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MJ Podcast #198: Ultrasound in Pre Hospital Care

We have a special guest joining Matt and I on the podcast this week talking about the potentials for ultrasound in pre-hospital care. In this edition, we're joined by Peter Bonadonna, CI/C, EMTP and  director of the Monroe Community College Paramedic Program.

Is there a role for ultrasound in EMS? You decide as we discuss everything from the how-to's and educational expanse needed. We also go over the technology and the situations it might be useful in. Peter gives us a review from A to Z on the uses of ultrasound and talks us though a series of ultrasound images delivered over the internet.

You can view a sampling of the live ultrasound images and hear Peters narration on our latest video "EMS Ultrasound" posted on our Video page. We'll also host the story and video on our newest emergency service blog; ProResponder.

Donate Today! You can help support mitigation journal by making a donation of $1.00.  Click the "donate" button on the right sidebar. Mitigation Journal is a listener supported independent podcast and blog… and any little bit will help.

 Get Mitigation Journal on your e-mail… subscribe to our free e-mail edition of the blog by typing your e-mail address in the e-mail subscription box.

 Subscribe to the podcast...FREE! Visit us on iTunes and subscribe to get all the podcast information delivered to you each week.

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Trauma Assessment Tips

Five assessment tips to better trauma assessments

Tip #1: It’s okay to be distracted by traumatic injuries. It’s not okay to be fooled by them.
Traumatic injuries to the face, to the head, or open injuries to the chest, abdomen and to the extremities can certainly be distracting to your assessment. Being distracted by The devastating injury or injury pattern is a natural, human response. The paramedic cannot be fooled, no matter how devastating these injuries may appear, that they are the only injuries or the most serious injuries the patient has. The point is that no matter what is ripped open, sticking out of, or impaled into the patient, the paramedic must fully assess the patient, mechanism of injury, and the surroundings. Bottom Line - You can be distracted...just don’t be fooled: as long as momentary distraction does not lead to being fooled by a nasty looking, less serious injury

Tip #2: What lies beneath? Anatomy!
Understanding of anatomy in relation to injuries, injury patterns and mechanism of injury. It’s not enough to simply observe and injury from the surface. The paramedic must understand the implication of that injury on the tissues, structures and, organs that lay beneath. What appears to be a superficial soft tissue injury on the outside can have substantial structural/organ injury underneath. Only by possessing a solid foundational understanding of anatomy will the paramedic be able to relate exterior body damage to where the true injury is… that is to the structure, organ, or system that’s impacted by the trauma. Bottom Line: Think about what lies beneath...Anatomy lies beneath and your understanding of anatomy will lead to better treatment.

Tip #3: Assess all critical areas...even if they're not injured.
No matter what the injury, injury pattern or MOI is, always assess the head, neck, chest, abdomen, pelvis, and long bones. These areas often go unchecked when we focus on a single area of the body or isolated injury. The point here is, that no matter where the injury is all of these areas have to be assessed… even if they appear on injured. Note on the neck...we spend a lot of time worrying about c-spine injuries and trauma to the posterior neck...thats good thing. But, we cant ignore the injuries to the lateral and anterior neck...vessels and airway. Bottom Line: Always assess the critical areas...head, neck, chest, abdomen, pelvis, and long bones...even if they’re seemingly uninjured.

Tip #4: Change you'll get a better look!
We too often assess trauma patients while they’re supine starring straight down on them. After all, that's how you were doing it in practice in EMT class...To be effective, change your point of view. Get down on the patients level and examine from the side, survey the patient from a short distance, observe a few breaths while kneeling at the patients feet or head. Bottom Line: Change your view...move around and look at the patient from various views and from a distance...get as much of the picture as you can before you're the only one who is going to be able to do this!

Tip #5: Assess any trauma patient for hypothermia and any hypothermic patient for trauma. Think: Trauma=hypothermia, hypothermia=trauma. Trauma patients may loose the ability to thermoregulate and have a difficult time keeping warm...especially if there is uncontrolled internal or external hemorrhage. Hypothermic patients may not be able to feel the pain of an injury or have the mental ability to comprehend the injury and report it. Bottom Line: Trauma and hypothermia...they go hand in hand. Any trauma patient should be assessed for hypothermia and any hypothermia patient should be assessed for trauma.

EMS uses of Ultrasound

EMS uses of introduction. This is a quick video created with the help of my friend Peter Bonadonna. Pete is the Paramedic Program Director at Monroe Community College and leader in EMS education. In this clip, we look at uses, training, and other issues surrounding the use of Ultrasound in the pre hospital environment. We recorded the ultrasound images live (Peter was scanning himself) via internet.  This video will also appear on our "Videos" page (see top row of tabs) and on ProResponder.  Join me, Matt and Peter as we discuss EMS and Ultrasound on Mitigation Journal podcast edition #198...available 11/29/ the Podcast Player in the right sidebar to listen.


