Mitigation Journal

The Coming Public Health Collapse

2012-01-26T05:00:00.000-05:00

Co-posted on Genesee Valley Nurse

Click here

The Anthrax attacks that followed in the days after 9/11/01 reminded us of the need for public health emergency preparedness.

Public health efforts have vaccinated millions, crushed Polio, and eradicated Smallpox, and they've done so while operating in the background of emergency management in relative obscurity...until September, 2001. The Anthrax attacks provided a wake up call to the Nation that our public health system was vital to the effectiveness of domestic preparedness efforts. Public Health was thrust into the public safety arena. With emerging biologic threats that jumped off the pages of a novel and into reality, it looked as if public health was destined to remain a part of the new traditional responder group.

Not so fast.

In Ready or Not? 2011, Protecting the Public from Diseases, Disasters, and Bioterrorism, the Trust for Americas Health reports that "key programs that detect and respond to bioterrorism, new disease outbreaks and natural or accidental disasters are at risk due to federal and state budget cuts."

We're still searching for preparedness in America. Rather than continuing to support efforts to maintain a durable healthcare/public health preparedness system, we're going to go backwards.

"We're seeing a decade's worth of progress eroding in front of our eyes," said Jeff Levi, PhD, Executive Director of TFAH. "Preparedness had been on an upward trajectory, but now some of the most elementary capabilities - including the ability to identify and contain outbreaks, provide vaccines and medications during emergencies, and treat people during mass traumas - are experiencing cuts in every state across the country."

Here are a few examples of the capabilities that will be lost:

51 cities at risk for elimination from the Cities Readiness Initiative
10 state labs at risk for losing "Level 1" chemical testing abilities
24 states at risk to lose Career Epidemiology Field Officers
14 universities at risk to lose Preparedness and Emergency Response Learning Center funds

Why? Because when nothing happens, nothing happens. And nobody wants to pay when nothing happens. We've seen concern and hype over SARS, Avian Flu, Swine Flu - and ~~nothing~~ not much happened. Our impression of preparedness is high visibility people with uniforms, badges, guns under the failed approach of Homeland Security. Healthcare and public health operate in the background of preparedness and lack that high visibility until some biologic threat is exposed. Then, and only then, is the value of a durable healthcare/public health system realized...temporally. Katrina reminded healthcare systems to be ready. How can they be if they're not assisted with the same level of resources afforded to other Homeland Security measures?

Preparedness for biologic events, natural or intentional, requires funding to remain constant for healthcare and public health. That funding needs to be on par with other traditional response groups. Without healthcare/public health we will face what it means to live or die in disaster.

Failure to maintain healthcare/public health durability will worsen the ripple effect from biologic events by increasing strain on traditional responders and healthcare systems and by worsening the impact on special needs and at-risk populations. These things add up to poor outcomes from natural or intentional biologic events. Poor outcomes that can be predicted, and prevented if we'd change the way we think.

Get this Biosecurity app before your next shift

2012-01-24T08:02:00.001-05:00

Co-posted on Genesee Valley Nurse

The Clinicians Biosecurity App for healthcare providers from the Center for Biosecurity of UPMC is one app you'll want before your next shift.

Home screen on iPad

The Center for Biosecurity of UPMC has released their latest app for iOS. The Clinicians Biosecurity Resource (CBR) App covers the basics of several diseases with feature rich content for further leaning. CBR easily overpowers their prior offering, BioAgent Facts app. Click here for my review of the BioAgnet Facts app.

Disease list on iPad

The CBR app covers six diseases with enough detail to make this a worthwhile reference to assist in the recognition of a naturally occurring or intentional biologic event. The information for each pathogen is broken down into categories and is referenced to fact sheets from the Centers for Disease Control and Prevention (CDC) and he Center for Biosecurity. The value of the CBR app is increased substantially by the addition of sections for each pathogen on naturally occurring states, post exposure prophylaxis, personal protective equipment (PPE). The content is digestible, concise, and easily accessed through the apps interface. Images of x-ray findings are included (see Anthrax below).

Access to Biosecurity News

Notification option

You can also access Clinicians Biosecurtiy News (CBN), published twice monthly, directly from the home screen. Clicking on the wrench icon on the CBN page provides an option to be reminded about CBR updates. The information icon (i) links to the 'about' page containing a disclaimer, developer credits and additional links for reference.

Typical bioagent page layout shown below (Anthrax page as example)

The Clinicians Biosecurity Reference (CBR) will be useful for emergency medical service professionals, nursing, as well as physicians. The layout/design and feature rich content take this app above and beyond. Navigation and user interface are simple and CBR runs smoothly on iPhone/iPad running iOS 5.0.1. The color scheme is much easier to read than BioAgent Facts. I highly recommend the CBR app.

Final Score 0-5: The CBR app gets a 4.5
Content: 4.5 Solid information from a trusted resource, easy to access and scan. External links to CDC and Biosecurity News add value. CBR app can go a long way being used as reference and learning tool. Dumping the Zombie section (as seen in BioAgents Facts) and adding sections for Naturally Occurring, PPE, and Post Exposure information is a major improvement.

Aesthetics/graphics: 4.0 Detailed graphics and color combinations that are easy on the eyes.

Ease of Use: 4.5 I found the tabs/buttons easy to navigate. Text is clear with pleasing color combinations. Stable on an iPhone/iPad (iOS 5.0.1) there is no clear support/FAQ available.

Wishlist for CBR:
Allow screens to rotate. This would be especially helpful for iPhone.
Enable gestures. Again, a big advantage for iPhone

Fight Fatigue, Reduce Error

2012-01-19T05:00:00.000-05:00

The Joint Commission says fatigue risks patient care

The Joint Commission has issued a position warning healthcare agencies to fight medical errors by fighting fatigue. Citing the link between health care worker fatigue and adverse patient care events, the Joint Commission revisited the issue of extended shifts and fatigue in a recent Sentinel Event Alert.

According to the Joint Commission:

Fatigue resulting from an inadequate amount of sleep or insufficient quality of sleep over an extended period can lead to a number of problems, including:

lapses in attention and inability to stay focused
reduced motivation
compromised problem solving
confusion
irritability
memory lapses
impaired communication
slowed or faulty information processing and judgment
diminished reaction time
indifference and loss of empathy

In 2007, the JC noted that strong evidence exists linking medical error, fatigue, and extended duration shifts. The findings indicate that exteded shift and night shift workers make 36% more serious preventable adverse errors than others and have a 61% more needlestick or sharps injuries.

The take home message is that healthcare organizations need to assess the shift work/hours worked environment in their institutions for patient and provider safety. Key to reducing errors is to provide a culture of proactive safety. Staff should be able to express concerns about fatigue in the same way they would express concern if a colleague were impaired by intoxication.

Can these findings be applied to prehospital care? Certainly. While not be the norm in prehospital care, many services do work 24 hour shifts. It's far more common to find EMS professionals who may work far more than 24 hour shifts between multiple jobs. That is, work 12 or 16 hours at one EMS agency then go work another 8 or 12 at a part-time gig. Part-time work and other "off duty" work is not addressed by the JC in terms of healthcare providers. The fact remains that many EMS professionals do work more than one job. There is, of course, the dreaded "late call" that threatens to turn you 16 hour shift into much, much more.

Read The Joint Commission News Item/Action Alert: Click here
Direct Download Sentinel Event Alert: Click here

MJ 230 Your 2012 Preparedness To-Do List

2012-01-18T05:00:00.000-05:00

Welcome to 2012 and another year with Mitigation Journal. This weeks podcast is a summary of the challenges we face for planning and what we can do about it! Rather than give my predictions (as good as they are) I'd like to share a to-do list - a list of items that will help prepare for large scale events as well as the every day events.

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Less than lethal can still be deadly

2012-01-17T05:00:00.000-05:00

Planning, decontamination, proactive response is needed.

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Riot control agents are considered “less-than-lethal” but they possess the potential to create multiple patients, decontamination issues, and respiratory hazards to the responders. Although usually not deadly, exposure to riot control agents stress the respiratory and cardiovascular systems. Like many other respiratory irritants they exacerbate a variety of respiratory and cardiovascular medical conditions and cause hypoxia resulting in critical patients.

Exposed persons with liquid product remaining on the skin or clothing is another concern. Certain types of chemical mace and pepper spray can cause skin irritation and burns. Ocular exposure can result in loss of sight. Persons who remain contaminated with product also threaten secondary contamination by exposing responders to off-gassing. If exposed, contaminated persons are allowed to get into an ambulance or worse, into the hospital, without proper decontamination, the risk of significant secondary contamination and potentially hinder hospital efforts. Along the same theme is the risk of self-referring victims. People who have been exposed to a riot control (or any other irritant liquid or gas) may leave the scene prior to being decontaminated and triaged. Victims self referring to hospitals or urgent care centers pose a significant threat of secondary contamination. This risk is even greater when the local health care institutions are left out of the pubic service information loop.

When encountering a situation involving riot control gases, I recommend the following:

Never assume the obvious threat is the only threat; other potentials should be considered. When someone tells you "its only pepper spray", don't believe them. Consider the potential of other agents such as cyanide, hydrogen sulfide, nitrates, chlorine, and phosgene can cause similar signs and symptoms to riot control agents.

Proper personal protective equipment and atmospheric monitoring devices must be used. This should include respiratory protection for responders. Canister masks or self contained breathing apparatus may be the appropriate level of protection. Atmospheric monitoring and non-invasive monitoring of patients should also be considered to help identify the agent.

Anyone with reasonable exposure to the material should be assessed and decontaminated prior to leaving the scene. Little can be done for the internal exposure a gas. Those with exterior contamination, those who have residual agent on the skin or clothing, must undergo emergency mass decontamination prior to transport.

Local health care systems, including urgent care centers and walk-in care centers, must be informed of a chemical event occurring in their area. Health care systems must be able trigger their Emergency Operations Plans as soon as possible in order to prepare for the possibility of contaminated self-referring victims.

Fire and EMS resources should be deployed to appropriate health care locations in effort to assist with secondary decontamination efforts and management of contaminated self-referrals.

Priority must be given to pre-planning at areas of critical infrastructure. Schools, hospitals, government buildings, and sporting venues are examples of soft targets that may also be considered critical infrastructure. Collaborative planning and training efforts between traditional and non-traditional responders (ie: EMS/Fire and school officials) will pay big dividends during crisis.

Response plans must be tested, practiced and revised. Tabletop exercises are a great low-cost way of doing this. Plans should be general in scope with annexes for specific threats. Planning for school events must include accounting for weather, media, dispersal of victims prior to arrival and site security. Don’t forget to build in communication with local hospitals.

Concern over too much school security has asserted that school security measures are a result of paranoia and not actual potential for an event. My stance is that schools are facilities of critical infrastructure by virtue of occupancy and potential impact of an attack/event. A natural disaster such as an earthquake or a Columbine-like attack will yield panic and disruption in any community. We cannot simply dismiss an event, any event, involving health care facilities, schools or other areas of critical infrastructure. They are soft targets and should be hardened and protected.

Four Drugs Cause Most Problems for Seniors

2012-01-12T05:00:00.000-05:00

Free Podcast

A study published in the New England Journal of Medicine indicates that four medications cause the most adverse drug reactions resulting in hospitalization of seniors. According the CDC study and Medscape article, two thirds of the 100,000 hospitalizations of seniors each year are caused by Adverse Drug Reactions (ADR) involving anticoagulants and diabetic medications.

According to the CDC website, four medications, used alone or together, accounted for two–thirds of the emergency hospitalizations:

33 percent, or 33,171 emergency hospitalizations, involved warfarin, a medication used to prevent blood clots.

14 percent involved insulins. Insulin injections are used to control blood sugar in people who have diabetes.

13 percent involved antiplatelet drugs, such as aspirin or clopidogrel, which prevent platelets, or pieces of blood cells from clumping together to start a clot.

11 percent involved diabetes medications that are taken by mouth, called oral hypoglycemic agents.

