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Cold Weather Emergency Incident Rehab - PrePlanning and Incident Action Planning for EIR

This is final segment of our four part series on the topic of Cold Weather Emergency Incident Rehabilitation (EIR). In this segment we'll discuss the importance of planning and pre planning for EIR. We also discuss the role of the incident safety officer and Incident Action Planning that includes EIR. Joining me for this series is Dr. Jeremy Cushman, Medical Director for Monroe County, NY.

In this series we've reviewed the need for rehab, special logistical considerations in cold weather EIR operations, and the importance of "pre-habilitation" and remaining fit for activity during cold weather.  Changing weather conditions and the use of Incident Action Planning in relation to rehabilitation operations are covered in this final segment. 

Cold Weather Emergency Incident Rehabilitation was produced for emergency responders off all disciplines. Health care professionals who may treat responders in the hospital environment  will also benefit from this background information. For more on cold weather emergencies, click here.

Click the player below for the audio from all four parts in this series.


Cold Weather Emergency Incident Rehab - "Pre-Habilitation"

This is part three of a four part series on the topic of Emergency Incident Rehabilitation. In this segment we'll discuss the importance of "pre-hab" and physical fitness. Joining me for this series is Dr. Jeremy Cushman, Medical Director for Monroe County, NY.

In part one we reviewed the need for rehab, in part two we discussed special logistical considerations.  Changing weather conditions and the use of Incident Action Planning in relation to rehabilitation operations are covered in part four. 

Cold Weather Emergency Incident Rehabilitation was produced for emergency responders off all disciplines. Health care professionals who may treat responders in the hospital environment  will also benefit from this background information. For more on cold weather emergencies, click here.


Click the player below for complete audio version.


Cold Weather Emergency Incident Rehab - Logistical Considerations

This is part two of a four part series on the topic of Emergency Incident Rehabilitation. In this segment we address the special logistical considerations for establishing Emergency Incident Rehabilitation in cold weather. Joining me for this series is Dr. Jeremy Cushman, Medical Director for Monroe County, NY.

In part one we discussed the need for rehabilitation. In part three we'll cover the importance of "Pre-Hab" and physical fitness. Changing weather conditions and the use of Incident Action Planning in relation to rehabilitation operations are covered in part four.

Cold Weather Emergency Incident Rehabilitation was produced for emergency responders off all disciplines. Health care professionals who may treat responders in the hospital environment  will also benefit from this background information. For more on cold weather emergencies, click here.

Click the player below for complete audio version.


Cold Weather Emergency Incident Rehabilitation - The Need for Rehab

This is part one of a four part series on the topic of Emergency Incident Rehabilitation. In this segment we'll discuss the need for rehab at all situations - truly a "sector for all seasons". Joining me for this series is Dr. Jeremy Cushman, Medical Director for Monroe County, NY.

In part two we'll discuss special logistical considerations, part three covers the importance of "Pre-Hab" and physical fitness. Changing weather conditions and the use of Incident Action Planning in relation to rehabilitation operations are covered in part four. 

Cold Weather Emergency Incident Rehabilitation was produced for emergency responders off all disciplines. Health care professionals who may treat responders in the hospital environment  will also benefit from this background information. For more on cold weather emergencies, click here.


Click the player below for complete audio version.

Traditional lectures find new life in "new media"

Co-posted on the GVNA blog

Using multi-media and internet strategies to reach today's health care and EM students.

I stumbled on this topic while reading one of my favorite blogs, Life in the Fast Lane. The post, Peer Reviewed Lectures, really caught  my attention. As a semi-pro blogger and podcast host, I truly appreciate (and honestly believe in) the incredible value of multiple instructional strategies and web-based interaction. Traditional topics will find new life when a "new media" twist is applied. All you have to do is embrace the New Media delivery!

This video from Academic Emergency Medicine outlines criteria for peer reviewed lectures.

Peer Reviewed Lectures from Academic Emergency Medicine on Vimeo.

Continuing education becomes cutting edge and lecture content can be taken at-will or on demand to satisfy specific needs. This New Media approach also reaches out (and grabs on to) the Millennial Generation as well as those who want that convenience offered by this media. In the video below, Danielle Hart, MD (Hennepin County Medical Center Department of Emergency Medicine) outlines the learning style differences between various generations and how this non-traditional instructional tool bridges the educational gap. 


What will the next AED be?

The following anonymous comment on Paramedic Future (Mitigation Journal July, 2009)

Anonymous wrote:
Thank you for your post. Examining your argument that technology will eventually replace the need for the paramedic I find some flaws. I feel like your argument is similar to saying why teach long division now that we have calculators. However, the computer diagnosis on the 12-lead is horribly unreliable. I don't know how many 911 calls I've made for "ST wave abnormality" on perfectly good 12-leads. As providers and educators we need to push for solid physical assessment skills and diagnostic skills. The ability to read and interpret a 12-lead is still a paramount paramedic skill. I currently work one of my jobs at a teaching hospital and while moving a trauma patient a physician shouted, "the patient is in v-tach!" the physician reached for the defibrillator without question as one of the medics explained that the alarm on the monitor was merely artifact from movement. If we've learned anything it is that common sense isn't common at all. We need to continue to educate and trust the interpretation of skilled providers over technology.
My response:

I don't believe that technology will replace paramedics. In fact:
" can't consider the patient as a whole and put all the assessment pieces together like a skilled paramedic can." 
In the original piece I bring up the possibility that reliance on technology may not be a good thing:
"...Like any other technology, once we become accustomed to it, we become dependent on it...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?"
The point is that technology may put appropriate diagnostic tools and treatment possibilities in the hands of more responders and may make it possible to speed treatment in the field, improved triage of limited (and costly) hospital specialty care services, and pave the way for advanced practice paramedics.

