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Sunday

2013/2014 Flu Update #3


Update #3 for December 28, 2013

ILI activity climbing fast, HAN Alert Issued

This weeks Mitigation Journal Flu Update includes publicly available data from the CDC FluView, Google Flu Trends and other media sources.

This report contains data from the Centers for Disease Control and Prevention 2013/2014 Influenza season for week 51 for the period ending December 21, 2013. In this period flu cases are described as "widespread" and Health Alert Network advisory published.

The  CDC's Heath Alert Network (HAN) has published an official CDC Health Advisory alerting clinicians to reports of severe respiratory illness/infection with influenza A (H1N1). According to the HAN Advisory, the H1N1 pdm09 virus has resulted in numbers pH1N1 hospitalizations and ICU admissions. Some fatalities have bee reported. The alert also notes "While it is not possible to predict which influenza viruses will predominate during the entire 2013-14 influenza season, pH1N1 has been the predominant circulating virus so far.

According to the CDC Flu View site:
During week 51 (December 15-21, 2013), shows continued increase of influenza activity in the United States.
  • Viral Surveillance: Of 6,813 specimens tested and reported by U.S. World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories during week 51, 1,639 (24.1%) were positive for influenza.
  • Pneumonia and Influenza Mortality: The proportion of deaths attributed to pneumonia and influenza (P&I) was below the epidemic threshold.
  • Influenza-Associated Pediatric Deaths: One influenza-associated pediatric death that occurred during the 2012-2013 season was reported.
  • Influenza-associated Hospitalizations: A cumulative rate for the season of 4.3 laboratory-confirmed influenza-associated hospitalizations per 100,000 population was reported.
  • Outpatient Illness Surveillance: The proportion of outpatient visits for influenza-like illness (ILI) was 3.0%, above the national baseline of 2.0%. Eight regions reported ILI at or above region-specific baseline levels. Six states experienced high ILI activity; eight states experienced moderate ILI activity; six states experienced low ILI activity; 28 states experienced minimal ILI activity, and the District of Columbia, New York City, and two states had insufficient data.
  • Geographic Spread of Influenza: The geographic spread of influenza in 10 states was reported as widespread; Guam and 23 states reported regional influenza activity; 12 states reported local influenza activity; the District of Columbia, Puerto Rico, and four states reported sporadic influenza activity, and the U.S. Virgin Islands and one state did not report.
Timeline Comparison
Below are CDC FluView maps that compare the prior two reporting periods against the corresponding weeks of 2012/2013 influenza season. They indicate ILI activity increasing steadily through weeks 48 to week 51, 2013. There is a noticeable difference in ILI activity between week 51 2013 when compared to week 51 2012. The 2013 CDC map demonstrates a much lower geographical impact of High ILI activity compared to the current year at this time.

2013/2014 CDC Flu Interactive Map for week 51 2013


2013/2014 CDC Flu Interactive Map for week 50 2013


Comparison: 2012/2014 CDC Interactive Map for week 51, 2012 

Google Flu Trends

Google Flu Trends remains a trusted source for ILI activity and comparison data. According to Google Flu Trends ILI activity has progressed from moderate to high between December 15 to December 22, 2013. 

Monday

Scheduling Your Mandated Vaccines

 When is voluntary compliance not enough?

Joint Policy Statement endorses mandated vaccine schedule.

The Infectious Disease Society of America, the Society of Heatlhcare Epidemiology of America, and the Pediatric Infectious Diseases Society have collectively endorsed recommendations made by the Advisory Committee on Immunization Practices (ACIP) concerning universal immunization of health care workers.

The joint statement issued December, 2013, called for voluntary immunization programs to be discontinued in favor of mandates when compliance falls below 90%. ACIP further recommends that healthcare workers provide "documentation of receipt of ACIP-recomended vaccinations as a condition of employment, unpaid service, or receipt of professional privileges." Full text of the joint statement can be found with the link below.

Mandated vaccine against seasonal influenza has been hotly debated for several years (see Mandate the Shot or Not). While this debate continues to grind on there has been little attention given to the non-pharmacologic strategies that go hand-in-hand with vaccinations.

Pharmaceutical shortages have occurred and are certain to play a role in vaccine production in the future. Requirement or not, if vaccine is not available, you won't get it. What about when no vaccine has been created to fight a given pathogen? To both situations healthcare workers should turn to personal protective equipment to help prevent the spread of disease (see Best Disease Prevention is Action).

Saturday

2013/2014 Flu Update #2


Update #2 for December 14, 2013

Modest increases in ILI activity 

This weeks Mitigation Journal Flu Update includes publicly available data from the CDC FluView, Google Flu Trends and other media sources.

This report contains data from the Centers for Disease Control and Prevention 2013/2014 Influenza season for week 49 for the period ending December 7, 2013. In this reporting period flu cases are continuing to increase but remain behind last year at this time.

According to the CDC Flu View site:
During week 49 (December 1-7, 2013), shows continued increase of influenza activity in the United States.
  • Viral Surveillance: Of 6,219 specimens tested and reported by U.S. World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories during week 49, 830 (13.3%) were positive for influenza.
  • Pneumonia and Influenza Mortality: The proportion of deaths attributed to pneumonia and influenza (P&I) was below the epidemic threshold.
  • Influenza-Associated Pediatric Deaths: No influenza-associated pediatric deaths were reported.
  • Influenza-associated Hospitalizations: A cumulative rate for the season of 2.0 laboratory-confirmed influenza-associated hospitalizations per 100,000 population was reported.
  • Outpatient Illness Surveillance: The proportion of outpatient visits for influenza-like illness (ILI) was 2.1%, above the national baseline of 2.0%. Three regions reported ILI above region-specific baseline levels. Four states experienced high ILI activity, five states and New York City experienced low ILI activity, 41 states experienced minimal ILI activity and the District of Columbia had insufficient data.
  • Geographic Spread of Influenza: The geographic spread of influenza in 14 states was reported as regional; 18 states reported local influenza activity; the District of Columbia, Guam, Puerto Rico, and 16 states reported sporadic influenza activity; the U.S. Virgin Islands and two states reported no influenza activity.

