan and the U.S.

When certain chemicals are mixed, Hydrogen Sulfide gas can be created. In some cases the gas has been created in concentrations greater than 2000 parts per million. Hydrogen Sulfide is more potent than cyanide, has a quick "knock down" - causing unconsciousness/respiratory failure - withing one to two breaths.

Chemical suicide events have taken place in hotel rooms, residential areas, and apartments. The latest trend is to mix the chemicals in a car parked in a parking lot. Both residential and vehicle borne events have the potential to cause responder deaths and mass casualty/multi-patient events.

In some cases, people have posted signs on the doors of apartments or windows of cars indicating their intent to commit suicide by chemical agent. Responders need to be aware of any unusual clues such as windows taped shut, open containers of liquids (chemicals have been mixed in small wash tubs), odors of any kind. We should also add a high index of suspicion for any "person over the wheel" calls - don't assume the person in that car is sleeping! If you think there has been chemicals involved in a situation - do not enter, do not open the car. Keep the area clear, create a parameter and keep yourself uphill and upwind - call for FD/hazmat.

Below is a list of links to prior Mitigation Journal posts from the podcast and blog...

Blog Postings:

Chemical Suicide in Cars

Suicide by Blood Agent

Mitigation Journal Podcast #72
Mitigation Journal Podcast #64
Mitigation Journal Podcast #59


DHS/FEMA Announce Shelter System

I've been expounding this concept for years now...reminding us to get back to the Civil Defence mindset. My meaning has been simple: prepare the individual and the family, provide for save shelters in public areas (a.k.a. Fallout Shelters) to give people a place to go when out in daily life, and we'll greatly improve our ability to mitigate natural and intentional events.

Someone must have been listening...finally.

DHS and FEMA have announced the creation of a Disaster Shelter System to house civilians in the event of a natural disaster. Details are still drifting in, but we are moving in the right direction!
Check the source materials from Los Angeles Times and National Terror Alert.

Homeland Security Secretary Janet Napolitano and Craig Fugate mentioned that we will only be as successful to the level of preparedness of the family - and I agree. September is National Preparedness Month and we should all be making plans, keeping informed and getting involved as best we can to prepare ourselves, our families, and our communities for crisis. Remember - local efforts will save lives!

Now, onto some interesting statements:

Craig Fugate, the new director of the Federal Emergency Management Agency, further stated “We are only going to be as successful as the public is prepared,” and “There are a lot of folks who are going to need very specific help that should not have to compete with the rest of us.”

I agree with the first quote here - public preparedness make for an efficient and successful (as much as can be expected) response to emergencies and disasters. But what is FEMA Director Fugate talking about in the second quote? “There are a lot of folks who are going to need very specific help that should not have to compete with the rest of us.”

Who is competing with whom? Moving towards a shelter system is an excellent idea...but, yet again, we will overwhelm those resources if people are individually prepared! Even the best Nation-wide shelter system will fail under the strain of an uniformed, unprepared community.

Attacking Hemagglutinin and Neuraminidase

Hemagglutinin and Neuraminidase are the proteins of the Type A flu. Hemagglutinin allows the virus to enter a host cell (remember, virus is must have the cellular mechanics of a host) and Neuraminidase allows the virus to reproduce and exit...going on to infect another cell. To date, antiviral agents attack Neuraminidase (Neuraminidase inhibitors). New research outlined in Medical News Today, highlights the possibility of attacking both the H and the N. See the article here: In A New Way Of Treating The Flu, Both The H And N Portions Of The Virus Are Targeted

This would be good news for all of us as virus begin to become resistant to medications such as Tamiflu.


Common Sense PPE

This clip talks about the common sense actions to take during and after encountering any patient with fever and respiratory illness, including influenza like illnesses (ILI) such as seasonal flu or Swine Flu. Hats off to this RN, Paramedic from Paratech Ambulance in Milwaukee, WI, and to the reporter for a job well done.

For more on the topic of flu, type in keyword "flu" in the search box in the upper left header on the Mitigation Journal blog page or into the search box on the right side-bar on the Mitigation Journal podcast page.


Cassandra, in Greek mythology, was given the gift of correct prophecy of forthcoming mishaps and calamities. Apollo, a Greek deity, because of anger, made certain that no one would believe her. Thus, Cassandra has become known as the bearer of evil tidings that no one will believe.

