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Friday

Mitigation Journal Podcast #179

Click for Edition 179
Mitigation Journal edition #179 is now available. This week Matt and I discuss several topics for emergency services...our theme this week is situational awareness. In this issue we discuss the need for correct use of non-pharmacological interventions in the prevention of disease spread. It's amazing how many people still do not wash their hands after using the toilet!  In an even more disturbing situation, firefighters respond to a dumpster fire and are ambushed; showered with fireworks by an angry crowd.

We also discuss the latest in medication delivery; micro needles and how they may change the way we give flu vaccine...IF we get flu vaccine. And finally, Matt talks about staging for potential dangerous situations; when we do it, how close we do it...and who makes the decision...and in this case, what can happen when its not done appropriately.  You can see video excerpts from this episode on the Mitigation Journal blog on the VIDEO tab or on YouTube

Unknown Chemical used in Attack in Rochester

Unknown Chemical used in Attack in Rochester...few details available.

All the media outlets in Rochester, NY are running a story about an assault involving an unknown chemical. One group, armed with baseball bats, confronted another group and then threw some type oc chemical on them. The injuries are reported as minor and the victims include at least one woman and an infant.

This type of attack is becoming more common. There have been several instances of chemical splash attacks and use of homemade chemical bombs in public assaults. 

See Homemade Chemical Bombs in Mitigation Journal August 15, 2006

Points to consider:
It CAN happen here
Decontamination MUST take place prior to transport
EMS must be aware of the potential chemicals and resultant injuries

We'll have more details as they become available.

Rx Abuse. Ready or Not?

Rx Abuse. Ready or Not? That's what we in emergency medical services should be asking ourselves.

Rx Abuse: Accident or Intentional
According to this story from Reuters found at MSNBC.com, prescription medication abuse is rising faster than methamphetamine and marijuana abuse. According to the Substance Abuse and Mental Health Services Administration, treatment and those seeking treatment for addiction to prescription medication has increased 400 percent. This rate was more than meth abuse, which has doubled, and marijuana abuse, which has gone up by nearly one-half.

They go on to claim that nearly ten percent of hospital admissions in 2008 were for prescription drug abuse; this is up from 2.2% in 1998. Pain killers were overwhelmingly the medication of choice; with hydrocodone, oxycodone and morphine are the medications of choice. Interestingly, the abuse included all levels of education, employment, race, and geography.

EVERY responder needs a guide!
A take-home note for EMS responders is that a majority of the people abusing these medications are in the 18-24 year age group. The rationale seems to be an [incorrect] belief that the prescription medications are "safer" than the street drugs. This translates into the need for responders to search out and document all medications found on a scene...not just those actually prescribed to the patient. Yes, I'm profiling and suggesting that the potential for abuse is there with all patients...keep in mind, it could be accidental, but the potential for prescription medication use/abuse; accidental or intentional, exists in all cases. Bottom line - include all medications on the scene in your medication history - make doing so a habit (no pun intended).

A good medication history may make the difference in your working field diagnosis. I also recommend that each responder have access to some kind of field references to identify prescription medications. My choice is the EMS Field Guides from Informed Publishing. A hard-copy pocket guide or the app for iPod/iPhone of the BLS or ALS version is the way to go (I have both on my iPod). Either way, every responder should have one...keeping a copy will help you identify medications by name and provide the insight that might just save a life. Read my review of the BLS/ILS iPod app

Thursday

Mitigation Journal Podcast #178

Click on my cool logo for download
Mitigation Journal Podcast #178 is a special request edition. Matt and I are planning to record the regular weekly segment shortly, but due to the number of emails...all requesting similar information...I decided to post a bonus edition. Don't worry, the weekly MJ podcast edition will not be interrupted.

So, on this special in-service training edition (MJ#178) you'll hear my talk on Clinical Decision Making in Critical Situations...previously delivered under the title of "When is dead, dead?" this program covers many aspects of interpersonal and scene management from the decision making model. If you're into managing difficult situations (and who isn't) this is the lecture for you. Best of all its recorded LIVE during one of my training sessions. So, hang on for enthusiastic EMS evangelizing!

One note of warning; this lecture was given for a group of firefighters and the analogies reflect fire service operation and themes. Other than that its 100% pure easy-to-understand for any level provider!