Timeline Comparison

Below are CDC FluView maps that compare the last two reporting weeks and 2012/2013 week 49 to this year at week 49. They indicate a modest increase in ILI activity from the week 48 to week 49, 2013. There is a noticeable difference in ILI activity between week 49 this year versus week 49 2012.

2013/2014 CDC Flu Interactive Map for week 49 2013

2013/2014 CDC Flu Interactive Map for week 48 2013

Comparison: 2012/2014 CDC Interactive Map for week 49, 2012 

Google Flu Trends

Google Flu Trends remains a trusted source for ILI activity and comparison data.

Monday

2013/2014 Flu Update #1


Update #1 for the week ending December 9, 2013

Flu activity increases slightly, but will we follow the 2012/13 pattern?

This weeks Mitigation Journal Flu Update includes publicly available data from the CDC FluView, Google Flu Trends and other media sources.

This report contains data from the Centers for Disease Control and Prevention 2013/2014 Influenza season for week 48 for the period ending November 30, 2013. In this reporting period flu cases are starting to increase most notably in the south and south east.

According to the CDC Flu View site:

During week 48 (November 24-30, 2013), influenza activity increased slightly in the United States.
  • Viral Surveillance: Of 5,306 specimens tested and reported by U.S. World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories during week 48, 536 (10.1%) were positive for influenza.
  • Pneumonia and Influenza Mortality: The proportion of deaths attributed to pneumonia and influenza (P&I) was below the epidemic threshold.
  • Influenza-Associated Pediatric Deaths: One influenza-associated pediatric death was reported.
  • Influenza-associated Hospitalizations: A cumulative rate for the season of 1.2 laboratory-confirmed influenza-associated hospitalizations per 100,000 population was reported.
  • Outpatient Illness Surveillance: The proportion of outpatient visits for influenza-like illness (ILI) was 1.9%, below the national baseline of 2.0%. Two regions reported ILI above region-specific baseline levels. Two states experienced high ILI activity, two states experienced moderate ILI activity, two states and New York City experienced low ILI activity, 44 states experienced minimal ILI activity and the District of Columbia had insufficient data.
  • Geographic Spread of Influenza: The geographic spread of influenza in nine states was reported as regional; 13 states reported local influenza activity; the District of Columbia, Guam, Puerto Rico, and 27 states reported sporadic influenza activity, and the U.S. Virgin Islands and one state reported no influenza activity.

Comparison to last year at this time.

In the 2012/2014 flu season public health emergencies were not declared in New York and Boston until well after high numbers of ILI cases and intensity had been experienced. By looking at the  trends displayed between these two maps, can we predict and prepare for increased flu numbers in the coming weeks? The following images compare the Influenza Like Illness (ILI) activity for week 48 of 2012 and 2014. Both maps indicate ILI concentrations in the South and Southeastern United States. By reviewing last years data we know that with in four-weeks high ILI activity had progressed to the Northeast. Can we predict the same for 2013?  

2013/2014 CDC Flu Interactive Map for week 48 2013




Comparison: 2012/2014 CDC Interactive Map for week 48, 2012 


Google Flu Trends

Google Flu Trends remains a trusted source for ILI activity and comparison data.

Friday

This Week in Preparedness 11.29.13

Mitigation Journal TWiP week ending 11.29.13

CDC buys into Social Media to Predict Flu - sponsors "Predict the Influenza Season Challenge" Enter for a chance to will $75,000 and CDC recognition. (CDC.gov)

Department of Health and Human Services balk at H7N9 Vaccine. Is HHS holding back on a vaccine that could dampen the threat of pandemic from H7N9? If so, why? Read Politix Why Won't HHS Approve Crucial Flu Vaccine? (politic.topix.com)

Always worth following - Google Flu Trends indicates low level of seasonal flu activity in the United States as of this posting. Current numbers reflect flu cases on par with average for this time of year.  (google.org)

New Guidelines on Managing Obesity Crisis - The American College of Cardiology and the American Heart Association along with The Obesity Society and National Heart Lung and Blood Institute have issued a updated set of guidelines to battle what is believed to be one of the largest threats to national security and public health...Obesity. (medscape.com)

H7N9 Has Virulence and Transmissibility - It's stupid and contagious! But then, these are the qualities of most viruses. Novel Flu Virulence and Transmissibility. (thealmagest.com)

Nurses have a role in creating new IT? Really, what the heck for? Read: Why nurses must be involved in developing new health IT (fiercehealthit.com)

Preventing Opimism Bias is cornerstone of MJ's Culture of Preparedness. We've talked about preventing the "it can't happen to me" mentality since day one. Mainstream media is starting to listen according to this piece from The Journal Gazette (Fort Wayne IN) Be Wary of 'it can't happen here' attitude. (journal gazette.net)

The Many Faces of H7N9. Indications are that H7N9 has as many as six different clinical presentations according to data gathered and presented in the Avian Flu Diary. Bookmark and check Avian Flu Diary often. (afludiary.blogspot.com)

Monday

Preparedness by Popular Demand

MJ Readers Suggest Topics for 2014


What preparedness topics are important to you as we move dangerously close to 2014? I asked that question on my Facebook page (rickrussotti) and was impressed by the depth of topics our readers and listeners came back with.

Steve Erb (Rochester, NY) suggested crowd/spectator control planning for events at malls, schools, sports ensues and outdoor events (civilian soft targets). Steve writes "we might learn some things regarding planning, communication and response from the Aurora, Colorado theater shooting as a case study." 

The Aurora situation is another tragic milestone with enduring lessons.  The rescue efforts have been questioned during that event and we've seen how politics can bog down readiness. In the end, what have we learned since Columbine? 

Michael Coffin (California) suggested a continued look at active shooter events along with a session on Zombie Apocalypse. Both are right up our alley. The zombie theme was mentioned by Lisamarie Pocza (Massachusetts), too. 