E.L. Quarantelli, 1988


Do it in your Sleeve

Here is a nice public education video on the topic of respiratory etiquette. Its lighthearted and factual. Check it out here:

Thanks to Mitigation Journal reader/listener, Ted Lenze, for sending this in.


Of Chicken and Expectations

OK, you've got to see this video! When watching, do so from an emergency management standpoint...that is, substitute antiviral agents, antibiotics, masks...for the word "chicken".

Also, change the question "how do I feed my family?" to "how do I protect my family?". How about instead of Popeyes...we use [insert your organization/community name here] ? Are you prepared for the onslaught?

How does simply changing from "chicken" to medication/masks (or whatever) impact this situation? What will changing from "feed my family" to "protect my family" do to social unrest and public health?

Is this a snapshot of what we can expect when the community expectation is not met?! These people are not actors, they are actual citizens with actual expectations...reacting when those expectations are not met.

Imagine your point of distribution running out of medication...or the neighboring jurisdiction running out of medication and how that will impact your community. If people react in the manner displayed on this video over a chicken combo special, what do you think they will do when we run out of antivirals, antibiotics, masks...or whatever?

I can hear it now..."What do you mean you didn't order enough antiviral medication and masks?! You knew this flu was coming two months ago!"

Special thanks to our Director of Apocalyptic Thinking, Officer Sundquist, for sending me this video and bringing this potential to our attention.

I await debate and comment!


Selected Reading on the Flu Situation

Here are a few of the many articles I've read in the last few days on the topic of Swine Flu and flu in general.

Avian Flu Research Sheds Light on Swine Flu
"...A new study by University of Maryland researchers suggests that the potential for an avian influenza virus to cause a human flu pandemic is greater than previously thought. Results also illustrate how the current swine flu outbreak likely came about..."

Is Swine Flu A Worldwide Threat?

Pandemic Flu Vaccine 6-Month Lag Time
"...the first wave of pandemic flu may be over before people are vaccinated..."

On the topic of N95's

Some questions about fit testing for N95 masks have come up.

Fit it worth the time?

and here is a joint NIOSH/OSHA/CDC study

Don't Expect Too Much from N95

OSHA comments on stockpile of masks

Flu virus is airborne...suspended in air - need for more stringent precautions?

Don't expect much from facemasks


What NOT to do for Flu

Here is some good info in the setting of flu from TIME/CNN: The top five things NOT to do in a pandemic situation -
  1. DONT go to the hospital
  2. DONT be afraid to eat pork (and yes, I think we should continue to call this SWINE FLU)
  3. DONT hoard anti-viral medications (lets add to this one...DONT take antibiotics...they wont work on flu - antibiotics are for bacterial infections, flu is viral. Taking any medication...antibiotic or antiviral...when you're not sick can lead to the development of resistance, too)
  4. DONT leave your home if you feel sick (lets add to that if you have fever and respiratory symptoms...or symptoms suggesting cold/flu of any kind)
  5. DONT panic (its Swine Flu...not an IRS audit)
And now for a few of my own...
  • Call 9-1-1 only if you need to...remember, ambulance crews are limited and calling an ambulance will NOT guarantee you get a hospital bed any faster (if at all)
  • Wash your hands...all the time
  • cover you cough/sneeze
  • practice appropriate social distancing


FEMA Preparedness Guide 101

The final version of the FEMA Comprehensive Preparedness Guide 101 is available. You can download the entire 176 page PDF here:

I read the draft a while ago and used that as a template for the Planning Series on the Mitigation Journal Podcast. I think it is a solid document with many good features for civilian and responder alike. My biggest joy from this document comes from an apparent return to a civil defense approach...something I am a BIG fan of...throughout the document.

I just hope someone at FEMA or DHS reads it.


Anthrax? Not. Lessons Learned? Not.

Check the story here...good video, too.

Envelopes containing the dreaded "white powder" have been found in numerous locations Sebring, Fl. Some of the envelopes were found on cars in the parking lot of a hospital, some at the town hall, others in various mailboxes throughout the area. In at least one instance, a person who found the item on their car, took it back into the hospital...a lock down and default quarantine followed...
Of course, responders in PPE and SCBA collected samples that later turned out to be "non-hazardous" to humans.
What strikes me about this situation is not the fact that someone did it...its how the public and media responded to it. We know that, of the three varieties of Anthrax, inhalational anthrax is not spread person-to-person, we also know that it is difficult to manufacture is quantity and distribute. Why, in today's culture, would you take a substance back into a hospital?