In Our Boots

This PSA comes from
It's worth a minute to watch...trouble is, were not the ones that need to see it...

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Donate Today! You can help support mitigation journal by making a donation of $1.00.  Click the "donate" button on the right sidebar. Mitigation Journal is a listener supported independent podcast and blog… and any little bit will help.

 Get Mitigation Journal on your e-mail… subscribe to our free e-mail edition of the blog by typing your e-mail address in the e-mail subscription box.

 Subscribe to the podcast...FREE! Visit us on iTunes and subscribe to get all the podcast information delivered to you each week.

Get the MJ app and support the blog and podcast! Visit the app store at iTunes  and for $1.99 purchase the MJ app...its the best way to get the podcast.


Cooking Safety

Cooking Safety...Don't let fire or injury put your holiday to a bad end.

We could all use a good reminder about fire safety in the kitchen. Especially us responders. The United States Fire Administration has a few good tips for use to keep in home and away.

According to the U.S. Fire Administration:

Watch What You Heat

  • The leading cause of fires in the kitchen is unattended cooking.
  • Stay in the kitchen when you are frying, grilling, or broiling food. If you leave the kitchen for even a short period of time, turn off the stove.
  • If you are simmering, baking, roasting, or boiling food, check it regularly, remain in the home while food is cooking, and use a timer to remind you that you're cooking.
  • Stay alert! To prevent cooking fires, you have to be alert. You won't be if you are sleepy, have been drinking alcohol, or have taken medicine that makes you drowsy.
  • Plug microwave ovens and other cooking appliances directly into an outlet. Never use an extension cord for a cooking appliance, as it can overload the circuit and cause a fire.

Keep Things That Can Catch Fire and Heat Sources Apart
  • Keep anything that can catch fire - potholders, oven mitts, wooden utensils, paper or plastic bags, food packaging, towels, or curtains - away from your stovetop.
  • Keep the stovetop, burners, and oven clean.
  • Keep pets off cooking surfaces and nearby countertops to prevent them from knocking things onto the burner.
  • Wear short, close-fitting or tightly rolled sleeves when cooking. Loose clothing can dangle onto stove burners and catch fire if it comes into contact with a gas flame or electric burner.


Action Items for Disease Prevention

Thinking about your PPE actions ahead of time will pay off

Mandated or not, personal protection equipment (PPE) can protect us from a variety of hazards; in EMS the standard body substance isolation PPE can protect us from everything from anthrax to hepatitis. Often times the value of body substance isolation or personal protective equipment is under realized… as is the value of a good infection control program.  Most responders think of personal protective equipment as masks, gloves, eye wear, and gowns. But our personal protection is more than  a “thing” we put on… our best personal protection is our action. Far too often responders don't think about their personal protective equipment until they have to use it so we decided to include a few tips in today's post.

Action number one: get vaccinated.
No matter which side of the mandated vaccine debate you happen to be on, vaccine is a top preventative measure. Vaccines are proven to be safe and effective. Not only do they provide the individual with protection from specific diseases, vaccination also provides herd immunity to a given population. That is,  a community that is vaccinated and protected against disease also protects those who have not developed immunity. Herd immunity is vital to those with compromised immune systems and even to some healthy groups such as schoolchildren.

Action number two: it's not all about vaccine
Okay, this was really not an action is a mindset… so pay attention anyway. Pharmacological measures such as vaccine are fantastic at preventing disease. However, the downfall is that they are not always readily available. As we saw with the swine flu situation 2009, vaccine production is time-consuming and with most vaccine production occurring overseas, delivery of vaccine is susceptible to breaks in the logistical chain. Additionally, deployment of pharmacological measures (oral medications as well as vaccine) can be challenging. Because of the shortcomings, it's important for everyone to understand the role of non-pharmaceutical interventions in disease spread control. The non- pharmaceutical interventions include; hand washing, respiratory etiquette, appropriate social isolation.

Action number three: hand hygiene.
Above all medications and science; hand hygiene (the simple act of washing your hands) is rated as the number one means for preventing the spread of disease. The use of warm water and soap for washing hands for between 15 and 30 seconds is a major component in effectively stopping disease spread in any population.

Action number four: respiratory etiquette.
Respiratory etiquette means covering your cough and your sneeze and any other secretions you discharge from your mouth or nose. Covering your cough and sneeze is a mainstay of respiratory etiquette and helps prevent droplet transmission of disease. Droplet transmission is a major mode of transmission for Type A influenza. And don't be afraid to wear a mask. That is, don't be afraid to put a mask on yourself or on the patient if they have a cough or sneeze. Placing a mask on the patient goes a long way to containing the source of the droplets and respiratory secretions at the source… placing a mask on you significantly decreases your intake potential of those droplets and respiratory secretions. And yes, you can place a standard surgical mask over an oxygen delivery device such as a nasal cannula or non-rebreather mask. And no, it does not have to be an N. 95 mask. The centers for disease control and prevention noted that standard surgical masks were sufficient to prevent droplet transmission in the setting of many respiratory illnesses including Type A influenza.