John Spaulding (Rochester, NY)suggested credentialing for volunteer fire officers, pre incident planning, and  social media in public safety. Johns topic about social media is exemplified by this post - all this subject matter came from one Facebook post!

Micheal F. Staley (Georgia) brought up an often overlooked topic - the importance of taking care of our family. 

Jim O'Kelly (Rochester) hit on another under-addressed topic - life in the post antibiotic world. 

You can follow me on Facebook and Twitter (@rickrussotti)

Saturday

Welcome to Year Nine

Mitigation Journal Begins Ninth Year

For a variety of reasons I've struggled to find the time and energy to get back to the keyboard. I've questioned the relevance and importance of what we've been doing with Mitigation Journal blog and podcast over these past eight years. Social media has exploded and resource sites such as the CDC and UPMC have grown exponentially since MJ started in November, 2005, leaving me to wonder if this project is relevant any longer. 

The answer to the self-imposed question of relevancy came while I was speaking at large conference on the East coast. A line of attendees formed at the conclusion of each of my talks; not so much to ask questions, but to tell me how much they appreciated Mitigation Journal. Some preferred the blog content while others relied on the podcast of information. More than fifty people stopped me to introduce themselves and say they had read or listened to Mitigation Journal. Fifty people - I know the number because thats how many business cards were given out. Not too bad considering my original goal for this project was to reach 100 readers/listeners in Rochester, New York. 

With my misgivings abated we will move on. Mitigation Journal has turned eight. We're proud to say the blog receives 300 hits per day (even during hiatus) and the podcast reaches thousands of listeners world wide. As I say in classes "this is audience participation" and your voice is important to our conversation. Please follow me on Facebook (rickrussotti) and Twitter (@rickrussotti) to carry on that conversation. 

On behalf of Matt, our podcast co-host, thank you for your support and welcome to year nine!

Wednesday

MJ 252: A Unique Perspective on Secret Spying




A Unique Perspective on Secret Spying on Mitigation Journal - keeping the use of tin foil to a minimum. 
This edition is all about the revelation that the United States Government has been collecting data from various sources on each and every one of us. The situation is breaking news and unnerving but should we be surprised? 
In this edition we discuss how the changes in technology have made it possible for secret spying on the American pubic to take place. In the name of “stoping terrorism” we’re collecting cellular, internet, and email data on everyone...just in case we find something worth investigating. 
WIll this type of surveillance work? No. It didn’t work during the Civil War and World War Two and it won’t work now. 
At the end of it all, we have to ask it now is the time to unplug? 

Check out this episode!

Monday

MJ 251: Tornadoes - first hand with Mike Ehrman



We have a special guest this week, Mr. Mike Ehrman is joining us by phone to bring a first-hand account of the tornadoe situation in Oklahoma. Mike has been posting updates to his Facebook page outlining the situation as well as rescue and recovery operations. Today we'll talk about the disaster backpack program, pet supplies for special needs populations, damage assessments, and shelters.
We'd like to thank Mike for taking the time to join us on todays podcast and we extend our thoughts and prayers to those impacted by the storms.

Check out this episode!

Tuesday

When Can We Stop Training for Terrorism?

Time to focus on what we're the threats we're seeing today

This posting was originally written in 2005 and reflected my views on how expenditures of time and money were being wasted in the name of terrorism training. Not much has changed over the eight years since I originally published this article' except for a decrease in preparedness funding, of course. We've seen several assaults on civilian soft targets resulting in mass casualties during this time as well. Some have been labeled "terrorism" some have not. While we can debate the usefulness of terrorism as a descriptor of what we face, we can't ignore the fact that our responses to these events are not much improved from the pre-9/11 days.

From 2005...
Our language reflects how we think and act. When we place a term on an issue, that term becomes face or imprint in our mind for that given issue. Terrorism and weapons of mass destruction (WMD) are two terms arisen out of the September 11, 2001 attacks that have been imprinted on us. Although not entirely new terms for many in the traditional response group of emergency medical service (EMS), fire service, and law enforcement; terrorism and WMD became the language defining events of National crisis. These and several other terms have taken on a center stage appearance since 9-1-1. Highly paid “experts” have become obligatory content in any number of trade journals and conferences. Emergency service organizations have received millions of grant dollars to purchase training/education, equipment, and supply all to be brought to defend against terrorism/WMD. 

Most of the training that has been conducted is next to meaningless. A majority of the training conducted lacks context to what is encountered and managed every day. That is to say; we need to take the all-hazards approach to training and relate the material to the bread-and-butter jobs paramedics, EMT’s and firefighters respond to. Doing so will keep the skills and knowledge fresh and usable. If we continue to wrap this material up and say “don’t open ‘till terrorist attack” we will not be able to use it properly. We must take the message given by intentional event training and project it across routine, every day events. I believe the terms terrorism and WMD should be replaced with intentional events.

A good example would be to apply the all-hazards approach to triage. Ask any group of emergency medical technicians or firefighters, veterans or rookies, if they’ve ever worked an event that they’ve needed to do triage. You might get one or two that have, but the majority will claim to have never needed their triage skills. In reality we all have. The fact is that we do triage on each and every call we’re on. Triage means to sort and prioritize. We do that with every patient, looking at injuries and complaints, making decisions about what to treat first and how. Firefighters triage the situation, the building and the fire…only it’s called size-up, and we’ve been doing it for years. Educators who can describe intentional event preparedness in this format will be giving the student the tools to truly be prepared.

"If we continue to wrap this material up and say “don’t open ‘till terrorist attack” we will not be able to use it properly."