The Centers for Disease Control and Prevention define an Adverse Drug Events (ADE’s) as a serious health problem, and have published the following Key Facts on Medication Safety:

It is estimated that:

82% of American adults take at least one medication and 29% take five or more [1];

700,000 emergency department visits and 120,000 hospitalizations are due to ADEs annually [2];

$3.5 billion is spent on extra medical costs of ADEs annually [3];

At least 40% of costs of ambulatory (non-hospital settings) ADEs are estimated to be preventable [3].

The numbers of adverse drug events will likely grow due to:

Development of new medications
Discovery of new uses for older medications
Aging American population
Increase in the use of medications for disease prevention
Increased coverage for prescription medications

For more on this topic, visit the CDC Medication Safety Program.

2012 To-do List

2012-01-10T05:00:00.000-05:00

No predictions! - Four actions for preparedness in the New Year

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Like many of you, I like to make predictions around this time of year and, like many others, these predictions fall short of reality and are forgotten in a few weeks. We can do better! For 2012 I’m not making any predictions...I’m giving you a to-do list! A four point list of actions to take that will make you, your agency, and your community more prepared for naturally occurring disasters and intentional events. Take these items one at a time...and take your time with each. You’ll be surprised how fast you’ll be able to improve your preparedness.

Conduct a Hazard Vulnerability Assessment (HVA). Some might call this a hazard vulnerability inventory (HVI). The Hazard Vulnerability Assessment (HVA) examines the occurrence or potential occurrence of a given hazard(s) in your community. The impact of the hazard(s) should be measured in terms of impact or threat to life and health, physical damage, and damage/disruption to critical infrastructure. Your HVA should also account for economic and social factors that will increase vulnerability to any given hazard. The Hazard Vulnerability Assessment is not a prediction but an analysis designed to answer questions or “what if” scenarios.
If you’ve done your Hazard Vulnerability Assessment, great. Then add a review and validation of that assessment to your To-do List for 2012.

Work on your Pre Incident Plans. Pre planning can be a never ending chore. Hazards change, threats increase and decrease, and capabilities may also change. The general basis for pre planning emergency and disaster situations is to maintain a certain level of preparedness and interoperability. Your pre plans should include regional and local response to biological events, both naturally occurring and intentional acts. Consider incorporating regional plans into your local pre planning as well. I’d also suggest a review of any plans to receive assets and resources during crisis situations. One such area to consider is a plan to receive assets from the Strategic National Stockpile or other supply. Consider including or updating pre plans that are specific for public information, explosive events, and active shooter events. Click here for more on Pre Incident Planning.

Define your Target Hazards. A target hazard can be defined as a location or area that poses an increased level of interest or attraction to an intentional event. Target hazards can also be identified as those areas or locations that have increased life hazard or secondary risk associated with them. Locations of critical infrastructure should be on your target hazard list as well. Critical infrastructure includes any location or service that, if lost or compromised, would limit or stop your ability to provide service. Power generation, water treatment, hospitals, public service should all be considered areas of critical infrastructure. When defining your target hazards, don’t limit yourself to those locations within your community. You should consider the high value/critical infrastructure locations in neighboring jurisdictions as well. Doing so will increase your preparation and effectiveness during mutual aid responses.

Combine your Hazard Vulnerability Assessment (HVA), Pre Incident Plans, and Target Hazard Identification into training. Use the Exercise Design Process to build realistic training opportunities. Don’t be afraid to start small or call on an outside expert to help construct your training activities. Build on what you do now...start with small seminars to summarize the training objectives and raise awareness to the situation, then conduct a tabletop exercise to add an element of stress yet provide a safe training environment. After you’ve built your training base, move on to a series of drills that test one or two elements of your plan. You can then move on to conducting functional exercises testing large plans in realistic field scenarios. For 5 tips to improve your exercise design click here.

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

2011-12-29T05:00:00.000-05:00

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"

2011-12-27T05:00:00.000-05:00

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.

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Click the player below for complete audio version.

Cold Weather Emergency Incident Rehab - Logistical Considerations

2011-12-22T05:00:00.000-05:00

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

2011-12-20T12:48:00.001-05:00

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.

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Click the player below for complete audio version.

Traditional lectures find new life in "new media"

2011-12-06T05:00:00.001-05:00

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.

The Millennial Generation & "The Lecture" from Academic Emergency Medicine on Vimeo.

For more on this and other topics, please support Life in the Fast Lane

What will the next AED be?

2011-12-02T11:56:00.001-05:00

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:

"...technology 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

2011-12-01T05:00:00.000-05:00

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

2011-11-29T05:00:00.000-05:00

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

2011-11-28T05:00:00.000-05:00

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

2011-11-25T05:00:00.000-05:00

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 -

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.
This could have been a probing attack...to evaluate vulnerability and assess reaction/response. A probing attack could indicate a larger cyber attack is on the horizon.
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)

Sources:

Global Post http://www.globalpost.com/dispatch/news/regions/americas/united-states/111121/cyber-attack-targets-illinois-water-system

CNBC

Global Control http://community.controlglobal.com/content/water-system-hack-system-broken

Mitigation Journal - 6 years later

2011-11-22T05:30:00.000-05:00

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 lecture...delivery 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 demand...health 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

2011-11-18T10:13:00.000-05:00

Reaction to Cold: How the body responds

Vasoconstriction.

Tachycardia.

Tachypnea.

Brochospasm.

Dehydration.

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

2011-11-14T05:00:00.000-05:00

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?

2011-11-10T06:00:00.000-05:00

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

2011-11-08T05:00:00.000-05:00

...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:

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 properly...is as important as annual fit-testing.
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.
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

2011-11-03T05:00:00.000-04:00

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

2011-11-01T05:00:00.000-04:00

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

2011-10-27T05:30:00.000-04:00

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 Veoh.com
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: http://www.atlantic-storm.org/flash/index-b.html and turn up you speakers!

What good plans have that bad ones don't

2011-10-25T05:30:00.000-04:00

Six points that every plan must have.

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
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.
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.
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.
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.
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

2011-10-24T05:00:00.000-04:00

Click image for free audio download

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

2011-10-18T05:00:00.001-04:00

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

2011-10-13T05:00:00.000-04:00

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

2011-10-11T08:34:00.000-04:00

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

Overview:

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:

Background
Illness
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.

YOU: the Biological Bomber

2011-10-06T05:00:00.000-04:00

Suicide bomber attacks are a fact of life in other nations. Suicide bombers are notorious for strapping on an explosive-laden vest, walking into a soft target location, and...detonating. Corpses, walking wounded bloodied and maimed walk in the midst of collapsed buildings and broken glass. (more on soft targets: Mall shootings here, MD shot in hospital here, 2011 planning problems here

Envision the carnage and hysteria caused by a suicide bomber.

Now envision a bombing scenario that's exponentially more deadly. More lethal than conventional explosives with an impact far greater than a nuclear weapon. In this attack there will be no detonation, no big bang to call us to action. Chances are we wont even know this bombing has taken place until our hospitals are overflowing.

The biological bomber is one such scenario. A Typhoid Mary of our time, rather than strapping on explosives, the biological bomber infects themselves with a disease and goes into society with the intention of infecting as many people as possible.

Like their suicide bomber counterparts, the biological bomber may actually be bombers working in a coordinated simultaneous attacks on several locations. Unlike suicide bombers who can only blow themselves up once, multiple biological bombers in a coordinated attack could infect hundreds in multiple locations. Would you be able to recognize a biological attack?

The biological bomber will want to spread a disease that is transmitted easily from person to person. A disease that has a lingering incubation period, a disease that will present with commons signs and symptoms of flu. Diseases of interest may come from the Centers for Disease Control and Preventions category A list. Something exotic like Smallpox, plague, or the Nipah virus may be the choice. Even seasonal flu would make an effective agent of attack. The strains of Type A influenza included in seasonal flu vaccine are know to anyone who can search the internet. A would-be biological bomber would only need to infect themselves with a flu strain not included in the vaccine or some novel stain of virus to bypass our first line of biological defense. Of course, our ability to obtain vaccine and other medications will be an issue.

Soft targets and locations of critical infrastructure would be prime locations for the biological bomber attack. Shopping malls, sporting events, and public gatherings make the list of potential targets. Of all the soft target/critical infrastructure locations, your local hospital takes the prime spot on the list. Hospitals hold special value for the biological bomber:

Many patients have compromised immune systems making them more susceptible to infection and a greater mortality.
Hospitals have a large transient visitor population in the form of visitors and suppliers. These people will move in and out the hospital and into the community and will help spread any disease.
Medical providers in the hospital will also be at risk for infection...a biological attack on a hospital may cripple the ability to respond to the medical needs of a community. Forget about surge capacity...there will be no capacity when physicians, nurses, and non-clinical staff become too ill to work or refuse to report to work. (not to mention a lack of preparedness on the part of many health care systems)

YOU: The Biological Bomber.
Much of what you've read about the biologic bomber is theory; apocalyptic, cataclysmic theory. But there is a biologic scenario that puts you in the staring role and can be every bit as dangerous as the terrorist biological bomber.

Failing to practice the personal responsibility of hand hygiene, respiratory etiquette, and appropriate social distancing when ill puts you in a position to spread disease including seasonal flu or other diseases. These simple practices along with getting the appropriate vaccines can help prevent YOU from becoming an unwitting biological bomber.

Vaccine and non-pharmacological interventions (hand hygiene, respiratory etiquette, appropriate social distancing) are also effective methods used to prevent the spread of disease, naturally occurring or otherwise. Proper use of these interventions along with personal protective equipment will boost protection for health care and traditional responders adding to our resiliency.

Lone wolf threat pales next to complacency

2011-10-04T05:00:00.000-04:00

Lone wolf terrorism is being predicted to be the next biggest threat to Homeland Security. As an offshoot of Homegrown Terrorism (formerly known as Domestic Terrorism), the lone wolf scenarios are seen as impossible to predict and difficult to defend against. The lone wolf is an individual who shares an ideation but is not formally connected to an “official” terrorist network. Ted Kaczynski, Eric Robert Rudolph, and Timothy McVeigh fit the lone wolf definition. These individuals conduct surveillance and plan independently. The interest in lone wolf terrorism comes from an assumption that the internet is providing a portal for radicalization. As if the internet itself is recruiting terrorists. Citizen radicals and idealists who intend to do harm on our soil has been growing for some time. Interest in domestic hate groups and political extremists has grown in recent years. Case study may show that their targets are typically high visibility and public locations. Although active shooter scenarios seem to be popular, the lone wolf cases cited above have made explosives their weapon of choice.

Lone wolf and domestic terrorism are serious threats. This type of attack is difficult to defend against or predict and should give us reason to conduct meaningful threat assessments especially on soft targets in our communities. Some refuse to believe it.

There is a threat far greater than the lone wolf or domestic terrorist: complacency. Complacency is the enemy that blinds us to our only all-hazards defense: resiliency.

In December 2010, I wrote on what I thought were biggest planning problems for the new year; intentional attacks on civilian soft targets, attacks on critical infrastructure, and the threat of increasingly virulent naturally occurring biological events.

Two of the three biggest problems included situations or at-risk locations for a lone wolf and domestic terrorist event.

There is more to soft targets than malls and coffee shops. Our national power grid, for instance, is a brittle system that shows its vulnerability with each stretch of extreme heat or cold. Emergency medical agencies remain understaffed and outside much of the grant funding circle. Fire and police departments continue to flail with ever-shrinking budgets and “what have you done for me lately” attitude from politicians and citizens. The economy of resiliency is making it difficult for local governments and civilians to adequately prepare. With today's level of complacency, even a “fun-size” terrorist event could yield a major impact.

Lone wolf and domestic terrorism is a threat. The threat is growing because of nuts with access to firearms and bomb materials...not because of internet radicalization. The threat also continues to increase because of our complacency and lack of resilience.

The all-hazards solution is to harden our weak areas through assessment and planning to create resilience. While not simple, those two actions would reduce the impact of natural, intentional (terrorist), technological, or accidental events.