In the 1950's, CPR was a physician-only skill. Defibrillation was a paramedic skill until the 1980's. Today, both CPR and automated external defibrillators make it possible for almost any member of the public to improve survival from cardiac arrest. We have to think forward to what the next "AED" will be.


Unwanted contacts on your phone

E. Coli on the list of nasty bugs in your contact list!

Think about this the next time you put your phone to your face -
A study published in October, 2011, found that 92% of cellular phones are contaminated with nasty bacteria...including E. Coli. The cause of the contamination is people using their phones while in the restroom. Texting while toileting has been identified as a contributing factor. 

According to research conducted by the London School of Hygiene & Tropical Medicine and Queen Mary, University of London:
  • 92% of phones had bacteria on them.
  • 82% of hands had bacteria on them.
  • 16% of hands and 16% of phones had E. coli bacteria.
How do you decontaminate your phone/handheld device after use in the clinical environment?

Read the full article from Medscape here.


7 Health Care Preparedness things you need to know

7  things you need to know...and why you need to know them

#1. Understand the broad scope of threats and trends in your community. Know what your local responders and emergency planners working on and what your community plans call for.

Why? Best reason why is to be a better prepared citizen, parent, [nurse] [medic]. You’ll be able to carry out your duties (at any level) during times of crisis and add to the success of the response.

#2. Know your internal emergency plans. Know your role within the plan and how crisis situations  change the way you do what you do every day. Know what triggers your emergency plans to be put into action and when to shift from your standard of care to sufficiency of care. Consider what will change when you have to shelter in place or evacuate.
Why? There may not be time to look things up during a crisis situation and the event will most likely change quickly. Being familiar with your plans ahead of time cuts down on reaction time and contributes to good outcomes. That is, lives saved...yours and your [patients] [citizens] If you’re

#3 Have a basic understanding of the Hospital Incident Command System.

Why? You will have to work within the HICS system during any crisis and you might be put into a lead role at some point. A basic awareness of the HICS and how to carry out the various functional positions within it will go a long way to success in the small scale and large scale of the event.

#4. Know the special resources of your institution and those around you.

Why? Knowing what specialties services are available gives you an idea of how certain cases will be triage into your system. You may also get an idea of the type of patients you can expect when a specialty hospital (burn unit, trauma or cardiac center) is over-run or has to evacuate. conversely, you can get a head of the decision making for sending your patients out to other appropriate facilities if you know their capabilities.

#5. Know how to prepare yourself and your family for community emergencies...and do it.

 Why? The best way to prepare a community for disasters is to prepare the citizens. Well prepared citizens  and communities lead to improved outcomes in disaster situations. On the professional side, having a prepared family means that we can continue to go to work and do our jobs better. Keeping staff coming back to work in times of crisis is a major concern. The best way to improve the numbers of people coming back to work is to help them prepare their families to shelter or evacuate as needed during crisis.

#6. Recognize incident indicators, signs/symptoms and heralding events that foretell a problem. In other words, pay attention to what's going on around you...even when you're off duty.

Why? You situational awareness may be all that stands between you and harm. Someone has to be the first to recognize danger signs...don't wait for someone else to tell you there's a problem...

#7. Get better accuainted with your Personal Protective Equipment. Even the stuff you use every day

Why? Some research has suggested that personal protective equipment may not be utilized properly and that annual training is not enough. Without regular and on-going practice, the PPE we have may not be used, or worse, used improperly.


MJ: 224 Emergency Alert System test -Part two

Click for direct download
FEMA conducted a never before attempted Nation wide test of the Emergency Alert System on November 9, 2011. The test included television, radio, cable, and satellite carriers. Despite the effort on the part of FEMA, there are many who suggest this was more like a pop quiz than a test.

This week we complete our discussion with Matt and Jamie talking about the success of the test, role of social media, and the continued need for the Emergency Alert System. We even get into the CDC's Zombie Apocalypse preparedness program. 

    Click the player below to listen now


Three reasons this cyber-attack is cause for concern

First foreign cyber attack destroys pump in Illinois 

Cyber attack - rather than causing physical destruction from direct force or assault, a cyber attack infiltrates a technology and turns the technology against the systems it's designed to control. For the first time we've had a foreign cyber attack in the United States. For more, read Technological Disasters, they're going to get worse.
An internet provider address traced to Russia is being described as the origin of a cyber attack that destroyed a pump at a water pumping station in Illinois. The pump was destroyed when access was gained to operational control software that allowed the pump to be repeatedly turned on and off causing it to burn out. The pumping station is reported to serve a population of over 2000 people. Mainstream media is reporting that there were no interruptions in service because redundant systems were in place and sufficient.