Action number five: appropriate social distancing.
Simply stated, appropriate social distancing means staying home when you're sick. That's not just staying home from work; this also includes staying out of public areas when you're ill. It does us no good to have someone stay home from work and/or school only to go to the local shopping mall or otherwise be out in public. I realize this is not a popular topic with many employers (emergency service or civilian employers) but the fact remains that people who are ill with gastrointestinal problems or respiratory illness should not be in a position to spread that disease whenever possible.

And finally, action number six: clean your work environment. Simply wiping down flat surfaces in your work environment will go a long way to preventing your exposure to disease and the spread of many illnesses. Cleaning your work environment means wiping down flat surfaces and other areas of your response vehicle. Many commercially available cleaning materials will do the trick… you don't have to get too fancy. Wiping down the dashboard, the steering wheel, and the microphone will go a long way to preventing illness amongst your crew and your patient. Don't forget your office environment either. A quick wipe on telephones and computer keyboards as well as other surfaces will prevent disease spread as well.


MJ Podcast 197: EMS staffing reduced, FF raises given and Casual talk on MCI/Triage

Note: We've got some phantom sound problems this if it sounds like we're talking in a coffee can, you'll know why. 

This week we're joined on Mitigation Journal by Matt Comer and Tom Sullivan and we pick up from where we left off last week. Our first topic is on a situation of EMS staff reductions...yet, included wage increases for the same department.

In the second half, we talk about mass casualty events and triage. We're unscripted (as we are for most of the podcasts) so, sit back and enjoy.

Also this week,  a new video released Sunday on the topic of natural disasters. I originally recorded this in response to the situation in Haiti back in April, 2010. You can find it on the main page at and under the "videos" tab.

Donate Today! You can help support mitigation journal by making a donation of $1.00.  Click the "donate" button on the right sidebar. Mitigation Journal is a listener supported independent podcast and blog… and any little bit will help.

 Get Mitigation Journal on your e-mail… subscribe to our free e-mail edition of the blog by typing your e-mail address in the e-mail subscription box.

 Subscribe to the podcast...FREE! Visit us on iTunes and subscribe to get all the podcast information delivered to you each week.

Get the MJ app and support the blog and podcast! Visit the app store at iTunes  and for $1.99 purchase the MJ app...its the best way to get the podcast.


Video: It Can Happen Here

This topic has come up well prepared we are...or, are not. This video will be available under the "videos" tab at


Carbon Monoxide Background

 Carbon monoxide exposure is one of the most common poisonings in the United States.  Although we often think of CO is a “winter time” problem, carbon monoxide exposure and poisonings can take place at any time of the year. Carbon monoxide exposure incidents tend to increase during the winter months we can also see an increase in these events at any time when a population uses auxiliary heating or power generating equipment; such as seen during major power failures or other natural events.

Carbon monoxide is known as the “Great Imitator” and can mimic a variety of other medical problems such as cold and flu. In fact a study done in 2006 indicated that one in four patients presenting to a hospital with cold and flu symptoms actually had carbon monoxide exposure. Carbon monoxide has also been linked to cardiac events after chronic exposure. Failure to recognize the potential of carbon monoxide exposure can lead to a deadly missed diagnosis. In some cases, carbon monoxide exposure and poisoning has been mistaken for substance abuse.

Common signs and symptoms of carbon monoxide exposure include headache, drowsiness, confusion, tachycardia. Continued exposure to carbon monoxide also lead to impaired thinking and sensory perception.  These effects of carbon monoxide reduce the ability of a person to recognize a hazard or self rescue from an environment.

Symptoms of carbon monoxide differ from person to person and level of exposure. Mild exposures (15 to 20% COHb) symptoms may include headache, nausea, vomiting, dizziness, and blurred vision. Moderate exposure is defined as 21 to 40% COHb and may present as confusion, syncope, chest pain, dyspnea, and general weakness. The severe exposure (41 to 59% COHb) may result in myocardial ischemia, rhythm disturbances seizures, and respiratory as well as cardiac arrest. Exposures to levels of carbon monoxide greater than 60% are usually considered fatal. It's important to note that CO exposure and COHb  levels do not have the same symptoms with all patients.

 Carbon monoxide alarm technology is reliable and found in many residential and commercial structures. In general, there are two types of carbon monoxide detection equipment. The first type is known is a biomimetic style detector. This type of detector uses a synthetic hemoglobin that reacts to acute and chronic carbon monoxide. Biomimetic style detectors are very common and usually resemble smoke alarms or are manufactured in combination with a smoke alarm.  These units typically have a module sensor built-in the battery compartment. Some of the most common manufacturers estimate a module life of two years and a total unit life of 10 years. This type of carbon monoxide detector can be influenced greatly by exposure to cooking products.
Another style of carbon monoxide alarm is the semiconductor style. this style of alarm uses an electronic sensor to measure carbon monoxide  and is typically plugged into a power outlet or other power supply. The general recommendation is that the unit be replaced every 5 to 10 years. Most carbon monoxide alarms activate at an estimated 10% of carboxylhemoglobin or 100 ppm of carbon monoxide.


