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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