The November 8 attack, described as the first foreign cyber-attack on the United States, has been acknowledged by the Department of Homeland Security (DHS) and Federal Bureau of Investigation (FBI). Both DHS and FBI claim there is no immanent threat.  The breach is connected with compromised passwords and security information from civilan a software vendor. 

The media is also reporting that whoever hacked this system actually had access to Supervisory Control and Data Acquisition (SCADA) systems for three months. SCADA systems are widely used software that controls engineering systems for critical infrastructure. Nuclear power plants, power grid systems, waste treatment facilities, and some rail transportation systems, use SCADA software. Read more on why you can't ignore your critical infrastructure.

Three reasons this cyber-attack is cause for concern -
  1. No early warning systems in place to detect an attempted or actual cyber-attack. This attack was discovered only after the damage had been done. There was no detection mechanism in place to alert of an attack or attack attempt. Without early warning/detection systems, there could be additional attacks on more critical systems at any point...or in progress. 
  2. This could have been a probing evaluate vulnerability and assess reaction/response. A probing attack could indicate a larger cyber attack is on the horizon.
  3. Critical infrastructure lacks resiliency. Impact in this case was limited because redundant systems were in place and functional. Our power grid, by comparison, lacks functional redundancies. Had this attack shut down an electric generator or destroyed a vital component of the power grid, the outcomes could have been much more dramatic. More MJ posts on the power grid; Of Power Grids and Black Outs
"... [a] power grid/power supply that may be the most vulnerable (critical infrastructure). Several references have indicated that the Nations power grid is the most "at risk" target we have. It stands to reason that the power generation and distribution network in any community would also be at risk..."      Three Planning Problems for 2011 (MJ 12/2010) 



Mitigation Journal - 6 years later

Thank You for six years of support.

We're celebrating six years of Mitigation Journal blogging and podcasting. When I clicked "publish" for the first time back in November, 2005, I couldn't have predicted how important this blog would become to so many readers and listeners. Our growth has been tremendous.

From blog to podcast to video to of material has grown. We've published over 600 blog posts and dozens of videos. More than 6000 people visit Mitigation Journal DOT ORG every month. I've met so many people through Mitigation Journal and I've lost count of how many places I've been asked to visit - to give a talk or consult on a project. I've met so many emergency service professionals through the use of social media. I've had the opportunity to review plans, provide opinions, and teach.

What's next? I can't begin to predict. The only thing I can say for sure is that Mitigation Journal will continue to provide unique perspectives on civil preparedness and emergency response. I don't like the mainstream way of emergency management thinking and would rather stay off the beaten(down) path.

Through blogging, podcasting, social media, and independent reporting, we'll continue to examine the limitless topics of preparedness and response for civilians, traditional rescuers and non-traditional responders.

We'll be reporting on current events, conducting case study, providing original material sprinkled with commentary. Mitigation Journal will cover everything from routine incidents to local disaster and national crisis. Professional responders and concerned citizens will gain valuable insight into preparedness and emergency response.

With real world experience and insight, Mitigation Journal will be there helping you prepare for whatever challenges your role in preparedness care, emergency medical service, fire department, public health preparedness...Mitigation Journal will cover it all.

With your help. With your continued support.


Reaction to Cold

Reaction to Cold: How the body responds


They are the major effects of cold that are the root of all other problems. These five body changes are the building blocks of system failure caused by cold environmental conditions. They all stress the healthy body.

Cold conditions do not have to be extreme to cause problems. Even mild decreases in temperature are enough to trigger those five major effects of cold can cause increased heat losses through radiation and conduction. Heat losses can increase 25 to 30 times when a body is in contact with a cold or wet surface.

Any condition or disease that involves vasoconstriction, respiratory or neurological impairment places a person at increased risk during exposure to cold. In general, increased cold exposure risk increases with:
  • age < 1
  • Circulatory, vascular or neurological disease
  • Raynaud's Phenomenon
  • Alcohol, tobacco, caffeine, or energy drink use
  • Trauma or Hypoglycemia
  • Prior cold injury
Better health means better performance in cold environments. Exposure to cold decreases mental capacity with increased risk of injury, accidents and errors

While often considered during the hot summer month, dehydration is a major threat during cold periods. Evaporation, sometimes referred to as insensible losses, increases with cold atmospheric conditions. Respiration moisture losses account results in large amount of fluid loss through evaporation. These respiratory/evaporation losses  increases dramatically in cold environments as the moisture in exhaled breath increases. Dehydration is more prevalent with excessive use of caffeine or alcohol. Prolonged exposure to cold and dehydration are important variables to evaluate as both increase risk for hypothermia.

Environmental exposure to cold is also linked to decreased mental capacity. Reduced mental endurance has been shown to increase the risk of errors and accidents. Responders should be taking this into account when operating in cold environmental conditions for any period of time.  Further, the physical discomfort associated with exposure to cold, even for brief periods, may contribute to decreased mental alertness.

Additionally, there is an increased risk of physical injury while operating in a cold environment. Joints and muscles become stiff and strength decreases. These factors lead to sprains and strains and muscular micro-trauma as well as acute injury. These effects can be seen in the well-conditioned person just as easily as in those who are not in good physical condition.

Factors in remaining warm include maintaining good food/nutrition status, adequate fluid and hydration and maintaining reasonable physical fitness.