3 things to know about seasonal flu

In this post will explore several areas of seasonal influenza. We'll take a look at what influenza is and is not, what causes it, and the various types. We'll also discuss the normal impact of influenza and the potential extraordinary impact of influenza.

1. Terminology.
The first thing in the need to know about influenza is the terminology… and we've come to recognize quite a bit of terminology surrounding the flu. Seasonal flu (sometimes called the common flu) is exactly what it sounds like; that strain of flu that circulates a given area every year. Avian flu (highly pathologic avian influenza) is the name given to a strain of flu that mainly circulates in Asia impacting various bird species with limited transmission to humans. Swine flu on the other hand, is the name given to a strain of influenza that emerged from South America–Mexico–in late 2008. This strain of influenza was particularly troublesome because it seemed to impact otherwise healthy people in a very dramatic way. And lastly, the term pandemic. A pandemic has been seen by the media as a term that indicates large numbers of deaths from disease. Although throughout history this is often the case, a pandemic is not an automatic term for mass fatalities. The term pandemic simply means the disease has spread around the globe and impacted many areas of population.

2. Types of Influenza.
There are several types of influenza viruses… so more concerned about, others, not so much. Influenza virus belongs to the category of diseases known as Orthomyxoviruses.   The three types of flu are Type  A, Type B,  and Type C. Type A influenza is known as a multi-host pathogen infecting both humans, swine, and birds. This is the most virulent  group and is classified by its surface antigens into subtypes. It is these subtypes that make up the H and N that we hear so much about on the news. H stands for hemagglutinin and N indicates neurominidase.  Both of these are surface proteins on the virus that allow the virus to get into a host cell, reproduce, and then escape. Remember, viruses are parasites and need to have a host to survive. There are 15 different types of H's and nine types of N's giving us a total of 135 potential combinations of type A influenza. Type B influenza is seen mostly in humans and although it's very common it is much less severe than Type A influenza. Epidemics involving type B influenza occur much less often than those involving Type A. It's important to note here that human seasonal flu vaccine includes two strains of Type a and one strain of Type B protection. Given that there are 135 potential type a influenza combinations and only two are included in the seasonal flu vaccine, indicates why we have years when the seasonal flu vaccine is less effective than others… that is, scientists have to guess which two strains of influenza should be included in the vaccine. Type C influenza infects humans and swine and has a completely different pattern of surface proteins. Normally Type C presents with rare occurrences and has mild or no symptoms. In fact, by age 15 most people have antibodies against Type C influenza.

3. Impact.
During an average flu season in the United States there are 35,000 to 45,000 deaths attributed to seasonal flu. The hardest hit by seasonal flu include those with severe medical conditions,  impaired immune systems, or extremes of age… young or old. Epidemics tend to occur in the winter months with peaks of hospitalization and death related influenza during this time.

Further Consideration.
Prevention of transmission of flu sometimes takes on a life of its own. We need to remember that the flu virus is one of the most infectious pathogens we know of and that type a influenza is prone to subtle changes in its structure that make it a challenge to our immune systems year after year. It's also important to remember that droplets aerosols and direct contact can spread influenza.  The flu virus can remain active on a contaminated surface or item for up to 48 hours.

We'll discuss prevention strategies, P. P. E., and pharmacology versus non-pharmacology strategies in our Medical/Biological posting next week.


MJ Podcast #196: Missile or Not? And, did that ambulance just duck?

This week on the podcast Matt and I discuss two important topics...the "missile' seen off of the coast of LA and how a DCFEMS ambulance may have ducked out of a multi-patient shooting. We had planned to discuss a couple of other topics, but ran out of time. We'll put those topics (first-in actions at MCI and paramedics cut to give FF's a raise) at the top of the list for next week.

So, was it a missile or not? That is still the question surrounding an object that was seen last week seemingly streaking towards the sky off the coast of L.A. Captured by a local TV helicopter film crew, the "missile like" object has been examined by a number of experts. We've heard everything from its a bird, its a plane, to...we have no idea what it was. NORAD was not able to track it...the FAA says we don't know what plane was in the area. So, was it a missile? If so, who did it belong to and what happened to it. Or, was it a plane with an odd vapor trail? You decide. See the video here.

Next, Matt bring us a story out of Washington, D.C. where a DCFEMS ambulance may have ducked out of an MCI-shooting event.  We'll pick up the triage and first-in actions next week!

Donate Today! You can help support mitigation journal by making a donation of $1.00.  Click the "donate" button on the right sidebar. Mitigation Journal is a listener supported independent podcast and blog… and any little bit will help.