MJ 221: RN Strike, Earthquake Trial, Doctors get Flu Vaccine

2011-10-03T08:23:00.001-04:00

Click for direct download

This week on Mitigation Journal Podcast #221:

23,000 California Nurses Association members staged a one day strike on September 22, 2011. The strike impacted 33 not-for-profit hospitals and was supposed to end the next day with nurses returning to work by 7am September 23. That didn't happen. The nurses did not return to work. Read full article here.

Can you predict an earthquake? If you could, how aggressive would your warning be? How aggressive should disaster warning be? Something happens and despite the planning and training and preparedness the situation escalates and the impact is worse (perhaps far worse) than originally anticipated or planned for. For failing to predict the unpredictable or protect the unprotectable, society demands someone be accountable... Theory of Successful Blame...and we feel safer as we attribute the outcomes of a situation to somebody's failures rather than the situation itself. Read the Cassandra Paradox and Italian Seismologists not "aggressive" enough.

Also, who is getting flu vaccine? A recent study indicated that doctors are the best protected while the number of vaccinated nurses is less than 70%

Listen to the podcast here

Lockout, Death follow Nursing Strike

2011-10-03T07:57:00.000-04:00

23,000 California Nurses Association members staged a one day strike on September 22, 2011.

The issues, according to the California Nurses Association website:

Sutter RNs are protesting 200 sweeping demands by Sutter executives that would:
Restrict their ability to effectively advocate for patients
Effectively force nurses to work when sick, dangerously exposing extremely ill patients to infection.
Sharply reduce nurses’ healthcare coverage and retiree health benefits.
The Sutter RNs are also protesting years of widespread cuts in patient care services...

and further:

"Sutter is making these demands and cutting services despite amassing $3.7 billion in profits the past half decade. Sutter pays 20 top executives more than $1 million in salaries."

Source: California Nurses Association

The strike impacted 33 not-for-profit hospitals run by Kaiser Permanente and Sutter Health in Oakland, CA. The strike was supposed to end the next day with nurses returning to work by 7am September 23.

That didn't happen. The nurses did not return to work.

Instead, Sutter Health locked out the nurses. There has been one death being blamed on this situation; a cancer patient died after what hospital officials are calling a "freak accident" by a replacement medical worker. The California Nurses Association claims that the death would not have occurred if they had not been locked out by the hospital.

According to the Associated Press, the patient was given a "non-prescribed dosage" by a replacement worker. The story doesn't identify the replacement worker was a Registered Nurse.

Press release from California Nurses Association

Strike on local Fox affiliate

California Nurses Association strike on Huffington Post. http://www.huffingtonpost.com/2011/09/23/california-nurses-strike-across-california_n_978131.html

Death as result of lock-out that followed strike http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2011/09/26/MNE31L9DP6.DTL

Nursing blogger comments on Madness: Tales of an emergency room nurse on the nurses strike

YouTube video posted on the California Nurses Association website

The Cassandra Paradox

2011-10-03T07:56:00.001-04:00

Of warnings and predicaments

I've noticed a disturbing trend. Lets call it the Theory of Successful Blame. Something happens and despite the planning and training and preparedness the situation escalates and the impact is worse (perhaps far worse) than originally anticipated or planned for. For failing to predict the unpredictable or protect the unprotectable, society demands someone be accountable... Theory of Successful Blame...and we feel safer as we attribute the outcomes of a situation to somebody's failures rather than the situation itself.

Not too long ago we talked about what may be the most influential decision that nobody is paying attention to. You’ll recall the Tenet Health/Katrina ruling requiring Tenet to pay 25 million to patients and refugees that took shelter in the hospital during Hurricane Katrina.

Later, in September 2011, I posted on a story from Italy - six seismologists on trial for deaths caused by an earthquake because their warnings were not “aggressive” enough and passed along the story to fellow blogger Jim Garrow (@jgarrow) of The Face of the Matter. Jim addressed the issue from the warning and information point of view in a recent post.

Jim also shared an important link to Google.org blog in his piece pointing to the fact that people turn to the internet during disaster situations. Until reading Jim's post I was skeptical that social media and internet resources would be a meaningful participant during disaster or crisis situations. I'm still skeptical, albeit somewhat more accepting.

For my part, I believe that warning systems have to tell what to do, when to do it, and why it must be done. We now have to add how bad it might, could, potentially will be and what might, could, potentially will happen if you don’t comply with the warning/prediction and take action.

And therein is the problem.

Emergency planners, managers, and responders (dare I say bloggers/podcasters?) are responsible for actions taken (or not) before, during, and after disaster situations. While emergency planners, managers and responder should be held accountable for their performance during crisis or the performance of their planning or training preparedness, it seems that the need to have a scapegoat overpowers the reality that many of the disaster situations are fluid and may not evolve as predicted. Unreasonable expectations need to hold someone accountable when an unpredictable situation goes astray.

What can we expect when naturally occurring biological event - seasonal influenza, for example, fails to follow an epidemiologists prediction? Will the Theory of Successful Blame hold? If the vaccine is poorly matched to the circulating strain of flu, will we hold the epidemiologist accountable for the illnesses or deaths?

Bus Rescue: Interior

2011-09-29T01:00:00.000-04:00

Front windows may not be an easy exit

For gaining access and ease of evacuation, remember three simple points: Use existing openings, enlarge existing openings, or make your own opening. The example used in this series is a full-size school bus has been turned on its passenger side. The side exits and passenger side windows have been rendered inaccessible leaving the front, rear, and roof as access points.

In Through the Roof we concentrated on gaining access and enlarging existing opening. Exit at the Back of the Bus demonstrated the need to open large areas for extrication. In this installment of Bus Rescue, we'll focus on interior operations that create space for extrication and disentanglement.

Side door access blocked by seats

Above: The side rescue door now sits at the top side of the bus. Access from the exterior can be difficult. Don't forget that access to this door may be difficult from the inside as well. Here we see two seats that will impeded the use of this exit door. These seats can be quickly and easily removed.

Hydraulic tools cut seat posts quickly

Above: Hydraulic cutting tools can be used to quickly remove seats by cutting the posts. Remember to cut the posts as low as possible, close to the floor. Gasoline power generators for hydraulic cutting tool systems must be positioned outside and away from the bus to prevent the introduction of carbon monoxide.

Below: A battery powered saw can accomplish the task of seat post removal. All tools must be well maintained with replacement blades readily available as well as batteries as needed. Hand tools and power hand tools are instrumental for arming additional work teams to speed the seat removal evolution.

hand tools are instrumental for arming additional work teams

Bigger is not always better, some cutting tools are too big for efficient interior operation

Above: Larger hydraulic cutting tools can be used but take more space to operate and may be too cumbersome inside a bus. It may be wise to monitor air quality inside the bus whenever gasoline powered hydraulic tools are used.

Reaching the interior door from the inside may be difficult

Above: Firefighter Lisa Coia-Bubel (City of Rochester Fire Department) demonstrates the difficulty of accessing the side interior door from inside a bus turned on its side. Note seats have been removed allowing for ladder placement into the bus. Roof or straight ladders can be placed into the bus via the side door for quick evacuation of minimally injured occupants.

Below: Further illustration of the side-to-side height created when a school bus it on its side. Note the seats are intact in this view demonstrating additional access limitation. Note also the proximity and size of the roof hatches (now side hatches). Intact seats will make placement of ladders difficult.

Height of side door and intact seats create difficult extrication

Above and below: Hand tools can be used to remove seats and some interior bus components when power/hydraulic tools are not appropriate.

School Bus Rescue: Exit at the Rear of the Bus

2011-09-27T05:00:00.000-04:00

When existing opening aren't enough...enlarge the opening for efficient extrication of victims.

Above: Firefighters assess access and begin dismantling rear door.

For gaining access and ease of evacuation, remember three simple points: Use existing openings, enlarge existing openings, or make your own opening.

In this installment we consider access and removal of the rear door. We'll focus on enlargement of existing openings and creating your own opening.

As seen in Through the Roof, this full-size school bus has been turned on its passenger side. The side exits and passenger side windows have been rendered inaccessible leaving the front, rear, and roof as access points. In Through the Roof, we looked at operations to enlarge roof hatch openings to improve access and rescue. This post will focus on access, opening, and enlargement of the rear door. In our next installment, we'll focus on interior operations for disentanglement and access.

Keep in mind that school bus accidents of this magnitude are rare, but when they do occur there is almost certainly going to be significant injuries, need for disentanglement, and protracted operational periods. Successful management of incidents such as these require solid performance of the first in units. A significant knowledge of scene size up and vehicle construction are also vital. The 7 basic bus rescue points will aid any responder in the setting of a large vehicle/school bus event.

Below: Most rear doors are hinged to swing open towards the passenger side. In this situation the door does not hamper egress. Most doors lack a hold-open device, meaning if the bus were on the drivers side, the door would need to be supported in the open position or removed to keep it from obstructing operations. In either event, keep in mind there are seats directly forward of the door that do impede the use of this space as an exit. Those seats will need to be removed (as seen in following) in order to maximize extrication space.

Note height of door from road level.

Interior latch assembly can be removed with wrenches or socket set

Above: This view demonstrates the robust latching system and bolt throw (receiver removed). The entire latch assembly can be removed with hand tools (wrench/socket) from the inside; thus freeing the door.

Below: Traditional forcible entry tools and techniques may not be successful on the rear door of a school bus.

Forcible entry tools and techniques may not be successful on rear doors

Use of a power saw to remove door hinge

Above: A battery powered saw can be used to cut away the door hinge and completely remove the door. The evolution can be completed fairly quickly with a well maintained saw and replacement blades.

Below: Once the door and glass from rear windows are removed, a cutting tool can be used to remove the door/widow frame and create and enlarged opening. Again, this can be accomplished quickly with well maintained equipment and skilled firefighters.

Hydraulic cutters remove frame between rear widows and door

Door/window frame removed. Note edge protection in place.

Above: Door/window frame removed providing greatly improved access. Note seat removal operation taking place adjacent to rear of bus. In combination, these two evolutions provide greater access/egress and facilitate removal of immobilized victims.

Below: Door removed and opening enlarged. Note the added space created by removal of rear seats. This creates an opening that allows for safe, efficient movement of immobilized patients.

Added space created by removal of door and rear seats. Note tape used to protect edges.

MJ 220: Consumer-Level HazMat and Chemical Suicide

2011-09-26T01:00:00.000-04:00

Consumer-Level HazMat and Chemical Suicide...

Click for Direct Download

A number of readers have written in with renewed interest on the threat of chemical assisted suicide asking that I re-release the popular Mitigation Journal entries on this topic.

I'm truly impressed by the level of interest shown by MJ followers. I'm also grateful to you for letting me help get this and other preparedness information out to responders, hospital staff, and emergency management folks.

This weeks podcast is a mixed compilation from the popular Consumer Level Hazmat talks taken from various epidodes.

Consumer-Level Hazmat and Chemical Assisted Suicide are covered in editions 59, 64, and 72. Full versions of the original Mitigation Journal podcasts are available from the Mitigation Journal archives with the links provided.

Click player below to listen to Consumer Level Hazmat and Chemical Assisted Suicide.

EMS considerations for School Bus Rescue

2011-09-25T06:30:00.000-04:00

A majority of passengers will be minimally injured after a school bus crash. Utilization of proper access/egress, triage and treatment procedures will improve the EMS response to these high stress events.

Bus Rescue: Through the Roof!

2011-09-22T05:00:00.000-04:00

Bus on the side is rare and challenging. Injuries are almost certain.

For gaining access and ease of evacuation, remember three simple points: Use existing openings, enlarge existing openings, or make your own opening.

Using existing openings will work well if patients can walk or have limited injuries and is the fastest and easiest to accomplish. In the pictured here, the bus is turned on the passenger side, rendering the passenger door, side and window exits unusable. In this scenario your best choice may be to use the rear door exit. Removal of the front windshield may also facilitate movement out via the front of the bus.

When existing opening aren't enough, enlarging existing openings is your next step. Enlarging openings such as roof hatches takes some time, personnel and equipment, but allows for rapid movement of rescuers and gear in and patients out. Once you start to cut on a bus be sure to reevaluate the need for structural stability and any effect on vehicle stabilization.