MJ: 223 Emergency Alert System Test

Click for direct download
FEMA conducted a never before attempted Nation wide test of the Emergency Alert System on November 9, 2011. The test included television, radio, cable, and satellite carriers. Despite the effort on the part of FEMA, there are many who suggest this was more like a pop quiz than a test.

This week on Mitigaiton Journal Podcast, Matt, Jamie and I discuss several important topics related to this test and the status of the Emergency Alert System. In this two part discussion we'll ask:
  • was the test a success?
  • what is the impact of omitting social media from the test?
  • what should the role of social media be in emergency alerting?
  • do we need the emergency alert System anymore?
    Click the player below to listen now


Zombies, the Public Health Mascot?

Zombies, the Public Health Mascot?

The Centers for Disease Control and Prevention (CDC) began a Zombie Preparedness initiative with the goal of engaging the public on preparedness. Obviously not just for a "Zombie Apocalypse", the information projected by the CDC's Office of Public Health Preparedness is useful in real-world disaster situations. Reaching a diverse audience is what this campaign is all about. According to the CDC website:
"If you are generally well equipped to deal with a zombie apocalypse you will be prepared for a hurricane, pandemic, earthquake, or terrorist attack." Dr. Ali Khan, Director
Are Zombies the enduring icon public health wants to be remembered by?
I appreciate the efforts of the CDC and believe they've reached a major milestone in pubic health awareness. Will the Zombie Apocalypses continue to be effective? What the CDC has done is to copy  what traditional responders have been doing for years: public education through an iconic mascot. The fire service has Sparky the fire dog and law enforcement has McGruff, the Crime Dog...and the CDC/Public Health has Zombies. Sparky has his own site as does McGruff. The CDC Zombies have an enhanced web presence with a graphic novel, apps, YouTube and webpage widgets. Each embrace popular culture with an appropriate message.

Is the Zombie audience going to get the message?
The fire service and law enforcement continue to put uniformed responders into the schools and at public events to reinforce the messages of Sparky and McGruff. Real world people teaching age-appropriate information. The Zombie Apocalypse initiative is web and social media savvy but it is also static. You have go out and look for it. Traditional public safety puts educators in contact with at-risk populations to deliver and reinforce the message.

Will the Zombie image be a motivating factor in getting a kit, making a plan, and being informed?

Putting an icon to a message is a good idea. I'm not sure that the Zombie image is exactly what the CDC and public health want their enduring icon to be. A large issue is the identity of public health. Is it time to consider public health part of emergency preparedness or public safety? I think so. With that in mind, is the public health preparedness message better delivered via a partnership with traditional response groups? Should police and fire educators take on public health awareness task?

One solution may be a partnership between the CDC and the National Fire Protection Association to deliver a joint public health preparedness message. That message (including the Zombies) could be delivered by local uniformed responders, personnel from the local hospital or health department during fire prevention week. I advocate for public health preparedness to become part of Fire Prevention Week activities (maybe Fire Protection Week needs a name change?)


Get Bio-Event Ready or Die

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

 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 and workplaces. Several studies have pointed out that practice with masks...getting proper fit and knowing how to put them on as important as annual fit-testing.
  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.


Report claims North Korea has Smallpox

Smallpox may be in the biologic hands of North Korea

A recent posting by the Global Security Newswire caught my eye. The headline reads something about North Korea and expanded WMD production. Normally this would get a "so what else is new" response from me but, a quick scan of the piece kept my mouse from clicking away. According to the October 27 article, South Korea claims...
"The military authorities understand that among the 13 types of fungus body of biological agents that North Korea currently has, five types -- including anthrax bacterium, botulinum, and smallpox -- can actually be used as weapons."
 Excuse me, did you say smallpox? I was led to believe that smallpox samples resided in only to repositories on Earth. The World Health Organization (WHO) believes this to be the case as well and since 1986 the has been arguing about the destruction of these stockpiles of Smallpox. Destruction of these virus reserves would mean the removal of the treat of this virus on our planet. Smallpox virus samples were due for destruction but received a stay of execution over the summer of 2011. (learn more on Smallpox stay of execution click here)

Does North Korea (or any other nation) actually has smallpox virus? Can it be or has it been weaponized? South Korea seems to think so and has undertaken an unprecedented bio-preparedness initiative. Good for them. The bad news is that, once Smallpox is let out of the freezer, it will not stay in Korea. One case of Smallpox any place on Earth will ignite a global health crisis. A crisis we are not ready to face. As we saw during the H1N1/Swine Flu episode, our health care system may not be "there" yet when it comes to being ready for a major biologic event.

In the United States we stopped routine vaccination against Smallpox in the 1970's and immunity of those vaccinated prior to that is unclear. There have been some promising data suggesting those vaccinated will still have protection but nothing conclusive. Those born after we stopped vaccination would have no immunity. (click here for more on Smallpox vaccine) Despite the vaccine and the virus, there are steps you can take to protect yourself and your workforce. (Be bio-event ready click here)

There are several things to remember about Smallpox as a bio weapon, chief among them is the estimate that one person with the disease can infect about 20 others. To that we should mention that Smallpox has an approximate fatality rate of 30% and is spread by aerosol transmission. (read my 5 points to remember click here)

A good place to start your refresher class on Smallpox is with a review of biologic tabletop exercises such as Dark Winter and Atlantic Storm. (Click here for more on DW/AS)


Biologic Worst Case: Smallpox Terrorism

 Exercise Highlights Biologic Devastation - Comparing Dark Winter and Atlantic Storm
Terrorist attacks using biological agents are potentially deadly beyond imagination. How would we respond to a devastating Smallpox attack?