 Get Mitigation Journal on your e-mail… subscribe to our free e-mail edition of the blog by typing your e-mail address in the e-mail subscription box.


Effective Tabletop Exercises

Effective Tabletop Exercises  
(Originally posted February 20, 2006) 
Do you remember Hurricane Pam? Despite having dumped 20 inches of rain with sustained winds of 120 mph and causing a storm surge that crumbled levees in New Orleans, virtually no one remembers Hurricane Pam despite the unfortunate fact that Pam has an eerie resemblance to Hurricane Katrina. How about the Dark Winter of 2002? That Dark Winter resulted in over three-million cases of smallpox and caused at least one-million deaths as the disease spread around the globe.

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

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

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

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

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

Problems and Messages

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

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

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

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

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

Group Problem Solving

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

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

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

Designing a TTX is Simple!

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

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

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

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

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

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


Exercise Design and Uses

Exercise by the textbook
                      With or without official definitions focus on these strategies for effective exercise design.

What's in a name? Well, an exercise bike textbook definition is a process designed to improve preparedness. An exercise is also designed to strengthen disaster capabilities and enhance functioning during times of crisis.

The focus of exercise is on performance. We look at operational and administrative actions. When we look at these operational aspects that have to be viewed and implemented from the perspective of an actual event. In other words, practice how you play. This means that all participants need to know their roles and duties not only on a daily basis but how those rules may change in times of crisis.

Effective exercise design motivates the participants. “Realistic” action is based on a realistic simulation. In this context, the term realistic is based on your reality. You need to use data from prior events and information gathered from your threat/hazard vulnerability study. Failure to keep your scenarios and simulation realistic is to plan for failure in your exercise program. Remember, and exercise should border on realism… realism, with a hint of dramatic flair.

What can an exercise be used to accomplish? What should an exercise accomplish? 
While many people claim that it exercised only tests a plan, I believe your exercise can accomplish much, much more. You can use an exercise or simulation to actually evaluate the plan as is the common occurrence. Did you know you can actually use your simulations or exercises to create a structure for plan? That's right, run and exercise, something simple, something that your people will not be overly stressed by. Evaluate how they respond. Based on the response (the impromptu actions) of your personnel, you may be able to see innovative ways of managing the situation that you hadn't thought of before. Turn this innovation into a plan. This unusual use of the planning and exercise process will help you as the emergency manager/planner think outside the box when dealing with crisis situations. Of course, you can always use an exercise or simulation to update or test a change in your plan.

 Regardless of how you use your exercise design and planning program make sure you're following these steps:

Start with seminars. 
Seminars are basically introductory meetings where you introduce the information you want to test or train on. There are low stress low-impact situations and are often thought of as synonymous with briefings.

The drill tests one specific function of a plan. They are focused on one activity or a small group of activities. They can have various levels of stress or realism, but in general do not tax too heavily on the personnel or resources involved. I typically do not recommend a high level of realism, stress, or time pressure when conducting initial drills.

Tabletop exercises. 
These types of exercises are my absolute favorite of all the exercise design possibilities. A tabletop exercise allows you to formulate a scenario and manipulate the situation as it goes. Based on your scenario you can add is much time pressure and stress is the group will allow. You can add certain messages (also known as injects) to the situation to keep it on track or further challenge the participants.

The full scale functional exercise is the grandfather of the exercise design program.
During these types of activities you actually deploy personnel and resources to your simulated situation. Full scale functional exercises can take months to years to plan… these are not events that should be planned and carried out overnight.

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 Responder preparedness is the main focus of Mitigation Journal.  As we all know, the better  prepared our civilian population as the more effective our emergency responders will be. In unprepared or uninformed public creates a larger special needs population. 

As we look forward to 2011, Mitigation Journal will begin running a regular segment every Wednesday called Civilian Readiness. These Wednesday postings will be geared towards the general public and are designed to be used as a tool by emergency responders to help keep the public safe.

Our first installment of civilian readiness comes to us from Today's post is a simple reminder of those items we should be keeping on hand for basic emergency kit.

Recommended Items to Include in a Basic Emergency Supply Kit:

  • Water, one gallon of water per person per day for at least three days, for drinking and sanitation
  • Food, at least a three-day supply of non-perishable food
  • Battery-powered or hand crank radio and a NOAA Weather Radio with tone alert and extra batteries for both
  • Flashlight and extra batteries
  • First aid kit
  • Whistle to signal for help
  • Dust mask, to help filter contaminated air and plastic sheeting and duct tape to shelter-in-place
  • Moist towelettes, garbage bags and plastic ties for personal sanitation
  • Wrench or pliers to turn off utilities
  • Can opener for food (if kit contains canned food)
  • Local maps
  • Cell phone with chargers, inverter or solar charger


LOCATE the patient

Re-Introducing LOCATE.
(Originally posted December 28, 2005)

LOCATE is a system to guide the EMS provider on assessing the patient, the scene, and as a decision making aid

It seems simple enough; before you can provide treatment and transportation you have to find the person in need of your service. Actually finding the patient is only part of the job. Providers of emergency medical service (EMS) at all levels must prepare themselves prior to reaching the scene or patient for a variety of potential actions and outcomes. Waiting to arrive on-scene to develop a care plan or mental review of the potential scenarios places both provider and patient at a disadvantage. The fire services use the process of pre-incident planning and size-up to prepare firefighters for potential needs or dangers of any given situation. Pre-incident planning can be used to anticipate additional resources and special needs of a situation. Emergency medical services can and should do the same.