I’ve found numerous training officers who would come to me after a lecture and buoyantly declare “this WMD stuff is all well and good, but my guys need to get back to basics”. I usually ask those officers if they believe the “basics” include training on poisons and toxics like organophosphate materials. Or, might we be able to find time in our zealous training schedule to include basics of mass casualty management. Oh, the irony of it all! For these same training officers do not hesitate to defend the need for hazardous materials or mass casualty training yet miss the more than obvious relationship between intentional events and the hazardous materials event or bus crash. I guess if we call it haz-mat they’re OK with it, but; terrorism…hell, terrorism can’t happen here, right? Not to mention the probability of a natural event impacting any community.

The point here is this; we have to blend what we’ve come to know as terrorism/WMD training into the “basics” of EMS and fire service. To do so is simple because of the similarities between the intentional (terrorist/WMD) event and haz-mat accidents, mass casualty events, and natural disasters.

What do accidents, man-made events (human initiated to be politically correct), and natural disasters (ice storms, hurricanes, earth quakes, floods) have in common? The short list of examples include:

  • Little or no warning
  • potential for large numbers of civilians needing assistance
  • multiple casualties and fatalities
  • protracted operations
  • limited resources


The all-hazards approach looks at preparing us for a multitude of potentials. Not everyone has to be ready for a blizzard or a wildland fire, but we should all be cognizant of the need for self-protection, working within the incident management systems, triage and the like. We also must take advantage of our existing knowledge and skill base by putting them to use in the context of terrorism/WMD events.

The labels of terrorism and WMD may have been a great disservice to our responders and citizens. Those terms imply an event that most people don’t believe will ever happen to them. However, the principles, tactics, and added knowledge that training for intentional events advocate can traverse a multitude of disciplines and events.

Let’s try to change our thinking...when will it happen here?

Wednesday

Rescue efforts questioned after Aurora

EMS NOW - a weekly highlight of emergency medical services

Paramedics cited as unprepared but system preparedness should be in question.
By Rick Russotti, RN, EMTP
This article made possible with the support of KMS Medical

"When a shooter sprayed a movie audience...paramedics were not prepared for the extent of the carnage and arrived with too few ambulances..."  - CNN.com Ben Brumfield and Cristy Lenz, CNN
The above quote occupies the opening lines of a recent CNN article outlining the Aurora Fire Department Preliminary Incident Analysis of the July, 2012, theater shootings (link provided by Denver Post).  The incident took place on July 20, 2012 at 0040 hours, according to the report. A chaotic scene was described by initial responders who were met by nearly 1400 movie goers. Also, according to the report, responders were swarmed response vehicles and access/egress points.
"The number of critically injured patients encountered prior to reaching the theater slowed the process of apparatus reaching specific locations. Responding units were stopped by frantic moviegoers covered in blood and carrying critically injured patients." - AFD report
The report also notes that communications between traditional response agencies was lacking, resulting in delay in notification and deployment of EMS resources. Communications improvement and responder interoperability were major areas of improvement described by the McKinsey report after 9/11. The National Incident Management System (NIMS) also held interagency coordination at major events as a bedrock goal.

A gunman opening fire in a crowed multiplex theater is one of the most terrible situations conceivable perhaps trumped only by the release of a chemical agent. Preplanning and training for civilian soft target locations cannot be overstated. As I've said in past postings "skip the airport disaster drill and train for todays emerging threats."

While the AFD incident analysis reads with striking similarity to the after action report from Columbine High School in1999; we have to wonder how well have we remembered the lessons from Columbine?  How ready are we for an active shooter situation in a civilian soft target?

The threat of attacks on soft targets (movie theaters) continues. Why was EMS taking the headline fault for issues during this event? Faulting EMS for large-scale, multi jurisdictional failures seems to be a trend. It would be rare for an EMS agency, including one attached to a fire or police department, to take the incident command role in an active shooter event and more likely be operating as a division within the NIMS/ICS framework. So, why then do we continue to see headlines describing EMS as the weak link in a system-wide response? Natural events in Pittsburgh, Washington D.C., and NYC have all cited EMS as the poor performer and contributor to deaths.

The traditional response groups to fire, EMS and law enforcement must work together in training for scenarios such as a movie complex shooting. An understanding of each services response objectives and standard operating procedure must be reviewed and drilled on. Tabletop exercises and functional exercises can make this a reality.

EMS NOW sponsored by KMS Medical

Tuesday

Why "Terrorism" is Obsolete

Words that no longer matter in todays preparedness world

I'm disappointed by recent reports of the Mothers Day shootings that took place in New Orleans for several reasons. My obvious disappointment, because the shooting happened during a celebratory parade (civilian soft target). The not-so-obvious disappointment; local government officials snapping out the "its not terrorism" phrase almost as bold as the headlines. It seems we're quick to ensure whats not terrorism, quick to define whats not a threat as if to tell the public to go back to sleep, nothing to see here.

The lines and definitions of what is and what is not have become too blurred to be meaningful.

19 people shot during a parade in New Orleans is not terrorism. Its gang violence. Would the presence of an elected official or religious leader at the parade make the shooting an act of terrorism? Perhaps.

In January, 2011 an individual opens fire at an outdoor gathering in Tucson, Arizona, hitting 18 people including U.S. Representative Giffords and killing 6 others. The incident was initially describes as "terrorism" by numerous officials.

Regardless of the title bestowed, the outcomes remain the same.

Another term thats outlived its usefulness is Homegrown Terrorism. We started using that little waste of text after some freshly re-worded, politically corrected preparedness documents were published. We're supposed to use Homegrown in place of Domestic Terrorism. According to WikiPedia Homegrown Terrorism is the
 “use, planned use, or threatened use of force or violence by a group or individual born, raised, or based and operating primarily within the United States or any possession of the United States to intimidate or coerce the United States government, the civilian population of the United States, or any segment thereof, in furtherance of political or social objectives.”
To understand how moronic this is, realize that, according to this definition, the attacks of 9/11 were Homegrown Terrorism.

Why not retire terms like terrorism and homegrown terrorism? They taint our thinking, planning and response. Instead why not embrace Rule of Outcomes Thinking that prepares us for a variety of outcomes from events...regardless of the motive. Rule of Outcomes Thinking leads to preparedness based on what we can expect the outcomes of a given event to be. Its a close cousin to all-hazards. We don't need to stress over who's in charge if its a terrorist event or not. Manage the situation based on the outcomes or anticipated outcomes.