Firefighters use hand tools to augment power tools in this evolution

Above: Two properly protected firefighters use hand tools to cut the roof outer skin. Its important to rely on hand tools as a back up to hydraulic or battery powered cutting tools. Hand tools can also be affective for arming multiple teams when power tools are in short supply.

Below: The roof hatch opening enlarged (hatch removed) to facilitate movement of a backboard or rescue basket and personnel in and out of the bus. Note the jagged sheet metal. These hazards must be covered. Sharp edges will be present in the interior of the bus as well as a result of cutting the interior skin.

Note the inner and outer skin and the presence of structural hoops

Above: Marked by black arrow - Note the sharp edges on the outer skin (yellow) and the presence of the inner skin (red). Both will need to be removed and edges covered to prevent mechanical injury. FF John Harnischfeger (Ridge Road Fire District) points out a support hoop that has been cut to enlarge the opening. Hoop locations can be determined by the sequential line of rivets. Although these hoops can be cut, caution must be used as the structural integrity of the bus may be compromised.

Below: A triangle cut made towards the rear of the bus facilitates interior extrication/disentanglement and removal. Caution must be taken to remove any victims from that area prior to beginning cutting operations. Note the intact roof hatch to the right.

Gaining access no matter what side the roof is on.

Up Next: School Bus - Exit at the Rear of the Bus

Seismologists warning not "aggressive enough"

2011-09-21T15:05:00.000-04:00

Last month we talked about something I called the biggest decision in healthcare that nobody was paying attention to. I was referring to the July, 2011 court decision requiring Tenet Health to pay $25 million to those patients and civilians who took shelter at Memorial Health Center and died or suffered injury during Hurricane Katrina. The court ruled that Tenet failed to establish an evacuation plan and that by poor design, the backup power system was vulnerable to flooding. See Mitigation Journal "Message from Katrina" part one and part two to hear me, Jamie Davis (MedicCast) and Matt discuss this on the podcast.

This month I want to tell you about a similar situation, this time from Italy.

Six Italian seismologists are being brought up on manslaughter charges for failing to predict a deadly earthquake. Yes, your read that correctly...for failing to predict an earthquake. According to MSNBC, the Italian seismologists are specifically accused of failing to warn the public "aggressively enough" ahead of the 2009 earthquake that killed 300 people.

This will be an interesting situation that should may have implications for disaster and emergency management here in the United States. This Italian case combined with the recent Tenet Health decision is ought to be enough to give anyone working in emergency preparedness a moment of pause.

How far can the legal ramifications of prediction (or failing to predict) a situation go?

If the situation were reversed; a prediction with "aggressive warning" that resulted in evacuations (and injury/deaths from that evacuation) that turned out to be a false alarm - would that also be grounds for indictment?

What level of warning is appropriate or "aggressive enough" and how do we gauge the severity of a predicted situation to warn appropriately?

What are the implications for those who study and predict natural phenomena? To break this down even further, will epidemiologists be held accountable when the flu vaccine is poorly matched to the flu strain that actually shows up?

This could be another influential decision in domestic preparedness that nobody is paying attention to. Nobody but us anyway.

Bus Rescue points you can use now

2011-09-20T03:00:00.000-04:00

7 take-home recommendations when dealing with any large passenger vehicle collision.

Knowing the construction and type of bus or large vehicle involved can be your first clue to the potential severity of the incident. Type A and B buses are the converted van style while Type C and D are the classic school bus types. Size-up must include the type of bus, number of occupants, and the position of the bus. Experience has shown that most collisions involving school buses result in little damage to the bus and the bus remaining upright.

Remaining on all four tires is not a guarantee of no injuries inside, while finding a school bus in any other position almost certainly predicts a variety of injury patterns. This is a good time to remind everyone that there may (most likely will) be injuries in any passenger vehicle that has collided with the bus.

Your size-up must include factors such as traffic conditions and environmental conditions. These contingencies will impact rescue efforts as well as treatment, triage and transport as well as longevity of responders.

You should plan for distractions. Anticipate the media will have been contacted and will show up as well as parents. Plan for their arrival. Consider that patients may have walked off the scene prior to your arrival as well.

Control the hazards simultaneously with stabilizing the vehicle is a priority. Shutting off the electrical master switch and ignition as soon as possible may be your best bet. If you need to disconnect the battery, remember two things; there may be more than one battery and disconnect the negative cable. It is not uncommon for buses to have multiple batteries in different locations. Removing the negative cable and securing it to prevent contact with other parts of the bus is a good safety tip.

Solid stabilization has to be done at either end of the bus or under the center frame rails. Never attempt to crib a school bus under the skirting on the sides. Keep in mind that you'll need more cribbing than usual. Simply choking the wheels may be sufficient if the vehicle is upright; otherwise, the situation will dictate where best to crib and stabilize the bus.

For gaining access and creating evacuation , follow three simple steps points: Use existing opening, enlarge existing openings, or make your own opening. First, using existing openings will work well if patients can walk or have limited injuries and is the fastest and easiest to accomplish. Enlarging existing openings such as windows takes some time, personnel and equipment, but allows for rapid movement of rescuers and gear in and patients out. Once you start to cut on a bus be sure to reevaluate the need for structural stabilization and any effect on vehicle stabilization. You can make your own openings, too. I would leave this tactic as a last resort. Cutting into the side or top of a school bus is personnel intensive, time consuming and can add to the hazards. Cutting into the bottom of a bus is doable, but next to impossible.

MJ 219: Understanding Flu and Biological Events

2011-09-18T03:00:00.000-04:00

Click for direct download

If I told you that there was a biological event coming this winter that would kill 36,000 to 40,000 people, would you be concerned? What if I told you that this biological event would target the old, the young, and those with chronic medical conditions; what would you say?

If I told you that flu season is around the corner, how concerned would you be?

This post is an introduction to our popular classroom session Understanding Flu and Biological Events. In this program we tackle these issues and compare seasonal flu (a predicable, natural event) and intentional events involving biological material.

This weeks posting is a primer as we enter flu season.

Click the player below to view the movie:

Click the player below for the podcast audio only version:

Bus Crashes

2011-09-15T05:00:00.000-04:00

Next in our review series is this post on school bus types originally published July 2010. This series is a primer for upcoming posts on school bus events and gaining access.

A recent news report posted by MSNBC.com about a "church" bus crash got me thinking on this topic again. The report states that there were 29 people on the bus, 23 were children. According to the report, the crash may have been caused by driver over correction causing the bus to overturn onto its side and resulted in nine injuries.

That's what got me thinking about bus accidents again. So, with more to follow, lets do a quick overview of buses and some quick tips that you can use today.

Types of buses

Various Type A and B vehicle

Type A and B - described as van-style vehicles, are usually small van conversions with a gross weight around 10,000 pounds. Type A vehicles may carry 8-12 passengers with the main door behind the passenger side front tire. Type B vehicles may carry slightly more with a capacity of 16-24 passengers. The door is in the same configuration as the type A. In the setting of type A/B van-style vehicles, don't be complacent; these vehicles are a measure of quality versus quantity. The van-style buses are often used for transportation of special needs populations adding an entirely different medical, emotional, and evacuation element to the situation. These vehicles may also include special ramps, lifts and restraint devices...you'll need to be familiar with these items to be effective in your rescue efforts.

Wide range of type C/D buses

Type C and D vehicles are the larger buses that you normal see used as school buses or other transportation uses. Type C vehicles have a capacity of 30-70, also with the front door behind the front wheel. Type A/B/C buses have a rear exit door and may have a side exit as well. Type D buses are those with the flat front and the engine in the rear. They have a capacity of 40-120 passengers. The rear exit is an escape widow above the rear engine.

Use of Exits
Keep in mind that the bottom of rear and side exit doors are about four-feet above the ground. Side escape windows can be six feet off the ground and open upward...with no "hold open" device.

Command and Control
These events will be challenging. Multiple agencies and responders, media, traffic and the environment will all play a role in your bus event. Add to that the fact that many school-aged kids have cellular phones...you'll have frantic family members on scene with, or perhaps a head, of you. Don't ever forget the probability your actions will be recorded, too.

Initial Operations at School Bus Events

2011-09-13T05:00:00.000-04:00

This post was originally posted in July, 2010. It is being re-posted now at reader request. We'll also be publishing an all new series on school bus/large vehicle events in the near future.

Initial Operations at School Bus Events are, like those at any other event, are critical to the successful mitigation of the event. We know the actions of the first-due units can make or break any situation; and large profile events will magnify that point. When dealing with an event involving a school bus, mass transit bus, or commercial over the road bus, we have to remember the physical resources needed may easily overwhelm existing services and carry the potential for surge capacity impact on existing health care systems.

In general, school bus incidents should be treated as multi-patient events or mass casualty incidents. It may be appropriate to consider these events in the same way we look at a target hazard location; sending multiple units and dispatching special call equipment on the initial assignment. Sufficient resources should be sent on the initial assignment based on a jurisdictions Hazard Assessment, rather than waiting for first arriving units. While this may seem contrary to conventional response plans, these events hold high potential for rapid deterioration, need for personnel rotation, additional specialized tools and equipment; and of course, an effective rehabilitation program.

Size-up should work in concert with established per-incident plans based on a hazard assessment and include 360-degree assessments on the horizontal and vertical. Bus and large vehicle incidents frequently involve other vehicles. The injury-fatality-rescue ratio will depend on the size of the other vehicle involved. You may wish to consider the other vehicle as a separate event with an entirely separate response and resources.

Triage has to be completed both on the bus/large vehicle and in the crowd. Keep in mind that those able to self-rescue will do so and will scatter into the crowd. Some may even self-refer to area hospitals or home. Accountability for all passengers will be difficult. Although we're accustomed to the priorities of triage and treatment, it must be understood that the first people out of the vehicle may not be the most critically injured...removal of walking wounded or non-injured persons should be done to reduce exposure to further injury and create space to assess and treat others. This also includes removal of deceased.

Keep in mind that there may be persons with special needs on the vehicle. Once these people are removed, they cannot be left unattended.

9.11.01 The Headlines Tell the History

2011-09-11T05:00:00.001-04:00

9.11.01 The Headlines Tell the History...its our history...

All of us can recall where we were around 9:00 AM on Tuesday September 11, 2001. I've been collecting headlines and magazine covers for ten years now. Each one has a memory attached to it.

Click the player below for the video:

Looking at the images on T.V. I commented what we, safe in our station, knew: nobody at or above that fire was getting out alive.

The T.V. voice said the obvious "I think we're under attack...its pretty clear that impact was intentional..."

I called my wife: "get Sammy from school...now" I was concerned that more attacks might cause police to restrict movement...we lived near a target in the form of one of the largest chemical/industrial facilities in the Nation; the Eastman Kodak Company.

Moments later another commentator broke in with news about an explosion at the Pentagon.

Several years of my career had been dedicated to thinking, planning, dreaming up doomsday situations to prepare responders for mass casualty events and natural disasters.

Response to such events had been an important part of my professional life since the 1989 Loma Prieta earthquake. I was captivated by the response to that earthquake. Amazed at the scale of devastation. I was inspired to learn something about urban search and rescue, about crush injury syndrome...

This was an area of expertise that let firefighting, paramedicine, hazardous materials and planning merge...

The media was still sorting out what had happened to cause such a huge smokey fire from the upper floors of the tower.

I remember being in the day room of our headquarters fire station with the smell of that perpetual pot of coffee in the background that morning.

This was different. How many targets could there be?

I'd been at my desk in the special operations/training office...someone called and said something about the World Trade Center being on fire. Shortly thereafter everything changed.

Then in a wide-angle, slow motion approach, another aircraft entered the frame. What is this guy doing?! Then it hit. Then it erupted. It began to sink in...

Waking up in a Different World

2011-09-11T05:00:00.000-04:00

Its not the time of day you get out of bed.

Today, September 12, 2011, we are waking up in a different world.

We awoke to September 12, 2001 to the images of the day before ingrained in reality. Ingrained forever in history. The world woke up a different place. It wasn't the first time, either.