EMS and fire service text are filled with acronyms that have become part of daily conversation. Acronyms are memory aids that range from the simple ABCDE’s that remind us of the basics of patient assessment to SLUDGE as a memory jog for organo-phosphate exposure symptoms. In this installment we will introduce the acronym LOCATE as a means of assessing not only the patient, but the scene and patient needs as a whole.

Location. In the real estate business location is everything and so it is for EMS. What do we as EMS providers need to know about the location we are responding to in order to accomplish our goals and objectives? What can we tell about a situation before we enter the environment? Let’s consider the following questions:
What type of occupancy are we at?
How well do you know your response district?
What geographical special needs or special hazards have to be considered?

Response to group homes, rehabilitation centers, and senior living centers demand special attention by the responder. The structure itself can yield important clues as to the special needs of those inside and impact your options. Calls to medical facilities and clinics add yet another dimension to your response such as dealing with medical professionals and therapy-in-progress. The key to situational assessment is to anticipate, not stereotype.

Obstacles such as ramps, lifts and the presence of customized vehicles should prepare you for the special needs of the person inside the location and warn you about special hazards of getting in and out with all your equipment (including your lumbar spine) safe and intact. Commercial buildings and public places offer some challenges that are not as obvious. Small elevators may prevent your crew from arriving or returning together. Who will stay with the patient and what vital equipment will you keep with you? In public places on-lookers can become an obstacle. Patient dignity and privacy in the public venue must be addressed differently than in a private residence in effort to preserve the comfort and cooperation of the patient during treatment. The responder must also consider the presence of security video surveillance, camera phones, and other digital recorders. Responders must anticipate that a majority of the public owns some type of digital recording device and consider the impact these devices may have on privacy and care.

Conditions such as post medical conditions are a routine part of EMS assessment. Now consider the living conditions you find the patient in. By being observant to living conditions; EMS providers have a unique opportunity not available to others in the health care system. Situational awareness can yield important clues that must be relayed and addressed by the health care system. The GEMS diamond used in Geriatric Education for Emergency Medical Services is a good example. The EMS provider must again ask themselves a number of questions:
Are the patient, the family, and the care givers able to carry our daily activities?
Has there been a change in how the patient cares for themselves? If so, is the cause of the change medical in nature, such as in the setting of CVA/TIA, or social a aspect such as the loss of a spouse or other supporting person?
Family support or lack thereof plays an important role in every situation. The EMS provider must not only find medications but assess if the patient is physically and mentally able to take them.

The presence or absence of Accessories is closely related to conditions and considers physical items.
Is the patient using the cane or walker? If not, is lack of use or lack of the device a cause of falls and injuries?
Has the patients’ ability to use such a device changed and are they no longer able to use their accessories?
Other accessories that should be assessed include home oxygen units, air-powered nebulizers, ventilators, hospital beds and lifts, commodes, and orthopedic devices. The presence of basic medical supplies can also indicate the level of care a person should receive on a daily basis. The presence of many other medical accessories may also indicate the need for another and arguably more important need; and educated caregiver in the home. There is no substitute for the love and compassion provided by a family in the home-care situation. EMS providers must harness the educated family or caregiver as a precious piece of the assessment puzzle. Failure to do so can result in the loss of valuable information, inaccurate diagnosis and treatment, and poor public relations.

Treatment is what you do for the patient. Your assessment should lead to a working diagnosis list and guide your treatment. Treatment provided by previous EMS responses and discharge paperwork from previous emergency department visits is also important. We all have a list of frequent users of our services but, do we communicate what we’ve done to help these people? We shouldn’t have to reinvent treatment each time we see a previously treated patient. Multiple requests for “lift assists” for example, may indicate subtle changes in patient condition or change in social status indicating the need for augmented services. The key is to anticipate, not stereotype.

Evaluate the need for Education and Extra help. The EMS provider has the ability to see the patient in their surroundings as they are every day. EMS should also be knowledgeable of patient education topics pertaining to safety and well-being, social programs, and signs of abuse. Consider the following questions:
Are you aware of the signs of elder, child, or domestic abuse? If so, what are your reporting requirements?
Are you aware of the community programs that may be of benefit to those in crisis?
Being able to provide information on social programs and domestic support are vital for the EMS provider.
Evaluation must begin prior to response. Weather conditions and time of day must also play a role here. Other events; natural disasters and intentional events locally, nationally, and internationally must also be taken into account. It is here that you have the opportunity to help any member of the public prepare for crisis…even those that are not medically related.