Monday

MJ 250: Focusing on New Flu and NCoV




Why wait? The writing is on the wall indicating N7N9 and Novel Corona Virus situations could follow similar paths that Avian Flu and SARS did. Those subtle warnings should be calling us to action now. 
On Mitigation Journal Podcast this week: 
Editorial changes: We’re attempting to publish blog topics on regular days (by reader request). Go to mitigationjournal.org for details.
University of Pittsburgh Medical Center Center for Health Security (formerly center for biosecurity) Follow them on Twitter @UPMC_CHS
Pandemic on the horizon? Maybe two. This is our reminder that pandemics and biologic events usually start small with subtle warnings. Those warnings are there now. We should be paying attention. MERS-CoV is gaining momentum and the future of H7N9 is unclear. Now’s the time to become engaged in “Determined Awareness” and educate yourself - get in tune with the CDC by visiting their website, visit your local health department website and coordinate with responder groups. 
Action now will pay off. 
See Related MJ topics:

Check out this episode!

Friday

Nurse Triage Line Project at Public Health Preparedness Summit 2013

Nurse Triage Line Project - a fresh look


The highlight of covering the Public Health Preparedness Summit was meeting the people behind the scenes in public health. We had a chance to discuss a variety of critical preparedness topics including the Nurse Triage Line Project. In this session, we're honored to be joined by a panel of experts at the Public Health Preparedness Summit on the topic of the Nurse Triage Line Project and preparedness for major events and disasters. Our guests in the podcast studio are:
  • Dr. Aaron DeVries, Medical Director of the Infectious Disease Division at the Minnesota Department of Health
  • Dr. Lisa M. Koonin from the Centers for Disease Control (CDC)
  • Dr. Gregory M Bogdan, PhD, Administrative Director for the Rocky Mountain Poison and Drug Center at Denver Health
For more follow the channel here or over at MedicCast.tv for more segments from the PHPS summit sponsored by NACCHO.

Special thanks to Jamie Davis of the MedicCast and Promed Network for his efforts producing this video series. 

Wednesday

Biologic Update for the week of May 6, 2013

Weekly report on biologic events and emerging disease

H7N9 - Avian Influenza

According to both World Health Organization and the Centers for Disease Control and Prevention, there are currently 130 confirmed cases with 31 deaths from H7N9. Both WHO and CDC further report no indication of human to human transmission of this avian flu virus at this time. WHO isnot recommending  any special screening or travel restrictions at this time. There have been no cases reported outside of China and as of this posting, the situation seems to be following a similar path to H5N1 in 2005. 

The CDC, however has urged US hosptials to remain alert for H7N9 cases and has issued interim guidelines on the use of antivirals for this avain flu. 

Novel Corona Virus (NCov)

The most recent updates to the novel corona virus include a change in name. The virus is now being described as Middle East Respiratory Syndrome-CoV or MERS-Cov. According to published information as of this post, there have been 13 people infected with MERS-CoV with 7 deaths. All sources indicate that human to human transmission is probable. 

According to UPMC Center for Health Security there are several important similarities and significant differneces between SARS (2003) and the current MERS-CoV :

Similarities between MERS-CoV and SARS include:
  • Disease is caused by a novel coronavirus.
  • Bats are the suspected reservoir species from which the virus originates.
  • The intermediary animal from which the virus spills into human populations is not known.
  • Disease spread may be occurring in healthcare facilities.
Significant differences between MERS-CoV and SARS:
  • There is no evidence of human MERS-CoV superspreaders who disproportionately transmit the virus among people.
  • There is no evidence yet of sustained human-to-human transmission.
  • MERS-CoV infects a broader range of cell types throughout the body.
  • MERS-CoV may respond to treatment with medications similar to those used to treat hepatitis C.

Friday

Acute Radiation Sickness

Overview of biologic effects of radiation, acute radiation sickness


Biological effects of radiation are dependent upon the type of exposure a person has with the duration of the exposure and intensity of the material playing a key role. We also have to include the role of personal protection such as time, distance and shielding.

Acute Radiation Sickness (sometimes called Acute Radiation Syndrome or ARS), occurs when an individual is exposed to a large amount of radiation in a short period time or a total doses greater than 100 REM (100 RAD  for gamma radiation).  Acute radiation sickness has a variety of clinical features; some are obvious, some not.In general, the clinical manifestations of acute radiation sickness include the following:
  • changes in blood cell count, specifically lymphocytes decrease
  • vascular permeability changes
  • gastrointestinal irritation; nausea, vomiting, and diarrhea
  • fever
  • hair loss, in uneven patterns
  • skin rash, skin burns, in general skin irritation
  • vague symptoms such as flu-like symptoms
The appearance of these symptoms may begin within minutes after exposure or may not appear for several days. Symptoms may disappear after a few days and resurface with severe illness. Individual unique response to radiation is variable that has to be accounted for as well as age and pre-existing medical condition.

Acute radiation sickness has four phases and may manifest with four separate syndromes.
The four syndromes of acute radiation sickness  are:
  • Hematopoietic Syndrome
  • gastrointestinal syndrome
  • cardiovascular syndrome
  • and central nervous system syndrome
The four phases of acute radiation sickness are:
  • prodromal phase
  • latent phase
  • manifest phase (sometimes called the period of illness)
  • and recovery or death
From: REMM
 Hematopoietic Syndrome  effect the blood cells and platelet counts. The lymphocyte count begins to drop and is seen is the earliest marker or indicator of the degree of severity of exposure and subsequent acute radiation sickness.  Complications associated with Hematopoietic Syndrome  including infection and internal hemorrhage. Changes in lymphocyte counts are detected or measured on a Andrews Curve. The Andrews curve graphs the lymphocyte count for the first 48 hours. In addition to being a marker for severity of exposure to radiation,  decreasing lymphocytes are also all marker for treatment and prognosis. In many cases red blood cells and red blood cell production remains fairly normal after radiation exposure. Neutrophils decline in a gradual rate, while platelets may decrease slightly over time. Again, lymphocytes and lymphocyte counts are critical for determining the degree of severity of acute radiation sickness.