In 1993 the World Trade Center was the target of an attack. Albeit far less devastating, the '93 WTC event showed us a glimpse of what could be. We were in a different world.

We again woke to a different world on April 19, 1995. A day when we woke up to the reality of Domestic Terrorism when the Murrah Federal Building was destroyed. Ammonium nitrate/fuel oil and a truck. 163 dead...including the kids in a day care.

On April 20, 1999 our alarm clock went off again. This time in a high school. Semi-automatic weapons and secondary devices. Random Domestic Terrorism.

A few years after September 11, 2001 Mother Nature voiced her opinion. And she did so over and over in the past few years. In 2003 we woke up to the reality that a naturally occurring biological event could make a terrorist attack look like a cake walk. Hurricane Katrina forced the evacuation of a major metropolitan area...for the fist time. Katrina also showed us the gaps in our response ability. We were in a different world. Not to be outdone, biological events made a comeback in 2009 with the sudden appearance of H1N1. And we realized that we couldn't make vaccine as quickly as we need...and ~~misinformation~~ information on how to handle a predictable event was not readily available.

Today, September 12, 2011, we are waking up in a different world.What will it look like? Will it be explosions and gunfire? If it is, what will you do?

I think the next event will be a bit more subtle. We'll wake up in a different world when we flip the little switch on the wall and no lights come on. What will we do?

9.11 More than terrorism

2011-09-09T08:00:00.000-04:00

September 11, 2001 taught responders and emergency planners many lessons. There are many more to learn. Its important for us to look at all hazards; natural, man made, and technological as if they have the same potential as an intentional terrorist attack. This video underscores that importance.

I hope that in the wake of ten years in the post 9-11 era we will realize that public health, emergency medical service, and other traditional response agencies deserve our support. I also hope that we'll realize that mother nature can cause devastation on a scale that dwarfs terrorism.

Its time to stop living in the post 9-11 era and start training in the Pre-insert next event here-era.

9.11 a decade later "what have you done for me lately?"

2011-09-08T05:00:00.000-04:00

Newsweek cover

September 11 will be filled with remembrance ceremonies, flags, pictures and exhibits commemorating the September 11, 2001 terrorist attack on the United States. People will recount where they were when the heard the news, saw the second plane hit the second Tower, and express anguish when the World Trade Center towers collapsed.

Many will use the phrase "Never Forget" in their speeches. Perhaps the news clips of the plane hitting the tower, the explosions and eventual collapse of the towers will be shown on television again. Perhaps not. Many have decided the video images of the Pentagon and WTC are too graphic, too upsetting. We certainly won't see the clips of civilians, trapped in the inferno of the towers jumping to their deaths. Too graphic? Maybe. A reminder of intensity and brutality of the attacks and suffering inflicted on a civilian location...absolutely.

In our race to "Never Forget" we wouldn't want to insult any group or label anyone as extremist. Maybe we don't really want to remember how we felt in the days directly following the attacks. Maybe we'd rather pretend the aftermath of September 11, 2001 is not as bad as we remember and get back to work being a cog in the one global nation farce.

The flag will seem a bit empty without EMS and Fire

Maybe we'll see the clips of New York City streets lined with civilians holding signs that read "hero" and "thank you" as emergency services roll into the World Trade Center site; a reminder of attitude towards emergency medical service and the fire department on September 12, 2001. A period before public safety budgets, salaries, and retirements became the target of municipal shortfalls and pubic outcry. Never Forget is an interesting concept as today we look to eliminate responders, cut benefits, dismantle public health services in the name of balancing budgets.

Never Forget is an interesting concept as ten-years later, first responders will not be welcome at the 9/11 memorial service in NYC.

Ten-years later "Never Forget" reads more like "what have you done for me lately?"

It's national preparedness month

2011-09-06T05:00:00.000-04:00

September has been designated national preparedness month by FEMA… so what

Nobody knows (possibly nobody cares) that National Preparedness Month even exists.

The heart of the national preparedness month effort is an offshoot of FEMA/Department of Homeland Security using the website ready.gov. The website encourages us to prepare, plan, and stay informed. We're told to do this all we need to do is to get a kit, make a plan, and be informed. Throughout the website, again, at the heart of the national preparedness month effort is a sprinkling of information tips for the public and for responders. Albeit a little oversimplified, FEMA presents a fairly decent message for the public. The information for responders is minimal at best.

Despite the urging to prepare, plan, stay informed; and to get a kit, make a plan, and be informed, the efforts of national preparedness month initiative to little to entice members of the public to do any of that. I believe one of the key reasons that the general public remains unaware of initiatives like this is because the focus on Homeland Security… security equating to badges and guns. As of said before, Homeland Security is a failing model for preparedness. We have to shift the focus back to a more neutral preparedness ground. That is, to be able to look at and prepare for natural, man-made, technological, and intentional events.

A recent earthquake that impacted a majority of the East Coast and was quickly followed by hurricane Irene was a stark reminder of our vulnerability to natural events. Carbon monoxide deaths (which are described by many as completely avoidable) continue to climb in the United States. Consumer-Level hazardous materials events and acts involving use of consumer level hazardous materials with intent to harm self and others is seen as a growing threat. Although these events may have gotten some media attention they don't typically appear in one's mind when we think about homeland security. Yet, these events are quite capable of causing harm to people and infrastructure on par with any ~~terrorist~~ intentional event. The challenge is to bring our Preparedness Pendulum back from the extreme edge were we look only at terrorist events… and I think that is what National Preparedness Month is trying to do.

Just like the other specialty areas that have their own special “day” or “month” the general public outside of that specialty area remains unaware of the national preparedness month effort. Further, what useful information is on the ready.gov website goes unnoticed by most. Bottom line is, the National Preparedness Month initiative remains stagnant and has little if any impact on improving civilian readiness.

FEMA could learn a lot from successful initiatives such as fire prevention week. Fire prevention week has historically involved a reasonable media campaign as well as some type of open house affair at a local fire station. Key to success is that some officials and the local community are engaged in spreading the word and promoting action among individuals, families, and communities. The combination of a marketable media campaign along with their open house ability brings the community together and puts the information provided into a tangible format. National Preparedness Month efforts lack that tangible format and community leadership effort.

Despite being around since 2002, ready.gov and National Preparedness Months have done little more than provide information on a website. While they do provide decent public service announcements in the form of videos and audio clips, there is little effort to get the general public to turn this information into action.

So, I guess it now becomes our responsibility (perhaps it always has been) to get the message out to the public about the national preparedness month initiative. It will also be our responsibility to turn that information into action.

I recommend that everyone visit ready.gov and explore the content there. Become familiar with what the site in the initiative has to offer. Then take that information and turn it into something useful… that is, explore ways it can benefit your community. Maybe coupling national preparedness month activities with existing awareness topics such as fire prevention week, EMS week, or any other specialty area that has their own “holiday” would be a good place to start. That might be a good place for the folks at FEMA to start marketing National Preparedness Month as well.

A Message from Katrina Reader Comments

2011-09-01T02:00:00.000-04:00

Direct download part one

Direct download part two

Long time supporter of Mitigation Journal, Michael Ehrman sends in his commentary on our recent podcast A Message from Katrina: Hospitals be Ready. Part One and Part Two are available on the Mitigation Journal homepage.

You can contact Michael directly via Twitter @MichaelEhrman

Michael writes:
First point. When I went to National Red Cross training and National Fire Academy training in the middle 1970's with some of the Public Safety Officers of New Orleans, the levies were a disaster waiting to happen and they knew it in the 1960's for sure so with 50 years to prepare for what I call their worst nightmare and not have gotten their public prepared and themselves is NO excuse. When I worked in California, almost every public organization, most businesses to varying degrees and most residents prepare for that big 9+ earthquake they know is coming. May not be prepared for San Onofre, the nuclear power plant to explode but their worst nightmare they prepare for and practice.

As for NIMS and Jamie's comments. NIMS is simply a way to organize and help control a bad situation in an orderly fashion. Not a resource to mitigate the situation. Just an orderly set of step to follow to help the responders mitigate the situation and to play well with each other.

As for Matt, FYI, regardless, there will be lawsuits-for any reason. Hey, you had one less stored supply for one more person that you had. Hey, you should have built your ATM to work perfectly while being under 10-feet of water. Get real here. If one attorney lives, there will be at least one lawsuit.

Improvements since 9-11? Look at communications, one of my pet peeves. We are still bantering about allocating a portion the 700 MHz frequency for first responders. Every major disaster has had communications as the base shortfall in that disaster. Read the reports, books, etc. And we still have not resolved that one. And we expect the population to be prepared for X days and we, ourselves, are not prepared? Let us totally fix our house first before we complain about the neighbors.

Hey, don't bitch about the bus. I have preached long before Katrina that every community should make a contract with their school district or buy a school bus, whether used or new but used is cheaper by a mile if maintained. Every bus can mass move in first responders. Every bus can mass move out casualties and every school bus comes with its own set of red lights. Just paint it fire engine red or police blue.

More PSA's is right. Jamie hit the nail on the head.

As for Dr. Pou, she did what she had to do when her world was ending for her patients. If we were there and faced with the limited information available at that time versus the type of death your patients would suffer during this world ending crisis (for you), what would you do? I know I would not want to give up and would try to find a solution until it was too late, but that's me and my patients would have most likely suffered. It is a shame the situation got to that point. And she was not alone in making he decision to euthanize some patients. Remember that.

Jamie was right, Katrina was a lesson of the worst, and the best and that we need to prepare. Bigger question now is, will we. Or will we be stating, like a broken record, the same solutions are needed that we said for the last XXX disasters and still do nothing to fix the problem except to spend money to say let's fix it...again.

Got me on a rant on this one. Good job!

NIMS Incident Types

2011-08-30T02:00:00.000-04:00

NIMS info from DHS

Today's post come in the form of an email question and answer on NIMS incident typing. The question comes from Ben Hazlerig, a Paramedic who has transitioned into Emergency Management. The answer from Alan Bubel, Assistant Chief of the Gates (NY) Fire District, an authority on NIMS, and frequent contributor to Mitigation Journal blog and podcast.

NIMS Field Guide from Informed Publishing

I love NIMS job aids and memory helpers. The best guides I've found have come from Informed Publishing. Informed offers a wide variety of field guides for the traditional and non-traditional responder. The NIMS ICS Field Guide puts all the needed information in your pocket...for any NIMS/ICS position. Available in electronic and hard-copy, it's a tremendous aid for any experience level. You can also stay current by reading the Mitigation Journal and listening to our podcast. The Mitigation Journal podcast App is also available on iTunes!

Note: I endorse Informed Publishing products. Neither Ben nor Alan have any involvement with Informed.

Ben writes:

I’ve been a listener of your podcasts for some time now, especially during my days of Paramedic school. I’ve now transitioned from EMS into an office Emergency Management job. One thing I’m having a hard time grasping is the NIMS Incident typing. The company I’m with uses the Incident Type 1 to 5 scale to classify events in the beginning stages. I haven’t been able to find anything within the FEMA online materials that clearly defines who officially determines Incident Types as it relates to National disasters. We are essentially mimicking the NIMS system within our own organization and putting the job of Incident Typing on our Senior Level Executives who have limited Emergency Management experience. It seems to me that this classification is better implemented after the fact as a way to summarize what resources were used. Do you have any thoughts on this subject or know of any reference material online I could refer to. Thanks for any information you can provide.

Alan responds:

Here are some thoughts on the topic of Incident Typing:
One of the responsibilities of the Incident Commander (IC) is to analyze the complexity of the incident. This helps to identify resource requirements and manipulate the incident management structure appropriately. Complexity analysis factors include such things as safety, resources, size of the incident and impacts to life, property and the economy. More information on this can be found in the ICS200 curriculum.

Categorizing an incident by type, then, is based on the incident's complexity. You're aware of the 5 to 1 scale (Type 1 incidents being the most complex) so we don't need to get into that discussion. However, your question pertained to who officially determines incident type relative to a national disaster. With that being said, there are only two incident levels where Federal resources come into play - Type 2 and Type 1; of those two, only a Type 1 incident is considered an "Incident of National Significance". A national disaster would fit the criteria for an "Incident of National Significance", activating the National Response Framework (former National Response Plan) and likely resulting in Stafford Act declarations. But, WHO determines the incident type?