The ability to assess the scene and the patient before you arrive is a skill learned with experience. The acronym LOCATE is:
Evaluate, Educate, Extra help
Use LOCATE to guide your patient care plans on-route, on-scene, and after care to build your assessment of the patient as whole. Pre-planning and size-up are important aspects of patient care; if you LOCATE each patient you will be better able to keep these points and patient care in focus.


MJ Podcast #195Mail bombs deliver failure, Canadian ambulances getting bogged down, and Instinctively Health

This week on Mitigation Journal we discuss the situation with the mail bombs delivered through UPS and FedEx air freight planes is a disaster! It's a disaster without one of the bombs even going off… we found out about the situation because of a tip from an informant not because of our preparedness or hardening of the target. I go on a pretty good rant about this particular topic on this weeks podcast. Tune in to hear what I think we should do about the failure of the Department of Homeland Security and the T. S. A.

Also this week, Matt takes a look at a situation in Canada where ambulances are becoming bogged down in emergency department waits. This is a great topic for all of us to check out as it is not limited to any one area. We all feel the pinch when hospital triage times are slow and when hospitals are operating in over capacity. Chances are you've experienced this as well. Long wait times tying up ambulances and hospitals enhances the ripple effect of even the smallest event. Forget Surge Capacity, hospitals around the world are having a hard time managing day-to-day routine events.

In the second half of our podcast this week I speak with Ms. Lori VanScoter from Instinctively Healthy.  Lori  is an oncology nurse and a health coach. In this phone interview we discuss the benefits of having a health coach in different ways you can look at your own health and stress with just a little help from a friend.

Donate Today! You can help support mitigation journal by making a donation of $1.00.  Click the "donate" button on the right sidebar. Mitigation Journal is a listener supported independent podcast and blog… and any little bit will help.

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Instinctively Healthy with Lori VanScoter

Instinctively Healthy with Lori VanScoter...
                                                making sense about staying healthy.

I had the pleasure recently of interviewing a terrific nurse, her name is Lori VanScoter, and she is the driving force behind Instinctively Healthy. I actually met Lori last year during one of my clinical rotations in oncology and found her thoughts and insights on health promotion and health care to fit well with the mission of Mitigation Journal.

Our recent conversation will be posted on Mitigation Journal podcast edition 195 (direct download available November 8, 2010) on Until then, let me hit the highlights of our conversation in this blog post.

What is a health coach?
A health coach is an individual with special training who helps dispel myths and helps clients meet their health goals. Instinctively Healthy helps clients meet their goals by guiding them down a slow, gentle, progressive path to change.

What are people most often looking for when they seek out a health coach?
Most people are looking to make a productive change in their life… most of the time they are looking to lose weight or help control their weight.

From your newsletter, what does it mean to “get slow”?
The term “get slow” simply means to slow things down in your life. It means finding the time to enjoy the moment that you're in. Here are a few quotes from the Instinctively Healthy newsletter…
"If we must accomplish many things each day, we can still change the quality with which we do things. How can we transmute that sprint to the train into something delicious instead of the usual gripping and tightening experience? Where can we find ease in the midst of stress? How can we cultivate the art of going slowly?"
"Take a few moments before you climb out of bed in the morning to remember your dreams and to think about what you want from the day. Leave your watch on the bedside table. Take the scenic route. Sit for a moment with your eyes closed when you start your computer. Check email only twice a day. Don't pack your schedule so tightly that there's no time for a short walk. Light candles before you start to cook dinner. Add one moment here and there for slowness; it can be done simply and will have a profound effect on your well-being." (Lori VanScoter, RN, Instinctively Healthy)

Be sure to listen to Mitigation Journal #195 (available 11/8/10) for the complete interview. You should also visit Instinctively Healthy at To subscribe get your own Instinctively Healthy newsletter email Lori directly


John D. Solomon, 1963-2010

I've just read the sad news about the death of John Solomon.

I've never met John. I don't know him other than by his work on the In Case of Emergency, Read Blog.

Since late 2008 I've been lurking on In Case of Emergency, always comparing the thoughts and insights to my own. As is far too often the case, we won't know what we had until its gone.

On behalf of the Mitigation Journal blog readers and podcast listeners, we wish to extend our heartfelt condolences to the family and friends of John Solomon. Our thoughts and prayers are with you. Those in the world of emergency preparedness bloggers all feel your loss.

Please visit In Case of Emergency, Read Blog and share your thoughts.


Week in Review November 5, 2010

A quick review of last week:

11/1/10 Mitigation Journal podcast #194. We talked about the Mail Bomb attacks on airline soft-targets and how traditional health care delivery is in competition with retail health/walk-in centers.