That is the exactly the scenario tested by the Dark Winter exercise (2001) and Atlantic Storm (2005).

Exercise similarities, important differences

Both Dark Winter and Atlantic Storm focused on government leadership and their ability to manage issues in public health, medical capabilities, diplomacy, domestic response, and critical infrastructure. Both exercises were well developed and planned...they did, however, reach different results. Despite commonalities in scenario and biological agent there are striking differences between the two exercises.

In order to compare the two exercises I studied the documents, video and layout of the scenarios themselves. Of course, some study of the Smallpox virus itself was helpful.

Comparison of Assumptions

Dark Winter focused on the United States as the only target in a “worst-case” scenario while Atlantic Storm targeted the international community with “best-case” circumstances. 

Although both scenarios simulated the use of smallpox as the agent with similar methods of dissemination, there were concerning differences in the projected infection rates, death rates, and person-to-person transmission potential. Smallpox deaths in the Dark Winter scenario were projected at thirty percent while Atlantic Storm used a twenty-five percent. Atlantic Storm also assumed that there was residual immunity among the affected population with 300 million doses of vaccine available. Dark Winter was somewhat less optimistic, assuming a stockpile of 15.4 million doses of vaccine would be available from the Centers for Disease Control and Prevention. Reality is present with vaccine assumptions as the scenario accounted for up to twenty percent of stockpile loss due to contamination or improper use.

Dark Winter hypothesized that 1gram of Smallpox could generate 100 infections when aerosolized resulting in 3000 first generation cases from 30 grams of virus. There is no mention of virus quantity in Atlantic Storm, however, both scenarios disseminate the virus via an aerosolizing device under similar conditions. Dark Winter used 1:10 transmission rate (every one person with smallpox could infect ten others) as compared to Atlantic Storms rate of only a 1:3 ratio. Atlantic Storm also anticipated 1: 0.25 for second to third generation while no mention was made in the Dark Winter scenario of second to third generation transmission. Dark Winter planners integrated herd immunity of twenty percent into the scenario which was not accounted for in Atlantic Storm. The lack of herd immunity in the later exercise may be reflect doubt that any immunity exists among the currently vaccinated population.

I found the following excerpt from the Dark Winter scenario an interesting commentary on person-to-person transmission rate.
“…Given the low level of herd immunity to smallpox and the high likelihood of delayed diagnosis and public health intervention, the authors of this exercise used a 1:10 transmission rate for Dark Winter and judged that an exercise that used a lower rate of transmission would be unreasonably optimistic, might result in false planning assumptions, and, therefore, would be irresponsible. The authors of this exercise believe that a 1:10 transmission rate for a smallpox outbreak prior to public-health intervention may, in fact, be a conservative estimate, given that factors that continue to precipitate the emergence and reemergence of naturally occurring infectious diseases (e.g., the globalization of travel and trade, urban crowding, and deteriorating public health infrastructure) [26, 27] can be expected to exacerbate the transmission rate for smallpox in a bioterrorism event…”
Atlantic Storm best-case scenario planned for adequate disease control, compliance with public health “social distancing” (quarantine/isolation), available vaccine, higher herd immunity, residual protection granted by prior vaccination, and lower transmission rates. The wide range of transmission rates between the two exercises may account for the differences in total number of smallpox cases and deaths. Dark Winters worst-case predicted 1,000,000 deaths with 3,000,000 infections while the Atlantic Storm exercise predicted 660,000 cases and approximately 495,000 deaths.

Learn more about Smallpox from the CDC- click here


Tabletop Exercises Predict Biologic Disaster

What we can learn from Dark Winter and Atlantic Storm

Everyone remembers Hurricane Katrina. Did you know that about a year before Katrina there was another devastating hurricane? Just about a year before Katrina hit the Gulf Coast, Hurricane Pam ripped through causing the levee system to fail, flooding New Orleans, and causing destruction on nearly a life for life, dollar for dollar par with Katrina. The storm was Hurricane Pam and you didn’t read about this storm in the paper or see it on television. Why doesn't anyone remember Hurricane Pam? You don’t remember Pam because it never actually happened...Hurricane Pam was a tabletop exercise (TTX) that predicted with eerie accuracy what would happen if a major hurricane scored a direct hit on the Gulf Coast. The point is that we can learn a lot from our own exercises if we listen. In this post I’m suggesting we learn the lessons from two biologic event tabletop exercises...

In the setting of a naturally occurring or intentional biologic attack how will countries manage shortages of medicine, vaccines, and medical supplies? What mechanisms will be used to control or halt the spread of disease? How will local and national leaders balance their responsibilities to their own citizens with their responsibilities to the international community?

These are the questions we should be asking ourselves and these are the issues addressed by two tabletop exercises Dark Winter and Atlantic Storm.