I'd love to hear your comments and constructive criticisms; email me at mitigationjournal@gmail.com or call me on the voice mail line 585-672-7844

Wednesday

Closing Schools During H1N1

Closing Schools During H1N. Will closing schools be an effective means of preventing the spread of a naturally occurring biological event?

A recent survey conduced by the Centers for Disease Control and Prevention looked at  214 households after a 1-week elementary school closure because of pandemic (H1N1) 2009. They found that students spent 77% of the closure days at home and 69% of students visited at least 1 other location, and 79% of households reported that adults missed no days of work to watch children.

In May 2009, an elementary school (kindergarten-4th grade) in a semi rural area of Pennsylvania closed for 1 week after an abrupt increase in absenteeism due to influenza-like illness (ILI) and the confirmation of influenza A pandemic (H1N1) 2009 virus infection in 1 student while other schools in the district remained open.

For each day of school closure, respondents were asked for the following information: where the student spent most of the day; whether the student went elsewhere, who watched the student; and whether the person watching the student missed work. Questions were asked regarding the oldest student if multiple children attended the school. Households that reported missed work incurred costs, even if those costs were only in terms of lost vacation or sick time.oldest students spent the days of school closure at home. However, most students left the home at least once during the closure period to visit routine venues (stores, locations of sports events or practices, restaurants).

This study bring up some interesting questions. Will school closings have any role in preventing the spread of a naturally occurring biological event if the schools are the only venue closed?I think the answer is no. For social distancing to work, all venues in a given are need to be severely restricted or closed...leaving some schools open while others are closed will lead to disease spread as many households have more than one student going to more than one school.

Also, keeping other venues open; malls, movies and others will encourage people to move outside their home location and may erode the sense of severity in the situation.


Kentucky Study MMWR http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5850a2.htm

Monday

Mitigation Journal Podcast #177

This week on Mitigation Journal Podcast - I'm solo from the Basement Bunker! Co-Host Matt had to work  and will be back next week.


Click here to listen to edition #177 of Mitigation Journal Podcast
MJ Podcast Line-Up for Edition #177
Special thanks to long time listener Russ for making a donation and supporting Mitigation Journal and to Kyle David Bates for working on the new MJ Logo.

In this edition we'll discuss the NFPA 2009 Firefighter Fatality Report, how school closings in the setting of H1N1 impacts home and work life, and a snapshot of immediate actions to take at school bus accidents.

Friday

Picture This!

Picture This! And do it now.

MJ logo by Kyle David Bates
Emergency service educators from all walks can struggle to make a point stick in the classroom. We've come to acknowledge the use of illustration as a means to "demonstrate" in class. As computer and digital technology has improved, especially for us Mac users (sorry, can't help it)so has the quality of our message to students when we use pictures and graphics that are realistic and meaningful.

I've recently become aware of the talents of a friend and colleague...I should say more aware, rather. I'm talking about Kyle David Bates. I've taught classes with Kyle and you've heard him on several podcasts including Mitigation Journal, EMS Garage, and most recently on First Few Moments. Kyle recently re-worked the Mitigation Journal logo and when I was adding the banner to his site (in the sidebar of this blog) took a few minutes to view his site...and you should, too. 


Here's what you do; go to http://www.kyledavidbates.com/Gallery/Gallery.html and take a look at the Clinical photos. They're so realistic...you'll have to resist calling 9-1-1! Jazz up your instruction and message to your students...check out www.kyledavidbates.com. You can also follow Kyle on Twitter @imagemedic.

Thursday

Immediate Operations at Bus Crashes

Immediate Actions at Bus Crashes ...there are quite a few to think about. Establishing command and control of the scene is paramount. Today I'll  focus on some points for the responders working on operations and we'll save the C&C for another post.

So, from an operations perspective, especially for those arriving early in the situation. A few "quick tips" if you will:

Size up - don't get tunnel vision and focus only on the bus. There most likely is another vehicle involved. For more on this, see Mitigation Journal post First in? Think first! and tune into the First Few Moments podcast at firstfewmoments.com

The fatality/injury ratio is proportional to the size of the vehicle that hit the bus (or that the bus hit). Keep this in mind when you arrive.

Think about where kids like to sit. Prepare for entrapment or multiple casualties in the back of the bus.