11/2/10 Blog Post: Sorting Out Triage This post highlighted the latest conversational on the First Few Moments podcast with Dr. Lou Romig. We'll be looking at the questions posed in later sure to tune into FFM podcast and check back here as I give my two cents on triage.

11/4/10 Blog Post: Two Pieces of Infrastructure you can't Ignore: Telecommunications and Power this post...its only the start of our infrastructure series.

Your reading list for the weekend:
Obesity to reach 42% from MSNBC
Kids on 9/11 now fighting from MSNBC

Be sure to check back at


Two pieces of Critical Infrastructure you can't ignore

Knowing what your defending is the first step in pre-incident planning.

What is your Critical Infrastructure List?  My critical what list?! Yes, you heard me correctly, what is your critical infrastructure list? This is a list of locations, events, structures, and services that could be vulnerable to natural disasters or intentional targeted events. Those critical things you just can't do without...and  doing without them would cripple your ability to carry out your mission. Brainstorming this list will help you in your personnel get to know your community a little better and start your planning process in the right direction.

Here is my sample list of critical infrastructure… these two are just for starters...those items that I consider essential locations or services that must be maintained and/or hardened. By the way, these are the two critical infrastructure systems that many feel are the most vulnerable...just say'n.

1. Telecommunications.
Telecommunications are one of the most vital systems we have available to us. These systems allow us to get messages to our public and each other. Telecommunications networks also are critical pieces of infrastructure in industry and commerce as well as our ability to operate our emergency operation centers.  We've become so accustomed to instant communication in the use of satellite and Internet features to add functionality to our processes that the loss of this technology will make it difficult for us to operate efficiently. Secondary communication systems easily  fall out of use and out of date… many secondary communication systems I've seen recently are in dire need of repair. Failure of telecommunications networks  from natural disasters or intentional targeted attacks will make it difficult for the event to be managed successfully. Therefore, telecommunications networks lead the list of critical infrastructure you should be planning to protect. It's important for every planner in every agency leader to understand the strengths and vulnerabilities of their local telecommunications network and backup systems. It is equally important for agency leaders and planners to understand the eventuality of telecommunications failures and have the communications plan “B.”

2. Electrical Power. 
I've talked about the potential impact of a power grid failure in prior posts and on Mitigation Journal podcast (listen to edition 173 here). I mean what I say. Our nation's power grid remains extremely vulnerable to natural disasters and intentional targeted attacks. Our current system of power distribution has no means for saving or storing energy. Also, because the electrical system operates at or near capacity most of the time, a failure in one location or plant may easily result in a cascade of failures throughout the grid. The effects of those failures will be felt almost immediately and manifest as brownouts or blackouts. The ripple effect from these events is insidious… with impact on other critical infrastructure sites such as hospitals.  The failure of our electrical power grid even for short periods of time will place increased demands on local responders. The ripple effect will continue through the community as civilians deploy alternate heating and power sources such as generators. While many of us are used to having the power go out from time to time, it is difficult for us to conceive going without electricity for weeks, months, or perhaps longer.

This list goes on...and we'll have more to say. In the meantime, I'd like to hear from you. Comment here or email

Thanks for visiting Mitigation


Sorting out triage...Questions we'll be answering

Triage. For most responders, we look at triage systems as a means to manage (sort) multi-patient events. These events can be difficult physically and mentally. Triage systems give us a tool to keep us on track and focused. We had a chance to have an in-depth conversation with Dr. Lou Romig, the creator of JumpStart Triage, on a recent edition of First Few Moments. I encourage you to tune in to this edition and apply the discussion to your every-day practice.

Triage in every-day practice? Yes, that's what I said. Far too often we reserve our triage skills for when the bad thing happens. Why not apply the triage model to every situation we encounter?

While we rely on triage tools to keep us on track managing patients. Triage systems can also help us track patients from the field to the hospital. They also allow us to track patient condition changes. But the key is that we have to be familiar with them...not just pulling the triage kit off the truck when disaster strikes.

Here are a few questions to ask yourself about yourself about your triage (we'll be answering these in the next few posts):
  • What would you change about your triage system to make it more every-day user friendly?
  • What suggestions can you come up with for improving original triage training for EMS providers?
  • How do we improve triage skills among experienced providers?


Lessons Learned on Mitigation Journal

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Lessons Learned on Mitigation Journal...Content for the MJ APP users.

Mitigation Journal app users receive additional features from our podcast. App users receive the weekly editions early and receive Lessons Learned installments. Lessons Learned is a ten-minute segment where we look at critical events and apply the "lessons learned" to today's needs.

The Mitigation Journal App is available at the iTunes App Store for $1.99 with 50% of that cost going coming back to us here. The app is a great way to get additional Mitigation Journal content and support our blogging and podcasting efforts. You can also make a donation if you'd like.

Ive received several emails asking to "test drive" Lessons Learned. So, I've decided to share the first two Lessons Learned segments a preview.

Lessons Learned B'nai B'rith

Lessons Learned Oxygen Safety