Yet, we don't seem to get the lessons from prior events. Emergency managers should be informing the media about the reality of inhalational anthrax and responders (with appropriate caution) need to be realistic about responses...not every white powder event is NIMS laden, large scale disaster event.

We knew this before 9-11-01, we knew this after 9-11-01, yet we keep reacting to white powder events as if we've never seen it before.


Sabotage: Back to the Stone Age

An act of sabotage in Santa Clara, Ca. has disrupted communications and left 52,000 without telephone, cellular phone, or internet communications. According to the National Terror Alert and someone got into (an unsecured)utility man-hole and cut four or five fiber optic lines. The disruption impacted not only "land line" service, but cellular service, ATM's, and emergency communications.

Although sabotage is the suspected (obvious) cause of this event, the report notes that the contract between AT&T and the Communications Workers of America (CWA) had expired at 11:59 (problem identified at 2am)...

According to both reports, the situation was noticed when an emergency communications center discovered they had lost phone service. Officials have given some interesting quotes published in both the National Terror Alert and

"We've never to this extent in recent history had this kind of phone outage,''and It's kind of like an earthquake" are two that stand out.

According to

The Santa Clara County Emergency Operations Center has been activated; the Santa Clara County Fire Department has moved more firefighters to south county fire stations; the county sheriff has increasing staffing and patrols; and additional ambulances have been positioned in the area."

Overall this is a good tactic. However, you have to consider that loss of communications is a precursor to another event in another area. If you move resources into the effected area, make sure other areas are also well supported.

A couple of things to point out, and this is what I'd be thinking if I worked in this areas emergency management:
  • Soft Target/Hard Target...communications service is part of critical infrastructure...protect it! Open utility vaults/man hole access are soft targets when they contain communication equipment, power supply access, water supply distribution and so on. They should not be soft targets...they need to be protected.
  • Despite the almost obvious link between AT&T/CWA contract negotiations, don't jump to conclusion that this situation was perpetrated by a member of either party. Keep in mind that people that want to do us harm read the paper, too. The contract negotiations may be just the cover an individual(s) would want to try an act such as this...bottom line, think deeper. Also, it wont take a lot of imagination to figure out what to cut/destroy to cripple a system like fiber optic communications. I think anyone with motivation could do it.
  • Consider that this act may be a probe, a test simply to see how a community responds to such an event. Although significant, this could be the tip of the sabotage iceberg.
  • Consider also that destruction of communications ability may be the heralding event for something else...disruption of communication may be just the start, with the primary event taking place later. Crippling of the emergency service communication and the public ability to report an event would signal trouble for responders...and increase the scale/impact of a concurrent event.


National Infrastructure Protection Plan

I've just received this link for the new National Infrastructure Protection Plan. We'll be reading it over in the next few days and reporting back here and on the podcast.

Until then, give the Plan and associated documents a look. All documents are available in PDF.

The updated document replaces the 2006 document...I think that one was over 200 pages...the update is only 188 pages. Your thoughts and comments are important. If you take the time to review the NIPP and documents, please let me know what you think.


Chemical Suicide in Cars

Information is circulating on the topic of chemical suicides. We've talked about them a number of times on Mitigation Journal and here, in the blog. I've added some links to the podcast and blog postings on the topic of chemical suicides...see the links below.

There have been numerous cases in Japan of people committing suicide by mixing various chemical products with the end result being Hydrogen Sulfide. The situations in Japan have occurred at an alarming rate, and due to the living conditions, created a number of MCIs and ripple effect casualties in apartment buildings.

Two cases are being talked about recently...both in the U.S and both involving people sitting in parked cars (sometimes sealed with tape on the inside) and mixing chemicals. By reports I've been reading, the chemicals are different from the types used in Japan and other places, but the end result is the same.

I have been aware of this type of activity for a while now and reported about it on the podcast and blog. I am aware of two events within the last 6 months or so (Georgia and California) where people have locked themselves inside their car and mixed chemicals. I am also aware of at least one other similar event in Portland, Ore, where a guy used chemicals heated by a hibachi in a hotel room to do the same thing. In many cases there is hydrogen sulfide (H2S) created. Chemical suicide has been a growing problem in Japan...these situations have caused MCI's in apartment buildings and numerous deaths. It would seem the trend is continuing and moving toward us.