The answer is the IC, based on the whole complexity analysis thing. In addition to analyzing incident complexity, the IC has the responsibility to call for resources. The level from which those resources are requested (local, state, or Federal) also speaks to the incident type. Type 5 and Type 4 incidents normally require local resources; Type 3 incidents local and state resources; and Type 2 and Type 1 incidents all three levels. So, if incident complexity is not enough for an IC to base an incident type decision on, the resource requests can serve as an added guide.

Although incident typing is very useful for summarizing the size, scope and complexity of an incident after the fact, the determination of the incident type needs to be made real-time during the incident by the IC. If your executives have IC responsibilities, they should be afforded the training and education required to identify incident type. (Training through the ICS400 level would be my recommendation). If they do not function as an IC, but support an incident as Emergency Management personnel, they should still be aware of the incident typing process and the role it plays relative to resources and geo-political impact.

My opinions on Hospital Emergency Preparedness are nothing new

2011-08-29T02:00:00.000-04:00

Click to download podcast

I've receieved reader emails asking if all this talk about hospital preparedness, accountability during crisis, and the after-the-fact accusations is a new outcome from recent legal decisions.

The quick answer is, no.

In fact, I've been talking about these and other hospital emergency preparedness topics in Rule of Outcomes fashion for a long time. Its nice to be ahead of the curve...

In response to those emails, I recalled discussion on the topic of Dr. Anna Pou and the allegations against her and other staff from Memorial Medical Center in the wake of Hurricane Katrina.

In this talk, from Mitigation Journal podcast (originally recorded in 2007) I discussed the issues that are now foremost on the minds of many in healthcare emergency management.

In this re-issue, we'll consider the implication of crisis decision making, triaging of limited medical resources, incident action planning, and standard of response versus sufficiency of response.

This clip will reiterate many of the points in from the recent Tenet Health/Katrina decision. It will also serve as a primer to get you thinking about the possibilities and adverse outcomes in crisis decision making.

Click the player below to listen on-line

Interview with Ceciel County, MD County Emergency Services

2011-08-28T12:15:00.003-04:00

Click for Podcast download

Welcome to a special interview with Mr. Richard Brooks, Director of Ceciel County Emergency Services, on the topic of winter storm activities. This is a re-issue of our podcast (#156). The planning and preparedness discussion in this segment remains one of the best on the web.

Although the topic is winter storms, the philosophy and actin-planning are universal to the current Hurricane Irene situation. This podcast episode is one of the most listened to and commented on by MJ followers.

For those of us thinking ahead to be ready for the next event, this podcast will be a great reminder of how to get things done.
Click the player below to listen on-line:

Sitting on the edge of Irene: cautiously optimistic

2011-08-28T09:04:00.001-04:00

Sitting here in Rochester, New York it's easy to be just a bit removed from the Hurricane Irene situation. Viewing the situation from a distance gives me the opportunity to reflect on the response of local governments, officials, and Federal agencies.

I'm cautiously optimistic that the actions taken by state and local government authorities will save lives. The forward thinking approach to evacuations and sheltering has been impressive up and down the East Coast. I am particularly pleased with the actions of New York City Mayor Bloomberg and the New York State office of emergency management. Although I have been critical of NYC in past storms; I'm encouraged to see that they are doing what I believe to be the best course of action possible.

Has the recent legal president from hurricane Katrina influenced emergency management decision making?

The decision to order a large-scale evacuation or shelter in place is never an easy one. Evacuations are not benign events and there are certainly risks associated with sheltering in place. Major metropolitan areas such as those cities on the East Coast have to make this decision carefully and well in advance of a potential threat. I think they got it right this time. Let's not forget that this is an area (the entire East Coast) that just suffered from one of the largest earthquakes in recent history. A 5.8 magnitude earthquake struck the entire East Coast last week. There is untold and unseen damage to buildings and infrastructure. While this earthquake did not cause massive collapses and instruction, it certainly may have caused some buildings to be weakened. It certainly may have caused unseen damage to below ground utilities, sanitation, and transportation infrastructure. These same structures and pieces of infrastructure will now be impacted by hurricane Irene and thus raising the level of severity and the need for pro-activity on the part of local governments and responders.

There has been tough and honest talk from governmental leaders. The information has been blunt… “if you don't evacuate we may not be able to rescue for several days…”. I think that's the reality of the situation and I think that demonstrates an understanding of when to switch from a standard of response to a sufficiency of response.

The physical damage to structures will be dependent upon the storm itself. The impact to life will be dependent upon the actions of local governments and local responders.

So, what's going to happen next?

Well, if the storm turns out to be less severe than predicted there will certainly be accusations of overreaction. I've also anticipate that there will be those in the media who will accuse many in emergency management of crying wolf and scaring the public.

On the other hand, if hurricane Irene turns out to be as severe as predicted and to cause as much flooding and damage as predicted the ends will have justified the means. In either case I believe no other decisions could have been made by emergency managers the net to evacuate far in advance of the storm.

The only certain next step is recovery… and recovery is largely dependent upon preparation.

"I'm cautiously optimistic that the actions taken by state and local government authorities will save lives. Imagine the level of domestic preparedness that could be achieved with fully funded and staffed health departments and emergency management programs?"

Rick Russotti, Mitigation Journal

So far, the Irene has the flag barely moving...0900 8/28/11

North East Earthquake: The Real Hazards are Beneath Us

2011-08-26T02:00:00.000-04:00

Top-5 list of issues responders and planners need to address

A magnitude 5.8 earthquake struck the East coast of the United States on August 24. The United States geological survey indicates that this quake was felt in 25 states reaching from the deep South to New England and possibly extending into Canada. Impacting more than 12 million people, this was the most powerful earthquake to be felt since 1944. It also happens to be the second earthquake felt in western New York in the last year. Its enough to make you ask: what if it did happen here?

NOAA photo

E. L.Quarantelli (Disaster Research Center of the University of Delaware) warned us of the increasing impact of natural disasters. In his paper "Future Disasters in the United States: More and Worse" (1988), he suggests that natural disasters will be more intense simply because they have more to impact in today's society. Again, this was written in 1988 and since that time we've seen our share of devastating natural events. We've also seen an increase in co-occurring natural events; earthquakes leading to tsunamis leaving to technological failures such as nuclear power plant failures. For more details, see Three Problems for Planning 2011. Related: They're going to get worse. (MJ July, 2010)
Critical Infrastructure:
the evidence of the quake was obvious in many buildings and while many monuments and tourist attractions were closed, the real concern is the impact the buildings of critical infrastructure… hospitals, for example.The recent decision from hurricane Katrina (Tenant Healthcare) has made us aware of the expectations for hospitals and healthcare facilities to be prepared for naturally occurring events. Furthermore, it seems the public has an expectation that hospitals will be in area refuge or shelter during crisis situations.

Co-occurring natural events:
Hurricane Irene is also projected to impact the East Coast of the United States within the next week. Changes in weather are often the most overlooked hazards in emergency response. With predicted sustained winds of over 85 miles an hour, hurricane Irene certainly has the potential for increased damage to structures weakened by the earthquake.

What lies beneath?
What we haven't seen (perhaps we haven't looked for yet) is what lies beneath… under our feet, below ground is where we may find the true potential hazards from this earthquake. Quarantelli reminds us that natural disasters will simply be worse because they have more to impact. We have to keep in mind that there will be an increased impact on technology. Perhaps most importantly, is the impact to aging infrastructure. Natural gas lines, power distribution systems, sanitation, bridges/tunnels and highway overpasses have all been cited as aging pieces of infrastructure. The impact of this earthquake may be harder to measure in this capacity as these items are mainly underground and problems may not be readily observable.

Communications:
Communications difficulties have to be considered a given in crisis situations. Even without widespread death and destruction cellular service was rapidly overwhelmed with the number of calls made during and after the quake. Social Media was also widely used to communicate and twitter was bombarded with “tweets” during and after the quake.

Access to goods and services:
Many retail outlets including gas stations and supermarkets lost power making it impossible for people to purchase fuel and causing untold losses of frozen food and other consumables. While the inconvenience in this case appeared minor, consider the impact had a large scale evacuation been required… with limited availability of fuel for vehicles. Also consider the possibilities of prolonged sheltering without ready access to refrigeration.

Forward thinking: Bringing the Katrina decision home

2011-08-25T02:00:00.000-04:00

Ken Beers writes in this week with tremendous insight. He's asking questions that focus our attention on what will happen when the fallout from the recent Katrina decision comes home to our communities.

Concerning the Katrina/Tenet health settlement, Ken writes:

Let’s extend the thinking in this case to rural America. Can a small one ambulance town have a class action suit brought successfully when the tour bus goes off the cliff and 48 of the 55 patients die since their nearest mutual aid is an hour away?

What an interesting dilemma. How do we prepare for every contingency? When have we planned enough? How much should we spend on being prepared for the “big one”. How does Mother Nature figure in?

It would appear that in this case, the hospital didn’t plan on the levy breaking and taking out all their ability to continue providing services. If this hospital’s evacuation plan was similar to many others I’ve seen, they were all set to depend on ambulances for evacuation of the sickest patients. This doesn’t work when it is a community wide disaster since the ambulances will be tied up on other tasks. So how do you plan for community wide destruction and continuity of service?

In a way this is both very scary and fascinating at the same time.

Thanks, Ken, for writing in on this!

When is 25% preparedness acceptable?

2011-08-23T13:39:00.000-04:00

...apparently, nearly ten-years into the "post 9/11 era"

"I would say Tampa is probably about 25 percent ready for a terrorist event. That's based on the training I've done throughout the State of Florida for the last five years. I think that there needs to be more funding and more education,”

Eric Dotten, Emergency Med. Learning & Resource Center Read more on this story from ABC

The above quote and the basis for this post comes from a story found over at ABC Action News. Please see the video below.

9/11/10 commentary

It caught me off guard. I expected to read about how the EMS providers were polishing their skills for dealing with a high profile event; an event that represented a high hazard, an event that held potential for an ~~terrorist~~ intentional attack with chemical or biologic weapons.

In my ignorance, I expected Florida to be a highly prepared state. Hurricanes, tropical storms, high heat, large special needs populations, big cities...Florida seemed to be a state that has prepared and practiced. Some of the best emergency management conferences I've been at have been hosted and presented by Florida. A state with solid Domestic Preparedness.

I seem to be wrong.

Tampa is Florida's third largest city with a population of 335,709 and Florida is the fourth largest state in the U.S. I think the Buccaneers still pay football there. But despite the size of the state and city, Tampa seems to be only 25% ready for a terrorist event. This after ten-years in the "post 9/11 era".

I've held the opinion that the current Homeland Security approach to preparedness is a failed model. If accurate, does Mr. Dottens quote reflect that failing? I've also held that we should not be (specifically) training for terrorism...we must integrate readiness for intentional events into an overall domestic preparedness program.

What, then should we expect...after all we're ten-years into the "post 9/11 era". Read my opinion from 9/11/2010. As one reader wrote in saying "25% is better than nothing".

And that may be the theme as we get ready to embrace 9/11/2011.

Effect of the recent Katrina ruling

2011-08-23T02:30:00.000-04:00

I wanted to share a brief email from Michael Ehrman. Michael has been a long-time friend of Mitigation Journal and encountered a situation that reflected the impact of a recent legal decision from Hurricane Katrina. You can listen to Message from Katrina: Hospitals be ready part one and part two now.

You can contact Michael directly via Twitter @MichaelEhrman

Michael writes:

Just saw an effect caused by this ruling.

Went to Midwest City Regional Hospital for my Kiwanis Club bi-monthly meeting. New signage on the revolving door and other doors stated "This hospital is not a shelter". I had not seen this before and I asked security when did that go on the door but he did not know. Could not understand it as the 8-story building is strong enough for current history of tornados including those that destroyed parts of the city years ago. Now I know why it was put on the door. Thank you judge.

Thanks, Michael. Make us wonder what could be next...