Gastrointestinal syndrome is a condition in which the epithelial lining of the G.I. system is gradually destroyed. Epithelial cells decline in results in nausea, vomiting, diarrhea, and sepsis. Sepsis is a result  of the loss of protective barrier that separates normal bacteria from the bloodstream. Gastrointestinal syndrome may impact the lower G.I. or upper G.I. tract, or both. In the lower G.I. system bloody diarrhea (frank in nature) is most common.

Large doses of whole body radiation can cause Central Nervous System and Cardiovascular syndrome. Both are caused by a destruction of blood vessels and an increase in capillary permeability. Symptoms usually appear fairly rapidly and take the form of cerebral edema, pulmonary edema, cardiogenic shock, and death. Victims exposed to large amounts of whole body radiation may often die within 72 to 80 hours, often before the symptoms of G.I. syndrome or hematopoietic  develop.

Acute radiation sickness may present within four distinct stages: prodromal, latent, manifest, and recovery/death. In the prodromal phase (approximately 48 hours after exposure) victims may present with:
  • nausea and vomiting, diarrhea
  • fatigue and headache
  • fluid shifts due to  increased permeability and electrolyte losses
 In the latent phase the victim may show signs of improvement. Depending upon the unique variables of the person and the dose/rate/body surface area of exposure. Symptoms may return in 24 hours to several days with greater severity.  The manifest illness stage produces compromise to the immune system and can present with symptoms of any one or all of the syndromes  (hematopooietic, GI, CV/CNS) discussed earlier. Symptoms may also be seen in major organ systems; particularly in the integument, neurovascular and G.I. systems of the body. The final stage of acute radiation sickness is the recovery or death stage. Unfortunately, treatment at this point is supportive in nature and the outcome is determined by the dose of radiation exposure and the body surface area along with the other variables we discussed. It should be noted that after a lethal dose of radiation, victims may progress through each of the four phases rapidly with a quick decline in status.


Wednesday

EMS NOW: Giving Feedback to the Trainee


EMS NOW - a weekly highlight of emergency medical services


EMS NOW: Giving Feedback to the Trainee

By Matt Comer, EMTP


"The first step is to realize a deficiency in learning exists and the learning domain the issues exists on"
As a field training officer or FTO, you are a clinical teacher of sorts whit the goal being to teach your trainees how to become solid, independent clinicians. Being an effective clinical teacher can be difficult at times and requires a calculated approach and understanding of how to give effective feedback. We must use clinical strategies for success. The first step is to realize a deficiency in learning exists and the learning domain the issues exists on. It there a knowledge deficit? Is there a an issue with skill performance? Is there an issue with attitude?

The trainee who fails to recognize the need for aspirin in the chest pain patient may be displaying a knowledge deficit. By contrast, if the trainee is unable to properly place a traction splint on a patient, the issue may be one of skill/psychomotor performance. A trainee who may be appear arrogant or not receptive to feedback could be considered to have an issue with attitude or personality. In all cases we should strive to understand the trainee

Once the issue has been identified and categorized, you can determine the best approach for delivering your feedback. A simple definition for feedback is "information about current performance given to improve future performance." 

Let's look at some examples of effective feedback for the clinical trainee. Feedback can be classified as positive and negative. Positive feedback is often easy to given and reinforces a correct action or behavior. Negative feedback can be difficult to give but, if delivered properly, can be a very effective teaching tool for the clinical education. 

According to the CJEM, there are four guidelines to follow when giving negative feedback. Those guidelines are as follows:

  • Give negative feedback in private taking care not to embarrass the trainee
  • Give negative feedback in a timely manner and delivered as soon as possible after observing the deficiency 
  • Give negative feedback should be specific and informative and must focus on the deficiency or problem and not the person
  • The trainee should be asked to provide a self evaluation and given an opportunity to solve the problem


Friday

Nurse Triage Line Project: Improving Service and Information During a Pandemic

Nurse Triage Lines provide information and reduce surge

Biologic and naturally occurring pandemic events share several commonalities. Whatever the cause of a large biologic event, like any other disaster, people need to know what to do and when to do it. In the case of a pandemic or similar biologic event, we also have to consider how we will manage getting appropriate medication to those who are sick. And no conversation on this topic would be complete without mention of surge capacity; a time when healthcare systems are overwhelmed with the flood of patients presenting with illness from the biologic or pandemic event.

Managing these situations and the many complexities within them requires a strong biologic event plan. There are numerous issues to consider when writing your biologic plan and it may seem like an impossible task. There are pitfalls to avoid in planning and you should consider having your plans reviewed to see if they include what every good plan should.  The bottom line: it all starts with information.

Getting information to the public and having them act on that information is key to successful operations during a pandemic event. Information is vital to getting people to the most appropriate level of care, medication, and in some cases, prophylaxis. The Nurse Triage Line (NTL) Project tackles these issues and more. The NTL Project goals inlcude:
  • Improving access to medications for the sick
  • Providing accurate and actionable information to the public
  • Promoting appropriate alternatives to medical care (to reduce surge)
Read the preliminary report on the role of NTL during 2009 H1N1 event here.

The public needs information they can rely on and take action on. The public needs to have access to this information in a timely manner, in a means that can be understood, and delivered by a medium that can be accessed. Key information points during a pandemic are when and where to seek medical care. Emergency departments, points of distribution (POD) sites, and clinics can quickly be overwhelmed by the surge of patients looking for information as well as those who are ill. The worried well or those looking for "what should I do" information clog the system and cause delays in seeing a medical provider and receiving medications.
From: Background, Purpose and Description of CDC NTL Project

The NTL Project seeks to mitigate these situations by building on existing systems such as 2-1-1 lines and Poison Control Centers (PCC). By implementing a NTL system into a PCC or other existing system, a caller could be triaged based on (a) need for information or (b) symptoms or need for care. The call would be screened based on need an then forwarded for medical advice, given information of where to seek face-to-face care, manage at home, or where to receive prophylaxis or antiviral care.