Mitigation Journal Podcast #72
Mitigation Journal Podcast #64
Mitigation Journal Podcast #59
Mitigation Journal Blog

More to follow...If any readers have better intel on this, please write in or call the voicemail line 585-672-7844.


Stand by for the Ripple Effect

One out of every four people said they're (or someone in the family) is putting off getting medical attention due to cost. Another 50% admit to over-reliance on folk remedy and over the counter medications in lieu of seeking prescription drugs and doctors office visits.

EMS providers hang on to your EKG leads! The combination of prolonged reliance on over the counter medications will lead to increased medication interaction and more severe disease. Sprinkle in a bit of denial and delayed access to care, and we'll be seeing sicker patients with masked symptoms. The situation reported by MSNBC should also be a warning for use to look ahead for the Ripple this case, the Ripple will be surge on hospitals and EMS with patients who have been under treated or have been non-compliant with treatment. Also, responders have to be ready for the prescription / OTC interaction and complication of history and exam.

Keep an eye on this one.


Protecting Nuke Plants from Air Attack

Shouldn't we have done this already?
You and I may have thought that nuclear power plants have been evaluated and made safe from threats on the ground and in the air. We're wrong. A story being run on states that new construction of nuclear power plants will have to be protected from dive-bombing aircraft.

Just think, it's only been seven years since the September 11, 2001 attacks on the WTC...and we're just getting to the protection of our nuke plants now!? To make matters worse, the requirement put forth in the article notes that "...require any future nuclear power plants to be designed to withstand strikes from commercial jetliners..." What about the current plants? Shouldn't we be doing something with them as well? I have to honest here, I thought that they were already protected to some degree from this scenario...guess not.

Once again we demonstrate the failure to learn from our emergency preparedness history. Billions of dollars have been spent and much of it wasted in the name of preparedness since 9-11-01. We've failed to make meaningful changes to our attitudes toward preparedness and been mediocre at best keeping up with man-made and biological threats.

If IT CAN Happen Here, IT CAN Happen Anywhere

For those of you remaining in the "it can't happen here" crowd; let CNN serve up this story as a reminder. I actually read this a few days ago and forgot to post it. The scenario is that an improvised explosive device was detonated inside a prison during a search. Although no one was injured, it is another reminder of the relative ease of construction and obtaining materials for an improvised explosive device (IED) or homemade chemical bomb can be.

If some motivated inmate, presumably with limited access to materials and under salience, can construct an IED...what makes you think your community is going to remain free from this type of event.

If the term "Domestic Terrorism" is not in your vocabulary...put it there today.
See these Mitigation Journal blog postingsand listen to Mitigation Journal Podcast for more:
Homemade Chemical Bombs
Chemical Fumes Risk
Domestic Terrorism in Aspen


Point and Click Equals Sick?

I found this story in the Orlando Sentinel interesting. The story suggests that more people are turning to the Internet for medical information and becoming "Cyberchondriacs" as a result of diagnosing themselves with a worst-case disease scenario.

Any access to information has to be put into context. Without qualified medical opinion and assessment the medical information found on-line or sought in texts is next to impossible to use correctly. Should we limit public access to medical information? Absolutely not. While a person may over diagnose themselves with a condition they may be just a likely to seek evaluation and treatment earlier. We may actually see a decrease in denial!

In any event, I think we as responders have to recognize the fact that people who call 9-1-1 have access to a great deal of information...and that information may lead them to incorrect conclusions about their health condition or situation. That means a charge in expectation. Responders have to be able to speak intelligently and factually in the face of "Internet self-diagnosis". We have to be able to do this in order to maintain our credibility, elicit the proper information from the patients, make the correct decisions...the list goes on.

If you fail to acknowledge the fact that the public you serve is may fail to meet their expectations or elevate fears. Both are failures of service.


1 in 5 Quit

Another story being run by MSNBC states that 1 in 5 nurses quit within their first year of service. Once considered a product of the over-worked, under-paid emergency services field, it seems as if the longevity and retention of nurses is reaching alarming rates.

This article is worth the few minutes it will take to read. I think it will open your thoughts to the situation in the Nations emergency departments.

On a final note, things that make you go HHHMMM...

"Many novice nurses like O'Bryan are thrown into hospitals with little direct supervision, quickly forced to juggle multiple patients and make critical decisions for the first time in their careers."