Rochester, NY EMT has Stolen Trust

2011-08-21T17:04:00.001-04:00

While attempting to steal prescription medications, a Rochester, NY, EMT steals public trust.

“Shocked that somebody that is that close to helping people with medical conditions to be able to go in and invade your property."

- Joseph Pula, 79 of Chili, NY

Sad but true. Here we are (once again) talking about a responder who defiles the public trust. Once again, we see that Rochester, NY is not immune from this behavior. Video below, full story here.

In this latest situation, Derek Carstairs (formerly an EMT with Monroe Ambulance) returned to the home of a respiratory patient and attempted burglarize the patients home for prescription medication. While the local media attention to this has been scant, it has rippled (but not shocked) the emergency response community here in Rochester.

Prescription medications are at the top of the list of abused drugs. Addictions drive otherwise good people to do terrible things; mostly impacting family and friends. In this case, the addiction/crime has cost many responders the trust of the public.

Its not the first time.

In November, 2005 I wrote about an EMS director who accused of using the internet to arrange sex from the girl who is actually an undercover Monroe County Sheriff's Deputy.

Also in November, 2005, we talked about California, not to be out done by NY, seems to have trouble with EMS providers and internet solicited, under-age sex crimes.

December, 2006 we found out about a forty-year-old volunteer firefighter has been arrested for sexual abuse of a minor.

More recently, in January, 2009, I got upset about six paid-on call firefighters have been setting fires to get work...at the rate of $10.00 an hour.

Its not just crimes that fail the public trust. January, 2006, a paramedic who has been fired as a result of her blogging activities, reminded us that public trust exists outside of the clinical arena. Just as the paramedics who responded to Jett Travolta defaulted on the public trust and gave the "inside scoop" about John Travolta's son to the media.

These are the cases I've written about...there have been many, many more.

This is obviously not a problem unique to Rochester or to EMS. The damage to responders is also not limited to any one agency, service, or location.

Back to the Carstairs situation. The patient turned burglary victim makes a very poignant statement:

"I have to be very, very careful of the people that come and help me that they don't rob me."

Don't you forget that this statement will be going through the mind of each and every person you try to help. Think about this when your service lowers its standards because of a lack of personnel...just to get a warm body.

MJ 216 Message from Katrina: Hospitals be ready. Part Two

2011-08-20T11:18:00.002-04:00

Click for direct download

Special Early Release by popular demand

This may be the most influential decision in domestic preparedness that nobody is paying attention to.
Join me, Jamie Davis (The MedicCast/The Nursing Show), and MJ Co-Host Matt Comer on this two-part podcast. In part one we discuss the general situation and organizational implications. Part two will address individual actions and decision making in disaster situations.

In part one we opened discussion on the situation with an overview and potential outcomes. The financial and precedence setting are on the top of the list. Also, we take a look at the impact on future planning and preparedness for healthcare in disaster situations. What will the impact be to health care costs? Should a community expect to shelter in a hospital during crisis?
In part two: public preparedness, the post 9/11 failing, preparedness pendulum, optimism bias and more!

Click the player below to listen to Mitigation Journal podcast on-line

MJ 215 A Message from Katrina: Hospitals be ready. Part One

2011-08-15T05:00:00.000-04:00

Click for direct download

This may be the most influential decision in domestic preparedness that nobody is paying attention to.

Join me, Jamie Davis (The MedicCast/The Nursing Show), and MJ Co-Host Matt Comer on this two-part podcast. In part one we discuss the general situation and organizational implications. Part two will address individual actions and decision making in disaster situations.

This will be an extended series on Mitigation Journal Blog and Podcast. Will be evaluating the pro's and con's of this important legal decision, implications for health care and traditional response. This podcast is important for hospital as well as non-hospital personnel.

Tenet Health owned Memorial Medical Center during Hurricane Katrina in 2005. Over one thousand civilians and patients sheltered in the hospital in the aftermath of the storm. The backup power had failed, there was no air conditioning, no power for ventilators, no running water or sanitation, and temperatures rose above 100 degrees.

But that's not all. Dr. Pou was accused of ~~euthanasia~~ "hastening" the deaths of some patients. Reports of inadequate triage processes for evacuation and lack or leadership quickly followed. Eventually, forty-five bodies were found in the devastated health center during recovery efforts.

A July, 2011 court decision requires Tenet Health to pay $25 million to those patients and civilians who took shelter at Memorial Health Center and died or suffered injury. The court ruling is based on the belief that the medical center failed to establish an evacuation plan and that by poor design, the backup power system was vulnerable to flooding...that is, they failed to plan, prepare, and implement adequate preparedness operations.

Part-Two available now.

Click on the player below to listen now!

Active Shooter, Revisited

2011-08-04T05:00:00.000-04:00

Active Shooter, Revisited

The topic of an active shooter event came up in recent conversation with some healthcare colleagues. Specifically, we were discussing hospital preparedness for an active shooter situation.

Being the Director of Apocalyptic and Cataclysmic Thinking, my opinion remains that an active shooter situation in a hospital (or any health care environment/open location) would be disasterous. Further, with all the attention and money spent on chem/bio/rad preparedness, I belive that the active shooter situation has been left behind.

Many of those in the conversation thought I was ~~nuts~~ not in tune with current thinking. What else is new?

Given this, I've decided to re-post Mitigation Journal podcast #187 (an interview with Net Talon) on active shooter situations, as well as excerpts from prior blog posts on the topic.

Check out the links below for Active Shooter situations and management:

Physician Shot in Baltimore Hospital. Mitigation Journal, September 17, 2010.
Active Shooter Brief: First-In Actions. Mitigation Journal, July 14, 2010.
Direct link to re-post of interview with Net Talon. Mitigation Journal podcast.

Click on the player below to listen to the Net Talon interview!

We're all about situational awareness. Numerous articles and sources have talked about the use of civilians as forward observers...that is, those who are engaged in a situation being part of the solution be providing first-hand data to responders. The best example of this is the cell phone videos that make it to mainstream media; those videos taken by civilians who are actually there and perhaps in harms way. Even more recently we've discussed how many 9-1-1 dispatch centers were now accepting emergency calls via text messaging. Suffice to say, those in the midst of a situation have technology available to get important data out to responders.

I had an opportunity to have Donald Jones, Director of Corporate Development, and Ronald DuBois, Director of Administration and Finance at Net Talon join me on Mitigation Journal Podcast edition 187 for an in-depth look at Net Talon and the Virtual Command technology. What you'll hear on Mitigation Journal Podcast this week is perhaps the most invigorating news on the topic of threat mitigation I've heard in a long time.

Please visit Net Talon on at www.nettalon.com. While you're there, be sure to watch their active shooter demonstration.

See Something Say Something goes to Wal-Mart

2011-08-02T06:00:00.000-04:00

More than 230 Walmart stores nationwide launched the "If You See Something, Say Something" campaign today, with a total of 588 Walmart stores in 27 states joining in the coming weeks. A short video message will play at select checkout locations to remind shoppers to contact local law enforcement to report suspicious activity.

DHS Secretary Napolitano encourages you to say something to local police or a Walmart manager if you notice anything unusual while at Walmart. This is a continuation of the larger "See Something, Say Something" campaign designed to help report suspicious activity.

Although not an entirely bad idea, the statistics have yet to prove it worth.

I'm also a bit sceptical that running to the local Walmart manager is the best practice for reporting potential terrorist activity. Further, the campaign has yet to be proven as anything effective...check out this New York Times report.

Here's a quote from MJ Blog "See Something, Say Something" posted in September, 2010:

"Another problem is that people simply don't know what they are looking for. We, as emergency managers and planners have not done a good job at educating the public...or, is it that we simply don't want to share information? The result is failure for this See Something, Say Something campaign. Without an idea of what to look for, we'll get little if any useful information."

Let me add to that: Each report, while it may or may not result in useful information, will require law enforcement to expend resources to investigate.

We also discussed this topic on the podcast edition #202.
Click on the player below to hear my comments:

DHS video shown at Wal-Mart can be seen on the DHS Press Release (http://www.dhs.gov/ynews/releases/pr_1291648380371.shtm)

Passenger Transportation Accidents: MCI in a can.

2011-07-26T08:44:00.000-04:00

I've received a couple dozen emails asking for comment and suggestions for dealing with bus crashes. My guess is that many responders are taking notice of the recent transportation accidents that have occurred in our area.

Here are my suggestions for planning, responding, and managing passenger-related transportation accidents:

Planning: Situational Awareness is important for all levels of the response community. Knowing your response area and the types of hazards therein is the first step. Pre-incident planning is also a necessity and must involve surrounding agencies. Don't forget to include the non-traditional responders and the health care system in your area in your pre-incident panning and training. Perhaps a best first step is to remember that it CAN happen here.

Responding: The actions of the first-in crews will dictate the outcome of the event. I recommend that everyone know where they're going, do something smart with your apparatus, and keep in mind there are events when it is better to not just do something...but stand there. LOCATE (Location, Obstacles, Conditions, Accessories, Treatment, Extra help) works for transpiration accidents as well as single patient response.

Managing the scene and incident command: The first suggestion...ask yourself how bad can this get? Then ask; Are we ready for this bus crash? Incident manages, rescue and triage branch leaders need to consider a few immediate actions when working at a passenger transportation accident: the injury/fatality ratio, understand where people (and kids) like to sit while riding buses, and that existing openings (doors and windows) may not be accessible.

School buses can be difficult to asses and manage. Knowing the construction and types of school buses can help improve planning, response and management. Click here for a great summary post from way back in 2008.

Lets NOT forget about Emergency Incident Rehabilitation. This may be the most important part of planning, responding and managing any event. Effective rehab helps to keep your personnel safe and working. We should be trying to run a good rehab at every incident. Use my 5 LEVEL Steps to Proper Incident Rehab and use these 4 points to make your Emergency Incident Rehab Functional.

MJ 214: Angelo's Podcast

2011-07-24T12:45:00.002-04:00

Click for direct download mp3

This week Mitigation Journal becomes Angelo's Podcast! Angelo is the son of our Co-Host, Matt Comer.

Angelo needs our help.

Angelo needs a live transplant...soon.

Angelo is only 5 years old.

Most of his life he has been in and out of hospitals in an effort to figure out what is wrong. After years of being misdiagnosed, the cause of his sickness has been found. Angelo has Progressive Familial Intrahepatic Cholestasis (PFIC) type 2. This is a rare genetic disorder of the liver in which the liver cannot effectively pump bile out of the liver cells leading to liver damage and ultimately, liver failure. He also has severe cirrhosis (scarring) of the liver and is tormented daily by intractable and mutilating pruritus (itching). The only course of action for Angelo, in order for him to live, is to receive a liver transplant.

Tune in this week as we turn over the podcast to Matt in order to tell Angelo's story. Its a story of frustration with the medical community.

Its the ~~story~~ nightmare of reality for moms and dads.

Click the player below to listen on line or the MJ graphic (above) for a download mp3.

You can help. Join us at the next event to support Angelo's liver transpant:

September 3rd, 2011

4:00pm to 10:00pm at the North Greece Firemans Pavilion click here for info and directions...

If you can't join us, visit Angelo's Fund homepage or on Facebook. You can also click the Angelo's Fund tab at the top of Mitigation Journal blog page.

Click the player below to listen to Angelo's Podcast:

U.S. Boarder Patrol to blame for recent bus crash

2011-07-23T07:55:00.001-04:00

Why was Canadian tour bus driver allowed to drive in U.S. with suspended license?

It looks like the U.S. Boarder Patrol took a page from the TSA playbook. A Canadian tour bus driver was allowed to enter the United States and drive his bus with a suspended license. The tour bus, with 53 passengers on-board, was traveling to New York City from Hamilton, Ontario.

The tour bus had been traveling on the NYS Thruway when the driver had to pull to the side of the road to fix a mechanical problem around 0130 hours on Friday, July 22. It is believed that shortly after pulling back into the travel lane, the bus was struck from behind by a tractor-trailer truck. The bus and the truck burst into flames.

The truck driver was killed, 30 passengers were injured, two critically.