The systems of a NTL Project are considered for use only during a severe biologic event or pandemic. They mus also be able to meet the needs of at-risk populations including uninsured or underinsured. The benefits of NTL's are clear; improved access to medications, direction of appropriated people to face-to-face care (minimizing surge), and providing accurate and actionable information.

Wednesday

EMS NOW: Understanding the Trainee

EMS NOW - a weekly highlight of emergency medical services

EMS NOW: Understanding the Trainee
By Matt Comer, EMTP
 "...we have probably all been intimidated by one thing or another in the world of EMS..."
 We have all been trainees at one time or another in our EMS careers. We know firsthand the difficulties and hardships of having to be the new guy / girl. Everything is new and simply completing a rig check is a task requiring concentration. Likewise, we have probably all been intimidated by one thing or another in the world of EMS. Maybe it was learning CPR, suctioning an airway for the first time, or maybe it was just talking to a stranger about their medical history. As field training officers or FTOs and clinical educators we must be able to remember what it was like to be in that stage of our EMS career if we wish to be successful in training. We must be able to meet the trainee where they are in their EMS career in order to facilitate successful training. Identifying with the trainee and realizing they are not a veteran EMT like ourselves; is the first step in becoming a great FTO.

The next step is to understand how the trainee will learn so that we can teach them appropriately.  Learning styles have been well studied in many areas of instruction including EMS. There are three domains of learning: Cognitive, Affective, and Psychomotor. Over the next few months we will post articles that focus on understanding and applying teaching styles which encompass all three domains. So let me quickly define the three domains individually.

Cognitive
Involves knowledge and the development of intellectual skills. Includes the recognition of specific facts, patterns and concepts.
Affective
the manner in which we deal with things emotionally, such as feelings, values, appreciation, enthusiasms, motivations, and attitudes.
Psychomotor
physical movement, coordination, and use of the motor-skill areas. Development of these skills re-quires practice and is measured in terms of speed, precision, distance, procedures, or techniques in execution.
(Definitions according to Bloom)

Tuesday

MJ 248: Boston Marathon Bombing: First Thoughts



Mitigation Journal - the All Hazards Podcast #248

Visit www.mitigationjournal.org click the "voicemail" tab and leave us your comments.

Boston Marathon Bombing - Mitigation Journal first thoughts

This edition of Mitigation Journal Podcast was recorded on April 16, 2013. Due to technical issues the publication was delayed.

In this MJ Podcast we discuss our reaction to the Boston Marathon bombing. We outline the differences between hard and soft targets and implications of See Something, Say Something. Also included is information on situational awareness, incident indicators and a few explosive event tips.

Check out this episode!

Friday

Biologic Effects of Radiation

Radiation Exposure Phases and Syndromes

The biological effects of radiation are dependent upon the type of exposure a person actually has. Duration of the exposure as well as the intensity of the material play a role. Factors of personal protection such as time, distance, and shielding need to be included.

Biologic effects can be categorized generically as acute or chronic. Acute exposure may be for a very short period of time to a higher level radiation source while chronic exposure can either be in extended exposure to low-level source or repetitive exposures to a variety of sources of radiation.

 Individual biological differences must be considered. Each person is different and will respond differently to radiation exposure.  Extremely high-level radiation exposure is an exception.

In general, radiation causes three major problems in our bodies.
  • Radiation can damage DNA and other cellular structures
  • Radiation exposure results in cell death immediately or shortly after exposure
  • Radiation exposure results in incorrect cellular repair and mutations that can cause cancer and other disease
The effects of radiation on each person differs in their biologic response to any given dose of radiation. The factors that influence radiological impact on the body include:
  • age- Younger patients and those with a higher metabolism and cell turnover rate are more susceptible.
  • sex
  • diet
  • body temperature and overall health
Acute radiation sickness can occur when an individual is exposed to a large amount of radiation in a short period of time (acute exposure). This level of exposure may be defined that radiation doses greater than 100 REM which is equivalent to 100 RAD for gamma ray exposure. The signs and symptoms of acute radiation sickness vary by the dose received and by the unique biologic factors of each individual. Symptoms can be as subtle as “flu-like” symptoms or as dramatic as rapid changes in blood cells. In general acute radiation sickness generates the following:
  • nonspecific (flu-like symptoms)
  • hair loss
  • fever
  • skin irritation
  • vascular changes
  • blood cell changes
While the initial symptoms may seem minor such as with G.I. upset, the sooner a person vomits or loses consciousness after cute exposure indicates severe exposure. Severity and course of treatment depend on how much total doses been received as well as how much of the body has been exposed taking into account individual susceptibility as a variable. Acute radiation sickness is not an all-or-nothing situation. The symptoms may appear shortly after exposure only to disappear after a few days. Symptoms may also reappear in a much more severe illness later on.

Acute radiation sickness has four phases and may manifest with four separate syndromes.
The four phases of acute radiation sickness are:
  • prodromal phase
  • latent phase
  • manifest phase (sometimes called the period of illness)
  • and recovery or death
The four syndromes of acute radiation sickness  are:
  • Hematopoietic Syndrome
  • gastrointestinal syndrome
  • cardiovascular syndrome
  • and central nervous system syndrome

Wednesday

EMS NOW: Clinical Education Strategies for Success

EMS NOW - a weekly highlight of emergency medical services

EMS NOW: Clinical Education Strategies for Success
By Matt Comer, EMTP

"...in order for the trainee to learn they must have timely positive and negative constructive feedback..."
The clinical educator faces many challenges day to day.  Let’s take a look at some of the big ones and some strategies for successful outcomes.  First and most obvious principle is that you must be able to teach during non protected clinical time.  Most of the time when you think of an educator you think of a classroom right?  Teaching during clinical time requires you to balance teaching with being the clinician who is responsible for your patient.  Effective clinical teaching also requires that the trainee have patient contact and make or be involved in making actual patient care decisions.  In addition, in order for the trainee to learn they must have timely positive and negative constructive feedback.  As we all know this may be challenging when the pagers are beeping and dispatch is calling.  Being an effective clinical educator can be a daunting task.  In order to succeed as clinical educators we must take a strategic approach.  Below are some effective and proven strategies for being an effective clinical educator.