The Cost of Texting

For many, its not the cost of text messaging service that's a's the loss of communications skills. This recent MSNBC story highlights a concern many of us (especially parents of teens) have about the texting communication craze. The story highlights the possibility of loss of traditional communication skills, use of grammar, inability to use proper sentence structure and so on. Thinking about my own experiences I'm not sure that I fully agree. I know my own writing, spelling and desire to write increased dramatically when personal computers (read: spell check) came to the commonplace . In my case, the use of technology (personal my case a TANDY notebook) made it possible for me to overcome poor handwriting and spelling. When all is said and done, the personal computer became a way for me to overcome limits and eventually produce Mitigation Journal, one of the finest niche blogs available today.

Can we say the same thing for text messaging or "texting"? I don't know, its far too early to tell. I do think that texting allows us (teens and others) to communicate with others who we'd not normally contact and share immediate thoughts. We've talked about the value of social networking sites such as Twitter (follow Mitigation Journal on Twitter) and Facebook. These sites have value in emergency service and public safety communication as well as message delivery to the public.

To put a public safety spin on it; the question that remains is one of integration. How will the "text" generation communicate with others in an official situation. Let me define that as, for example, communications face to face between paramedic and physician or paramedic and triage nurse. Although we can become concerned with issues of miscommunication or loss of data with texting and the impact of patient care, I suggest that texting posses no more threat to communication between people than poor use of grammar or body language. In fact, texting a brief EMS patient care report or fire ground situation update may improve communication. Texts are usually short and focused and contain the only the needed words to get the point made. How will we integrate texting and other social media into emergency service remains to assured, it will continue to evolve.

Think about the use of texting the next time you're giving a verbal report on a noisy fire ground or at a crowded triage station. Texting may be a solution to the "THEY never told me that"...phenomenon that happens to so many EMS providers.

We'll be following this one for a while.


Violence and Duty

We've just learned of an EMT in Jefferson County, New York, who has been shot and killed in the line of duty. We're also getting early news reports about a City of Rochester police officer who has been seriously wounded on duty.

There is a trend of violence towards responders of all uniforms...and yet we don't seem to take it seriously. We've been reporting on what seems to be a continual stream of attacks throughout 2008 and now into 2009. Yet, I have not seen nor heard of any training sessions or in-services being taught on the topic of scene safety. Why is this not a priority? I know, it can't happen here. (Sarcasm intended)

The fire service is full of scene size-up memory aids, COAL WAS WEALTH, WALACE WAS HOT, and others; none of them addressing personal safety. EMS is notable for teaching new EMT candidates to recite "BSI, SCENE SAFE!" upon entering any testing situation. Again, no translation to the actual assessment of a situation and personal safety.

Once upon a time a uniform, any uniform, would grant you respect and a certain level of protection in the community. EMS providers were looked at somewhat differently and could often move in and out of situations with little concern.

Times are changing. If we don't change NOW and start teaching our people to look at every scene for threats and start to size-up the people rather than the building we will invite more assaults and fatalities.

I'm going to challenge every responder to change they way they look at situations and consider all people a threat until proven otherwise. I'm also challenging instructors to begin cross-training with law enforcement on the topic of recognition of dangerous situations and self protective measures.

My commentary on this weeks Mitigation Journal podcast will be about the futility of BSI/SCENE SAFE/COAL WAS WEALTH.

Here are a few related entries from the archives:
Ready or Not (not even EMS)

Firefighter shot at fire scene

Rochester EMT saves Cop

Line of Duty Planning Series with Dan McGuire


After the Fire

This is the fire building from the 4-alarm the other night.

After the fire

Duty to Act Policy

Duty to Act; do you have it? Should your service have a policy on the topic? This post on the USFA Blog got me thinking about several issues. How many of us would even think twice about stopping to render assistance to someone in need? Chances are that we all would...

What are your organizational policies, if any, on the topic. The liability and insurance coverage is another matter. Would you be covered...malpractice...injury...the list goes on.

The first part of duty to act should be to protect yourself at all times. Your first duty is to yourself and your family. We often consider the use of PPE for various activities...but how often do you consider protection from legal issues?

Great blog posting - check it out here:


Not Alone Against Free Antibiotics

Free Antibiotics Are Bad. We posted on MJ earlier this week about a local supermarket chain here in Rochester, NY, that was jumping on the free antibiotics bandwagon. At the time of the posting there were few voices of warning. There were even fewer who wanted to remind the public (and maybe the Big Box Stores) that antibiotics are not going to help against the flu...think difference between viral and bacterial infection...and antivirals versus antibiotics.