Expect exits will be unusable. They'll be blocked by bodies or debris. Side exits are not usable if the bus is on its side. If you can use existing exits, I recommend doing so. If not, make the exits bigger and use them. As a last resort; make your own openings.

Monday

First in? Think First!

We just finished recording the First Few Moments podcast #3 the other night. The topic was So, you're first in...Now what? We had an All-Star cast including Wilma Vinton, Chris Montera, and Kyle David Bates.The discussion was lively...with viewpoints that as vast as the difference between Rochester, NY and Fairbanks, AK. If you haven't checked out First Few Moments, now is the time.

I was asked to chime in and, of course, had my own take on things.

"So, you're first in...Now what?"
  1. First of all, know where you're going before you're first in. Pre-plan (FD is real good with this, EMS not so much) - do you have areas of your district that are notorious for bad thing happening? A place where the bad wreck always occurs...a high hazard area, lots of commercial traffic, hazardous materials, or a roadway location that could impact a target hazard building or site? Tunnels and bridges fall into this category as well, as do locations with poor visibility. Areas that change hazards with the changes in the environment should also be considered. Knowing where your going also means knowing how to get there and get out...alternate routes for both! Table talks on these locations make for great "quick drills" for new members and the seasoned veterans. 
  2. Do something smart with your apparatus. Placement of first in apparatus can make or break the entire event. You can promote scene safety or put responders at risk. Know what other services are responding with you...fire department, EMS, law enforcement...and have an understanding of their operational priorities. No, you don't need to know everyone's standard operation procedures, just an awareness will do. Doing so may help prevent conflict and keep you from getting blocked in...or out. Also, when it comes to EMS appatus placement, begin with the end in mind. That is, think about how you're going to get out before you get in. 
  3. And finally; don't just do something, stand there. Take the time to do a good size-up of the situation and report your findings back to the communication center and other responding units. Resist the urge to rush in - prevent tunnel vision - just take the few seconds needed to gain preliminary situational awareness. To be a little more detailed; use the Two x 360 method...a 360 big circle of the event on the ground and a big 360 that looks above and below the incident. Remember, size up is dynamic...and you have to report changes or your findings mean nothing.
A few thoughts on the vehicles involved in a crash: You should always note the type of vehicle and fuel source. Fuel/power sources are always important but even more so when we consider alternate fuels such as hydrogen and hybrid/multiple power sources. Consider also the potential for ancillary hazards...guns, bombs,  and other hazards. Keep in mind that terrorists don't build the bomb at the place they're going to blow up...they make it someplace else and bring it to the target. So it is possible you'll find yourself with an MVC toting an IED!

Tuesday

Technological Disasters, They're Going to Get Worse

I've learned that disaster situations can be boiled down to just a few basics:
  1. Known threats that will have more to impact and strike an increasingly unhealthy population
  2. Technological failures that will cause enough problems on their own and will have a far reaching impact as our infrastructure becomes more technological dependent 
  3. New and exciting ways of deploying known threats
  4. Emerging threats that have not been discovered yet.
We'll stick with technological failures for this post. As a side note; some consider technological failures synonymous with man-made disasters while others differentiate the two.  I'm happily non-committed on this point but tend to blend them together, depending on the situation.

Okay, on to technological failures and why I think they're going to get worse. Despite the terrible ecological impact the BP oil rig disaster is creating, when discussed in terms of human lives and impact, it will be fairly limited (with respect to all those whose livelihood depends on the environment and tourism).

A few areas of concern:
Evacuation...or lack of. The lack of access to mass evacuation transportation, limited warning, and spotty notification or call to action set the stage for a major metropolitan area and its population to remain at risk. And while we're on the topic of populations; it is important to state that our population in general is getting older and living with more medical problems.

Reliance on technology...good news, bad news. One technological addiction we have is electricity. Although numerous sources have highlighted the fragile state of our power grid, little has been done to harden this frail piece of critical infrastructure.

The "techno-failure chain reaction" scenario. Not only will technological failures lead to possible disaster situations, the chain reaction within our techno-dependent societies will turn a little crisis into a disaster. Consider the toxicity of today's building materials and the inability to evacuate large numbers of people from high rise structures or sprawling living centers.