  • Orientation:  You must orient the trainee to the process in which the shift / call will flow.  The trainee must know where they fit in to the process.  This will give them the freedom to learn without being worried about the logistics of the shift / call.
  • Expectations:  You must set clear expectations for the shift / call.  Expectations allow the trainee to know how they will be evaluated.   Expectations should be discussed at the beginning of the shift in order to set the tone and create a positive learning environment.  
  • Feedback:  Both positive reinforcement of correct behavior / skills & constructive feedback correcting incorrect / inappropriate behavior / skills.  Feedback should be given as soon as possible and be as specific as possible.  
  • Demonstration:  You must role model and even demonstrate the desired outcome.  Whether it be patient rapport / communication or the skill of immobilizing a patient you must show the trainee the correct / appropriate way.  Role modeling gives the trainee a clear picture of what they should do, how they should act, and what cleared EMT / Paramedic / Nurse looks like.
     

Friday

Radiation Basics Demystified

Making Sense of Radiation

The threat or potential of harmful radiation can be expected from a variety of sources.
  • Nuclear weapon
  • Nuclear power plan accidents
  • Transportation and waste storage accidents
  • Military accidents
  • Vandalism
  • Terrorism

Rules for Radiosensitivity...made easy

“The sensitivity of cells to irradiation is in direct proportion to their reproductive activity and inversely proportional to their degree of differentiation.”                                          (Bergonie and Trubondeau)
What this means is:
  • The faster turnover rate (reproduction rate) a cell has the greater radiation exposure will effect it.
  • Unborn children and young children are affected more.
  • Effects can be terotgenic or mutagenic
Dose Rate Effects

From: REMM
Dose RATE is a significant factor. As the dose rate is decreased and the exposure time is increased, the biological effect for a given dose is decreased.

What this means is:

At lower dose rates more subleathal damage to the cell can repair and cell populations have time to reproduce and repopulate.




Units of radioactivity measurements

The three units of activity that are of concern to patient care are:
  • Units of activity.
  • Units of radiation dose or deposited energy
  • Units of biological dose equivalent.
  • Units of activity
From: REMM
Radioactive materials are classified by activity or rate of decay. Knowing radiation unit conversion is also helpful. The units of radioactive decay are:
  • The Becquerel (Bq) or disintegrations per second:
    • 1Bq = 1 disintegration per second
  • The Curie (Ci)
    • 1 Ci = 3.7 x 1010 Bq

Units of radiation dose

Units of radiation that is absorbed by the body is the dose.  The units of absorbed dose are:
  • The radiation absorbed dose (rad)
    • 1 rad = 0.01 Gy
    • 1 Gray (Gy) = 100 rad

Wednesday

EMS NOW: Future of EMS

EMS NOW - a weekly highlight of emergency medical services

EMS NOW: The Future of EMS
By Matt Comer, EMTP

"... if we hope to have a cutting edge provider as the future of EMS we need cutting edge clinical educators now..."
How does your agency/department select, train, and maintain its field training officers (FTOs)?  If your agency is anything like the ones I have worked for over the years, the process probably goes something like; “Hey you’re a good EMT or Paramedic , you’re going to be an FTO.”  FTOs are typically then sent out with little to no direction or continued education.  Unfortunately, this has been the model for FTO programs throughout EMS over the years.  In order to produce better EMTs and paramedics in the future we have to shift our model to view FTOs as educators.

As mentioned, typically the selection process for choosing FTOs has been picking our best    EMTs / Paramedics.  This selection process is based on the quality of the provider’s clinical care and perhaps whether or not they are a friendly person.  The selection process often does not take into account the future FTOs teaching style, personality type, or perhaps most importantly their passion to teach.  As EMS leaders looking to further our profession we must create a more comprehensive FTO selection process.  EMS leaders should place a strong emphasis on a provider’s passion to teach and become a FTO.  The future FTO will have to balance being a solid provider, a constant learner, as well as a passionate and skilled clinical educator.  The future FTO will become more than a trainer, they must become educators.

What is an educator?  According to Merriam-Webster it is:  one trained in teaching, a specialist in the theory and practice of education. “One trained in teaching”, that assumes some type of training specific to the science / art of teaching.  Rarely do FTOs receive any training on how to teach and may not ever receive any such training.  EMS training departments must develop and implement a comprehensive FTO training program in which the EMT/Paramedic can make the transition from clinician to clinical educator.  Our future FTOs are already experts in their field we must make them specialists in the theory and practice of education.  An additional challenge faces the FTO and that is being an effective clinical educator.  Over and above being an educator the clinical educator must teach their students in the clinical environment which offers many challenges.  The primary challenge we must prepare the new FTO for is how to balance appropriately treating their patients while allowing for a rich learning environment for the student.

So what does this new FTO program look like?  It begins with recruiting, seeking out, and selecting solid providers who are passionate about teaching.  Providers must be solid in their own practice as much of the additional training they receive will be on the theory and practice of clinical education.  The provider should be passionate about teaching as they now have to commit much of their time to teaching, guiding and mentoring students.  An FTO program must now offer initial and ongoing training on how to become and improve as a clinical instructor.  The program must place a strong emphasis on the education of the FTOs.  FTOs should be offered consistent and regular educational opportunities which give them a greater knowledge base not only as providers, but as educators.

The logic is fairly simple; if we hope to have a cutting edge provider as the future of EMS we need cutting edge clinical educators now.