Here is another opinion from Medical News Today about how free antibiotics are not a good idea for public health.

Nice to know you're not alone.


Less Sleep, More Colds

A recent study has me thinking. One of my changes for 2009 (not resolution, mind you...just a change) is to add more sleep. That is more sleep each night and more each week. A number of studies have looked at the effects and the toll of lack of sleep. It seems that from cardiovascular to immunologic systems are among the two at most risk. See Sleep Habits and Susceptibility to the Common Cold as published in The Archives of Internal Medicine.

Here is a summary of findings...
  • The less a person slept, the more likely he or she was to develop a cold (there was a graded association between infection rate and average sleep duration).

  • Participants who slept fewer than 7 hours were 2.94 times more likely to develop a cold than those who had 8 hours or more sleep.

  • The more efficiently a person slept (more of the time in bed actually spent asleep), the less likely he or she was to develop a cold (i.e. there was also a graded association between sleep efficiency and rate of infection).

  • Participants whose sleep efficiency feel below 92 per cent were 5.50 times more likely to develop a cold than those whose efficiency was 98 per cent or more.

  • Feeling rested was not linked to rate of infection.

  • These relationships could not be explained by the potential counfounders such as levels of virus-specific antibodies beforehand, demographics, the season of the year, body mass index, socioeconomic status, health behaviours, and psychological variables.


Iron Safety a Hot Topic in Rochester

The University or Rochester and the Rochester Fire Department have teamed up to help prevent burn injuries. A recent article in the Rochester Democrat and Chronicle highlights the efforts between the two agencies to develop a safety campaign to prevent these burn injuries. They are working on two solutions; first an educational brochure to be given to new mothers at the U of R and, second, a physical device to hold the iron flat and protect the sides.

The need for this type of information and protective device are evident based on the stats given by the U of R:

"...Between 2003 and 2007, the Strong Memorial Hospital Regional Burn Center treated 212 children younger than 5 for contact burns. While wood-burning stoves were the most common source, hot clothing irons burned 29 patients."

"Toddlers suffer second- or third-degree burns when they touch a hot iron or knock it onto their hands or face. Some of those burns require skin grafts, a five-day hospital stay and a month of recovery."

Check it out here.


Thoughts on extreme cold weather

Random Thoughts on extreme cold weather...

"evaluate every trauma patient for hypothermia and every hypothermia patient for trauma"

"life safety, incident stabilization, property conservation"

"confine it to the Zip Code of origin and keep it off CNN"

Extreme low temps and brutal wind chill expected here in next 24 hours due to last through the weekend...high temps predicted to be between 2 and 5 above with sustained 25MPH winds. That means wind chills well below zero.

Even small events take more resources and protection of responders can be difficult.
Don't forget Emergency Scene Rehab for cold situations (as important as during hot weather) and often forgotten.

Pumps can freeze, lines freeze turn into iron pipes, and the fire scene can turn into an MCI of responders.

"if there is snow on the can't be too hot inside"

MVC's on highways can become impossible blizzards...think rapid extrication...minor injuries and illnesses will deteriorate quickly.


Retail Health Clinics and Recession

We've talked quite a bit about the potentials of Retail Health Care Clinics on this blog and on the Mitigation Journal podcast. A retail health clinic is a clinic operated and located within a retail store such as Wal-Mart. These walk-in style clinics can be found in other areas like airports as well. Often, these privately operated clinics run within a profit margin and cater to those without health insurance.

Walk-in and retail health clinics are attractive because they are time and cost-effective. There have been questions of quality raised by medical associations in the last year, but no official complaints or awareness of errors have been noted. The trend throughout 2008 has been for these clinics to open and remain stable. That is stable until the shopping season tanked.

This article from Reuters talks about the possibilities of failure and impact on the economy when "big-box" stores decline due to economy and/or recession.

And Here We Are...2009

I've been anticipating this second, this day, this year for quite some time. There is a number of reasons, personal and professional for my focus on this year. If you don't know what I'm talking about; you long as you continue to follow MJ podcast and blog.

Without any resolutions for the year; I've been deciding how to make a few changes in life and activity. How will I do business, how will I conduct myself, how will I simply do all that I do just a little different...all questions that I'll continue to review throughout the year.

I hope you'll similar steps in your life. That is, any steps you take in 2009, may they lead you to where you want to be!

Best wishes for a happy and safe 2009.