Click the player below for staged media footage used in Dark Winter.

Watch Dark Winter Pretext for TOPOFF/CCMRF/CBRNE Martial Law Drills in Educational & How-To | View More Free Videos Online at
In June of 2001, the Johns Hopkins Center for Civilian Biodefense Strategies along with the Center for Strategic and International Studies, the Analytic Services Institute for Homeland Defense held a senior-level tabletop exercise that simulated the effects of a covert biological attack on the United States. The dissemination of highly contagious smallpox as an act of terrorism became known as the “Dark Winter” scenario. This one-of-a-kind TTx examined the ability of senior-level policy makers to face the challenges of a bioterrorist attack with outbreaks of highly contagious diseases.

A few years later, in January, 2005, a similar exercise took place. This time among the international leadership community, known as Atlantic Storm, this TTx continued on a larger scale from the Dark Winter exercise. Atlantic Storm simulated the heads of state and senior international governmental leaders attempting to manage a simultaneous bioterror attack. The attack was centered on Istanbul, Frankfurt, Warsaw, Rotterdam, New York, and Los Angeles with Smallpox as the weapon.

Already know it all? Think again. Atlantic Storm verbalizes many of the issues discussed in recent studies as well as historic preparedness problems. An excellent real-life example, Atlantic Storm is also a high quality tabletop exercise, complete with PDF user guides and downloadable documents, Atlantic Storm provides an outstanding example of power a tabletop exercise (TTX) can bring to the planning and training process.

A review of Dark Winter and Atlantic Storm is a useful tool for traditional and non-traditional responders. Take an hour and view the presentation, review the documentation. To view Atlantic Storm; go to: and turn up you speakers!


What good plans have that bad ones don't

Six points that every plan must have.
  1. Good plans are your plans. Taking the time to follow your own process and cover the basics of pre-incident planning pays huge benefits. Plans that are based on a template or borrowed from another agency are difficult to work with. Planning is not a one size fits all proposition.  The copy and paste template approach opens up gaps with little room for meeting the needs of your community and may be damaging to your credibility. Take the time to follow your planning process and do your own assessments and write your biologic event plan for the unique needs of you community. Do this and you'll be well on the way to preventing planning error and saving lives. Learn more about incident planning click here
  2. Good plans follow the exercise design process. Mainstream thinking is to write a plan then test the plan with a series of drills and exercises, then reevaluate the plan and edit as needed. I suggest turning this procedure upside down...challenge your people with a scenario presented in a tabletop exercise (TTX) and let their actions be the foundation for writing your plan. A simple TTX that is well thought out will give your people the ability to express concerns and put forth ideas that should become part of your plan. Your response community will feel like a valued part of the planning process (because they are!) making buy-in easier. You'll still need to follow the proper steps in establishing the plan such as training and reevaluating. Click here for tips on exercise design and click here for even more on the use and design of exercises.
  3. Good plans are written with your personnel in mind. Consider your personnel and their needs in any crisis event and the protection of personnel while drafting your biologic plan. Studies have indicated that large numbers of any workforce will be impacted by illness in a biologic event. Those that remain healthy may be indirectly impacted resulting from the need to care for family members or children who become ill. Some healthy persons may stay away from the workplace simply out of fear of the disease itself. Your plan should address the family care and education issues.
  4. Good plans are ready to receive help. A biological plan must have provisions for requesting and receiving help. Help can be in the form of mutual aid from local jurisdictions, state or Federal agencies. We're not talking only about money. Receipt of large resources such as the National Pharmaceutical Stockpile will be impossible to manage without a per-arrival plan. 
  5. Good plans distribute factual information. In the pre-incident environment information about the plan and areas of responsibility within the plan are crucial. Getting this information out to those who are responsible for actions within the plan will help ensure readiness. Plan for getting information out to the public. Public information planning should be in every emergency planners toolbox. Public Information Officers (PIO) and Joint Information Centers (JIC) are critical to a consistent and factual message. Social media, including text messaging and podcasting can also be used to your advantage. I recommend pre-event material be written/recorded and ready to be released much like press releases written ahead of time for any given event. 
  6. Good plans are made to be shared. Notice I said shared...not copied. Sharing your plans with other organizations within your jurisdiction brings the response community together. This applies to healthcare planning as well. Hospitals and healthcare systems should share their plans and compare planning needs with other institutions.


MJ 222: Writing biologic event plans - what good plans have that bad ones don't

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Its been another busy month in the basement bunker of knowledge! We're wrapping up one of the most exciting months of blogging and podcasting I can remember with our Biologic Events theme. Reader response has been fantastic and the blog has drawn another record number of visits this month along with several comments, emails, and podcast downloads.We still have a few posts waiting to finish the biologic topic, so be sure to check Mitigation Journal next week...or, join our free newsletter mailing and get MJ posts directly on your email as they are published. Email subscription is free. Just enter your email in the subscription box in the top right side-bar. Mitigation Journal podcast is available as a free subscription in iTunes

This week on the podcast we're pushing out a brief how-to on writing your biologic plan. We also discuss a few important items that every good biologic event plan has...and  bad ones don't.

I'm also working on a few extra features on the blog page. You'll notice changes in the coming weeks.

Click the player below to listen to the latest podcast!