Lets end with a quote from E.L. Quarantelli of the Disaster Research Center, on the topic of technology;
"...if the technology was created by human being and developed by social groups, it was inevitable that there would be accidents and disasters."

Monday

NORAD v. Cessna

Dear NORAD,

This is a CESSNA: 

This is a RUSSIAN STRATEGIC NUCLEAR BOMBER:

I was reading last week about how many "incursions" Russian naval and aviation forces have made near or into the United States over the last several months. Russian nuclear subs in international waters off both coasts, and bombers flying through U.S./Canadian airspace. Real Cold War stuff. Now, when I think of Cold War "incursions" by the Russians, I hear horns and klaxons and imagine fighter pilots racing across the tarmac, jets scrambling...the kind of thing you'd see when Godzilla was sighted...and backyard bomb shelters; you get the idea.

But, not so in today's world. The North American Aerospace Defense Command, NORAD, commander Adm. James A. Winnefeld Jr. is quoted in a recent Washington Times article:
"...beginning a couple of years ago, Russian strategic aviation forces began stepping up training flights of nuclear-capable Tu-95 Bear bombers near or through U.S. and Canadian airspace..."
And that means...?
"They are trying to show the world that they are a powerful nation, and we're not giving them the satisfaction … ."
So, do we do anything about it? Like in Top Gun; have a US fighter pilot flip 'em off or something?
"If we intercept every single flight that comes out in our direction, then we're really just feeding into their propaganda," 
No, really. What do we do?
"So we intercept them when we feel like we ought to, and we have various criteria that we use for that, to include just rehearsing our own skills to be able to do that."
Oh, OK. Is there anything else NORAD can do?
"we just leave them alone,"...[the Obama administration has] "done a good job of trying to hit the reset button with these guys, and sooner or later they've got to respond." Above quoted taken from the Washington Times on-line article.
Sooner or later they've got to respond!? Respond with what!? Anyone else see the problem here? Can you immagine where we'd be if we took this stance during the Cuban Missile Crisis?

But this situation is not all that has me wound up. Another story posted by CNN tells us the NORAD actually scrambled two fighters because a CESSNA violated "Obama airspace" over Las Vagas, Nevada. Okay, I can see the point of that. We've seen what kind of damage a civilian single-engine Cessna can do to a building...remember the kook who flew his plane into the IRS building in Austin, TX back in February, 2010 in an act of Domestic Terrorism? Oh, wait..it wasn't terrorism. Just a criminal act. (so that means we scramble fighter jets for the "criminal act" of violating Obama airspace...?)

Dear NORAD,
The point of all this is:
This is what a CESSNA can do to a building:

And, this is what a RUSSIAN STRATEGIC BOMBER can do to the Nation:

Next week: Building your own bomb shelter.

Saturday

EMS Points to Remember

Just a couple of points to remember...for anyone who delivers emergency medical service:
  1. If the person is unconscious, lay them down and open the airway. Its called putting them supine and its the beginning, not the end of care. But don't hold them up because it looks more natural...they're unconscious for a reason and probably don't care how they look.
  2. If the person is having trouble breathing, don't let them lay down. Especially if they are tired. Sit them up. This is called Fowler's position and you have some choices; low- semi- or high-Fowler's. It will make it easier for them to breath and easier to assess. 
And think about it, it only took 25 years for me to figure this out. 

Friday

The First Rule of Preparedness

Re-wright the textbooks. Change all the PowerPoint slides. Alert the TSA and wake-up someone at DHS...I am changing the First Rule of Preparedness!

The First Rule of Preparedness is: Make sure you love your God, your country and your family more than being popular...



Add this new First Rule of Preparedness to the growing list of Mitigation Journalisms...
  • Rule of Outcomes
  • Optimism Bias
  • Know Your Job, Do It Well
More on this to follow.

Wednesday

Heat Ready


We're all ready for the warm weather. But what about severe heat? The effects of a prolonged heat wave can be devastating to all of us. Emergency responders can find that simple "bread and butter" events can turn into extended incidents quickly...with the need for added personnel and effective rehab.