How to Write your Biologic Plan

The first step in creating a workable biologic plan is to realize that a biologic plan is not the same as a pandemic plan. Plans written for a specific disease rather than for a biologic situation will fail. Plans should be guidance documents for a spectrum of events addressing the commonalities among disease outbreaks and the reasonable steps needed to respond to the situation. Labeling your plan a Pandemic Plan or Avian Flu Plan implies that the plan will only be activated if the situation becomes a pandemic or a specific pathogen is discovered. This will delay plan activation resulting in further escalation of the situation. Planning for generalities allows for greater flexibility and integration of action into a variety of situations. Your plan should be established for seasonal events as well as an intentional acts of bio terrorism. Although the risk of a true biological terrorism event is small, the impact will be huge. One way to prepare for low-frequency, high impact events is to look for other similar events to hone our skills.

Seasonal influenza is an often overlooked opportunity to test our biologic planning. Expected seasonal outbreaks of various diseases provides us with the opportunities to review plans, test communications and public information, and even exercise “what if” scenarios with tabletop exercises. The added benefit of this real-world exercise is enhanced preparedness for large scale biological event as well as improved response to seasonal or expected biologic events.

Keys for workable Pandemic Biologic Plan

Follow a planning process. Every community and organization must follow a planning process. Establishing a consistent planning process helps reduce error in critical situations and supports positive outcomes.
  • Planning in stages or granular planning allows for mistakes and ideas to be identified and explored.
  • Identify a planning team and team leader. Written authority should be given.
  • The planning team should conduct a threat assessment and hazard analysis identifying not only the probability of a biologic event, but the consequences as well.
Conduct a threat and hazard assessment. Every jurisdiction should have conducted a threat assessment in hazard vulnerability assessment as part of their general preparedness planning. Our vulnerability to that hazard requires a bit of detail:
  • Loss of personnel - Personnel may not report to work due to direct or indirect impact of a biologic event. Personnel may become ill and not able to report (direct impact) or may remain away from the work environment resulting from indirect impact such as school or day care closure, ill family members, or fear. These losses apply to uniformed and civilian employees in public service organizations as well as clinical and non-clinical staff in health care.
  • Loss of surge capacity - surge capacity is a function of physical space, resources and personnel. Loss of personnel will limit ability to manage surge even when plenty of bed space exists.
  • Need for decontamination and personal protective equipment - if not properly decontaminated, the environment of care can act as a reservoir of disease and cause infection of otherwise healthy persons. Personal protective equipment (PPE) may be scarce and vendors may not be able to keep up with demand or deliver as needed. PPE should be appropriately stockpiled and not subject to just-in-time inventory.
  • Impact of surrounding communities on your operation - Are neighboring jurisdictions and facilities as prepared as well as you are? If not, expect an influx of people into an area that is prepared and operating well. This influx from surrounding areas can collapse even the best prepared organizations.
Conduct a review of existing infrastructure and systems. A proactive and constructive review of existing infrastructure will provide the framework for good planning. Assuming your systems will be viable if they haven’t been assessed or tested invites disaster.
  • Do you have robust planning, training and preparedness activities?
  • What is your ability to manage surge capacity measured by physical space, numbers of victims, and ability to provide treatment?
  • Have you established protocol for triage of limited critical services during a community-wide event? Are the triggers identified for making the change from standard response to sufficiency of response?
  • Has the preparedness of partner agencies, suppliers and vendors been evaluated? Without your partner agencies or contractors you may not be able to continue to provide service or carry out your mission.
Summary - your biologic plan should be:
  • a Pandemic Avian Flu Seasonal Flu generic plan written for a spectrum of events
  • following your established planning process and design activities
  • established for naturally occurring diseases and man-made intentional acts of bio-terrorism
  • become an annex to your larger preparedness planning document
  • be based on your threat and hazard vulnerability assessments
  • account needs identified while reviewing existing resources and infrastructure


Pre-incident Planning: An Introduction

 Steps to better Pre-Incident Planning

Pre-incident planning is known by many terms: emergency, contingency, disaster, crisis management planning all say the same thing. Regardless of the type of term you apply to the situation Pre-incident planning is essential for successfully minimizing the effects of crisis and disaster situations in any community. We've all heard the old adage “failing to plan is, planning to fail” . But how many of us put enough time into our pre-incident planning to do all we can to prevent “failing”? Here are some simple steps… a few things to think about… when doing your pre-incident planning:

What are you planning for? 
Pre-incident plans are valuable for any crisis situation or emergency. That is, anything that happens suddenly–disrupts daily activities, jeopardizes citizens and the economy, and of course, demands your immediate attention. The pre-incident phase is exactly as it sounds; planning before the situation happens. In order to do this effectively you have to know or at least be able to predict the possibilities that your community may face. You make these predictions based on your hazard assessment and risk assessment. Your pre-incident plans also become an important tool for successful training activities later on.

Planning Overview
Pre incident planning has a single yet complicated goal; that is to minimize effects of any given situation. again, we have to assess the threat, the vulnerability, and the potential risk of emergency or crisis. Keep in mind that there is no one single plan or pre-incident plan for every community. Also, your pre-incident plan is only as good is the data you build the plant on that is, you only get out what you put in.
Remember, most pre-incident plans don't deal with normal or everyday situations… and routine policies, procedures, standard operating guidelines may not apply in certain crisis situations. Therefore it becomes important to develop policies procedures and standard operating guidelines for disaster situations that go along (hand-in-hand) with your pre-incident disaster plans.

Planning expected outcomes
Your pre-incident planning process will help you ensure that appropriate levels of personnel supplies and equipment are available at times of disaster or crisis. Your planning process will also add your organizational structure and make sure the structure is in place and updated. Another major benefit of the pre-incident planning process is the ability to make recommendations in through the audit process; ensure that these recommendations are implemented. Pre-incident plans can also validate your risk assessment and hazard analysis by bringing all the data into one place.

Pitfalls in planning
 Above all else you must avoid Optimism Bias in your planning process. As said earlier, your plans are only as good as the data you used to build them. Along with that you have to evaluate your ability to implement the plan. Again, you have to be realistic and don't assume you have all the capabilities or resources you'd like. Emergency and disaster case studies throughout history underscore the need for pre-incident planning that emphasizes delivery of a sufficient operation over a standard operation.


BioAgent Facts app lacks virulence

BioAgent Facts app image UPMC
Facts, yes...pizazz, no.

BioAgent Facts app from the University of Pittsburgh Medical Center (UPMC) provides facts about diseases that could be encountered as a result of a naturally occurring event or intentional release. UPMC hosts the Center for Biosecurity and publishes several on-line publications such as Biosecurity News Today and Clinicians' Biosecurity News. I'm a subscriber to the UPMC/Biosecurity newsletter and familiar with their content quality.

Below is the text description of the BioAgent Facts app as given in the iTunes Store:
BioAgent Facts gives you facts about pathogens that could cause serious disease resulting from a natural epidemic or use as a biological weapon. This new app is offered by the Center for Biosecurity of the University of Pittsburgh Medical Center (UPMC) for those interested in learning more about these important diseases and the threat of bioterrorism. iTunes description

BioAgent Facts screenshot (UPMC/iTunes)
BioSecurity Facts are listed for each pathogen convered. The pathogens covered in this release are:
  • Anthrax
  • Botulism
  • Flu
  • Plague
  • SARS
  • Smallpox
  • Tularemia
  • Viral Hemorrhagic Fevers (VHF)
  • and...Zombies? (Yes, Zombies)

Facts for each pathogen are categorized by tabs for:
  1. Background
  2. Illness
  3. Treatment
Background information includes further details on transmission and potential for use as a bioweapon.

Background screen (iTunes/UPMC)
Under the illness tab the user will find general signs and symptoms for each pathogen and variations. As with Anthrax and Plague, for example, the various types have their own subcategories.

The treatment tab includes information on prophylaxis, vaccine, as well as decontamination and personal protection as appropriate for each pathogen. BioAgent Facts app users are reminded to contact local health departments for more information during a confirmed biological attack and encouraged to report to your local hospital if you think you've been exposed, or exhibit unusual signs or symptoms.

Generally speaking, information in this app is well defined and the content written for those of us without advanced microbiology degrees. The source (UPMC) is a trusted authority and the facts are consistant with other sources including the Centers for Disease Control and Preventions Bioterrorism Agents/Diseases page.

The graphics and color choices used in the BioAgent Facts app are appealing, albeit somewhat spooky. The app is rated 9+ by iTunes for Infrequent/Mild Horror/Fear Themes. (Click here learn more about iTunes ratings) While the graphics/color scheme are engaging, I found the white text on blue background difficult to read. Use of the app was complicated by the inability to re-size the screen with gestures and small text.

Although the pathogens included in this release are potential threats, Dengue Fever and West Nile Virus may be timely additions. The "special feature" on Zombies is a complete waste of valuable real estate in this app. With all respect to popular culture, including zombies in BioAgent Facts diminishes the value and credibility of the app. The section dedicated to Zombies would be better served by including details of personal protective equipment such as N95 masks, guidelines for hand hygiene, respiratory etiquette, and appropriate social distancing during a biologic event. A segment on the importance/risks/benefits of vaccines would be more appropriate use of space as well.

BioAgent Facts is compatable with iPhone, iPod touch, and iPad with iOS 4.2 or later. I'm running this app on an iPhone4 with iOS 4.2. Its stable and runs quickly. The link for BioAgent Facts Support on iTunes links back to the UPMC homepage where the BioAgent Facts app icon has you running in circles back to iTunes. There is no mention of versions, additional features or anticipated upgrades.

Final Score:
Content: 2.0 I'd like to see more detail and better use of information. Telling people to report to your local hospital may not be the ideal action to take in every biologic situation and contacting the local health department may be impossible. The inclusion of a Zombie category lowers credibility, too. Dumping the Zombies and adding personal protection information or vaccine facts, and provide links for information rather than reporting to hospital or contact health department makes this a 4.0 app! I would not recommend this version BioAgent Facts for anything more than casual use.

Aesthetics/graphics: 4.0 I liked the graphics and color combinations.

Ease of Use: 2.0 I found the tabs/buttons too small and kept hitting the info button when trying to tap the home tab. Text is too small and white text on blue background was hard to read. Although stable on an iPhone (iOS 4.2) there is no clear support/FAQ available.