One of the best things we can do for the public we service is to keep ourselves ready to respond. That means we:
  • Stay fit and healthy all the time, as best as possible. Remember, how you live off duty will effect your abilities on duty. 
  • Hydrate, and then hydrate some more. People ask me about the type of fluid to drink all the time. The best answer is...Water, the drink of champions! That's it...water, just water.
  • Eat. Fruits and veggies...put them in the freezer or keep them cold.
  • Review your rehabilitation program and equipment. Be familiar with your stuff before you have to use it...in hot weather I recommend early set-up of a rehab unit. Be proactive. 
These are also good times to test your special needs contact information. Give those you've identified in your special needs planning a call or visit. Simple phone calls and visits can identify problems early and provide a tremendous boost to your public support.

The public will also turn to emergency service for tips on staying well in the heat. According to the American Red Cross, civilians should:
  • Listen to a NOAA Weather Radio for critical updates from the National Weather Service (NWS).
  • Never leave children or pets alone in enclosed vehicles.
  • Stay hydrated by drinking plenty of fluids even if you do not feel thirsty. Avoid drinks with caffeine or alcohol.
  • Eat small meals and eat more often.
  • Wear loose-fitting, lightweight, light-colored clothing. Avoid dark colors because they absorb the sun’s rays.
  • Slow down, stay indoors and avoid strenuous exercise during the hottest part of the day.
  • Postpone outdoor games and activities.

Tuesday

Heat Wave

We're having a heat wave in the North East...even here in Rochester, NY. No, really, it can get hot here...sometimes it can snow here in July or at least be fifty degrees and rainy. We here in Rochester, NY complain when we get cool weather in the summer. Apparently we complain when it gets too hot as well. 

The weather man tells us that there is an Air Quality Alert and we're under attack by ozone. So, its not the heat, its not the humidity, its the ozone!

Below you'll find some of the research on ozone and your health...But lets make another point...air quality and ozone may also impact the responder. I think we'll include that in our PRE Habilitation plan and talk more about it in future posts and podcast episodes.

What does this all mean - well, here it is:

Air Quality Alert -  as defined by News 10 in Ohio Issued during times (usually on hot, summer days) when ground-level ozone and/or fine particle concentrations unexpectedly reach, or are approaching, unhealthy levels in your area based on monitored values. Sensitive groups are urged to limit their exposure outdoors.

The following is from a great website; AIR INFO NOW Consider the following selections from Air Info Now and check there for more details.
The properties that make ozone a powerful cleaner, disinfectant, and bleaching agent also make ozone dangerous to living tissues.
When it comes in contact with living tissues, like our lungs, ozone attacks and damages cells lining the airways, this causes swelling and inflammation.
Some have compared ozone's effect to a sunburn ... inside your lungs.
Other health effects include:
·         Irritation of the airway: a cough, an irritated throat, or an uncomfortable feeling in your chest.
·         Reduced lung function: you may not be able to breath as deeply or vigorously as you normally would.
·         Worsened Asthma: ozone can aggravate the effects of asthma (see Asthma below).
·         Potential health effects: ozone may aggravate the effects of emphysema and bronchitis, and may reduce the body's ability to fight infections in the respiratory system.


High ozone levels can affect anyone.
Some groups of people are particularly sensitive to ozone.
Sensitive Groups
·         Children
They spend more time outdoors, are more active, and their airways are not fully developed.
·         Adults exercising outdoors
Healthy persons engaged in physical activity breathe faster and more deeply. This increases the amount of ozone flowing into the lungs.
·         People with respiratory disease
Ozone can further irritate the airways of persons who already have diseases of the lung or airways.
 
Summertime can be ozone time.
First, there may be more ozone around. During the summer months high temperatures and bright sunshine lead to increased ozone formation. Second, people may spend more time outside engaged in physical activities.
Asthma and ozone.
Ozone can irritate the already sensitive airway of someone with asthma. When ozone levels are high, more asthmatics have asthma attacks that require a doctor's attention or the use of additional medication. One reason this happens is that ozone makes people more sensitive to allergens, which are the most common triggers for asthma attacks. (Allergens come from dust mites, cockroaches, pets, fungus, and pollen.) Also, asthmatics are more severely affected by the reduced lung function and irritation to the respiratory system caused by ozone. 


Referenced sites:
http://forecast.weather.gov/wwamap/wwatxtget.php?cwa=usa&wwa=Air%20Quality%20Alert
lhttp://www.10tv.com/live/content/weather/stories/story_weather_meanings.html
http://www.airinfonow.com/html/ed_ozone.html