Why was this tour bus driver allowed to even enter the United States with a suspended license. According to media reports, his license has been suspended for almost five years due to multiple speeding violations in the U.S.

How is it that the U.S. Boarder Patrol, who monitors the U.S. - Canadian crossings, missed this little fact? It's not like the guy is riding a bike into the U.S. - he's behind the wheel of a tour bus!

The point is that this incident was preventable. It could have been avoided if the Boarder Patrol checked the drivers status in the U.S. They either didn't bother to check or didn't have access to the drivers U.S. license information...both options worry me.

The Department of Homeland Security is a failed model of preparedness.

If the Boarder Patrol can't get a tour bus driver off the U.S. highways, how are they going to find other threats crossing the boarder? Has the Boarder Patrol been reading the TSA manual on Domestic Stupidity?

MJ 213: Getting Healthy, Instinctively

2011-07-16T16:03:00.000-04:00

Click to download MJ 213

I've been working on dropping a few pounds and getting into reasonable physical condition over the last few months. Back in March, 2011, my doctor used the word "obese"...I didn't like the sound of that. So, I changed. Changed diet and lifestyle. I bought (Joanne bought) a road bike and started biking in addition to running. Much of this change was brought on due to the sudden death of a friend and experiencing a little episode of SVT/PSVT.

The good news is that I'm well on the way to a level of fitness I've not had before. Even (years ago) as an amateur fighter did I have the level of endurance and cardiovascular health I have now...and I'm just getting going!

There has been a good bit of help along the way. The Mitigation Journal Health and Wellness Consultant (Lori VanScoter, RN) has been providing some Health Coaching from the sidelines! This week on the podcast, Lori joins me to discuss an individualized health history review. We discuss general lifestyle, cholesterol, nutrition, exercise, and supplementation. The discussion is candid.

We'll be posting the video segments here in the blog over the next few weeks, too. In the meantime, listen to this weeks Mitigation Journal podcast. You can find all of the services Lori provides by going to her website Instinctively Healthy (http://www.lorivanscoter.com/)

Note: We're co-posting this on The Occasional Vagabond blog

MJ 212: Paramedic Ultrasound part two

2011-07-11T07:01:00.001-04:00

Don't object until you have all the facts!

Click to Listen

We're back on Mitigation Journal podcast with Peter Bonadonna, EMT-P, CI/C, for part-two of our series on Paramedic Ultrasound. In part-one (MJ podcast 211) we reviewed the goals of ultrasound use, diagnostic ultrasound, training programs, and changes to paramedic practice and delivery of care.

In part-two, Peter answers the question: Ultrasound, why now? You'll have to listen to the podcast to hear the answer.

Lets leave you with a few points:

1. Don't object unless you have all the facts. How do I get the facts? Listen to Paramedic Ultrasound podcast part one and podcast part two view our brief ultrasound video on the Training Videos tab, then visit the Paramedic Ultrasound tab above to go directly to www.paramedicultrasound.com.

2. Training might not be as hard as you think. Again, view the Ultrasound Video...see for yourself.

3. Why not now? Paramedic Ultrasound is an assessment tool that might just change the way we assess and triage certain patients. It may just be the next best thing since the pre-hospital 12-lead ECG!

Decontamination Revised: Preparing for Decontamination

2011-06-30T05:08:00.001-04:00

Preparing for Decontamination

There has been an upswing in interest on the topic of emergency mass decontamination driven by the number of "drills" being planned for the summer months. So, for the responders and hospital staff that have called/written in, we've put together Decontamination Revisited; a three-part series that will encourage thinking and provide a unique perspective on healthcare preparedness. Contamination Differences will discuss a few basics on the types of contamination that my be encountered, Big Questions will tackle the question of who should actually "do" decon, and Preparing for Decontaminatio we'll provide a simple wrap-up on the topic.

Another issue is the logistics of preparedness for decontamination. Tents and shelters must be trained on and practices with. They must be maintained and checked. Self contained breathing apparatus must also be maintained and personnel continually re-familiarized with its use. Other logistical items that are often forgotten are water supply, cleaning solution, lighting, towels, clothing and runoff management.

It is simply not enough for a health care facility to purchase a tent and believe they are prepared.

To wrap this up, let me leave you with a few take-home points:

Emergency mass decontamination should be done on site of the event whenever possible
Hospitals need to be prepared for self-referrals who may be contaminated and that self-referrals can pose a serious risk
Traditional and non-traditional responders must be able to recognize the incident indicators of chemical/biological/radiological exposure
Keep in mind that simply removing a victims outer clothing can remove 85 to 95% of contamination
All victims being transported by ambulance must be decontaminated prior to transport regardless of triage score or severity

Decontamination Revisited: Big Questions

2011-06-28T05:11:00.000-04:00

Big Questions

There has been an upswing in interest on the topic of emergency mass decontamination driven by the number of "drills" being planned for the summer months. So, for the responders and hospital staff that have called/written in, we've put together Decontamination Revisited; a three-part series that will encourage thinking and provide a unique perspective on healthcare preparedness. Contamination Differences will discuss a few basics on the types of contamination that my be encountered, Big Questions will tackle the question of who should actually "do" decon, and in part three we'll provide a simple wrap-up on the topic.

The big question is; who should do decon? At an emergency scene the issue is clear that the jurisdiction having authority in a chem/bio/rad event (most often the fire department) should provide or cause to provide decontamination. The use of low pressure, high volume water streams and improvised shelters may be used in emergency mass decontamination, while specially trained hazardous materials teams may provide a more refined and specific decontamination. The problems begin to arise when victims begin to self-refer to emergency departments or clinics... that is they leave the scene prior to the arrival of traditional responders. This poses a major issue as these victims will likely arrive a health care sites with no warning and no clue as to what they may have been exposed to or contaminated with. When this occurs and goes unrecognized, the health care facility, civilians, and health care providers are at risk. Immediate action will be needed to stave off secondary contamination and serious impact.

The bigger question is; who should do decontamination at a health care facility? This argument has been going on for years and opinions are highly polarized. One opinion often held by health care organizations is that the local responders will not be able to provide decon services at a hospital during such a large event. This camp believes that hospitals must be able to provide decontamination on their own for a period of time. Still others believe that traditional responders will be able to provide protective services to health care sites by way of mutual-aid from surrounding departments. Both points have concerns.

How do we expect health care providers, security staff, environmental staff, or others to provide decontamination at a health care site?

This is often the pool of personnel that is called upon to take training and carry out the functions if needed. The concerns however, loom large. Who will carry out the duties of those assigned to decon? Will the people mentioned above be able to retain the training information and function in protective clothing, including self-contained breathing apparatus? These issues are just the tip of the iceberg.

While many hospitals in the nation have added some type of decontamination shelter or system to meet requirements most (if not all) walk-in care, urgent care and retail health care centers lack this level of preparedness.

As more and more people turn to these clinics rather than emergency departments for routine care, we must realize that the same level of preparedness must exist for these locations. In the non-hospital clinic setting the need for trained traditional responders doing decon operations is even more vital.

Next: The logistical reality...wrap-up.

MJ 211: Paramedic Ultrasound

2011-06-26T10:38:00.003-04:00

Click for MJ Podcast 211

This week on the podcast we move towards innovation and EMS technology...we're talking about Paramedic use of Ultrasound. This is part-one of a two-part series.

Joining Matt and I this week is Peter Bonadonna, CI/C, EMTP. Mr. Bonadonna has conducted considerable research on ultrasound use in the pre-hospital environment and is considered a local expert on the topic.

In this session we'll review the goals of ultrasound use, diagnostic ultrasound, training programs, and changes to paramedic practice and delivery of care.

This is an outstanding technology that will enhance the ability of Paramedics to assess and prepare to treat a variety of patients. The goal of this series on Mitigation Journal will prepare you for the challenge. We've added a tab on Mitigationjournal.org for Paramedic Ultrasound that will provide you with background infromation, tutorials, links, and study materials. You can also contact Peter Bonadonna directly (www.paramedicultrasound.com) and request additional materials, information, and in-person training.

What to see more? Check out the Training Videos tab on Mitigation Journal...we've posted a narrated video of an actual ultrasound exam...you'll see how easy it can be!

Decontamination Revisited: Contamination Differences

2011-06-25T10:17:00.000-04:00

Contamination Differences

There has been an upswing in interest on the topic of emergency mass decontamination driven by the number of "drills" being planned for the summer months. So, for the responders and hospital staff that have called/written in, we've put together Decontamination Revisited; a three-part series that will encourage thinking and provide a unique perspective on healthcare preparedness. Contamination Differences will discuss a few basics on the types of contamination that my be encountered, Big Questions will tackle the question of who should actually "do" decon, and in part three we'll provide a simple wrap-up on the topic.

There have been several instances over the last many years that highlight the need for emergency decontamination at health care facilities. People contaminated with a hazardous material showing up at random to emergency departments or other health care locations poses untold risks to the health care provider, the facility, other patients, and the community. Events at walk-in/urgent care clinics and increasing Consumer-Level Hazardous Materials incidents have underscored these risks. With the number of walk-in care, urgent care and retail health clinics growing, the issue of emergency decontamination needs to be revisited. Let's face it; even routine events have the potential for turning into a contaminated situation for responders and patients. We've seen local situations involving the intentional use of chemicals in violent civilian attacks. Chemical assisted suicide and homemade chemical bombs increase the threat level to responders, healthcare facilities, and civilians.

Lets start with the understanding that there is a difference between chemical, biological, and radiological contamination.

Chemicals and radiological material is perhaps the most concerning as the longer the material remains in contact with the person, the greater the exposure and subsequent effects will be. Also, if externally contaminated the person may be able to "off gas" or spread the contamination. With chemical materials off-gassing can cause serious inhalation and mucous membrane irritation and secondary contamination in other people. The facility can likewise become contaminated.

The spread of radiological contamination has a higher risk of secondary contamination...although the onset of effects will most likely be delayed...and the possibility for occult contamination and extended cleanup measures will be needed. For more on radiological contamination visit the Radiation Emergency Medical Management site, the Radiation Treatment Network or Biological Effects of Radiation Part#1, Part#2, Part#3 and summary (contains references used) in Mitigation Journal.

Biological contamination can take the form of a person ill with a disease (flu) or the presence of disease containing solid material...like anthrax in a powder. We should point out here that a difference exists between exposure, contamination and reasonable risk. Exposure simply means you've come in contact with something and may or may not suffer from it.

When we talk about exposure we usually are not overly concerned with decontamination unless visible product remains on the person or clothing. Contamination commonly indicates that a residue or material remains on the victim and that material is able to be spread. Contamination comes in two forms...external - able to be spread and internal - not able to be spread. A person who ingests a radiological source most likely would not be capable of spreading that contamination nor would a victim exposed to vapor or gases unless the vapors permiated the clothing.

The point is that once a material is inside the body the risk of secondary contamination is much less as is the need for decontamination. Reasonable risk exists when a person has been in an area and, with or without symptoms, is anticipated to have been exposed or contaminated...prophylactic decontamination is warranted.

Next: Decontamination Revisited: Big Questions.

Kill Smallpox Now

2011-06-21T07:52:00.000-04:00

Eradicated from nature, we continue to defend this deadly virus.

Imagine if there were only two nuclear weapons left on earth. You have one, I have one. All the other nuclear bombs and missiles have long since been dismantled, destroyed...eradicated. Can you picture the scene? Just two bombs away from being nuclear weapons free.

While you and I could easily dismantle the last two remaining bombs and rid the planet of the threat, we don't. Instead you and I claim that more study must be done. There's more to learn about nuclear bombs we say.

Now imagine that the threat is not the last two remaining nuclear weapons, but the last two remaining stockpiles of a virus so lethal that, if it should escape its container, could devastate the human race.

It's in our hands to remove the threat...and we're not going to do it. It seems that Smallpox is getting a stay of execution. Again.

Since 1986 the Wold Health Organization (WHO) has been arguing about the destruction of the last two remaining stockpiles of Smallpox, otherwise known as variola. Destruction of these virus reserves would mean the removal of the treat of this virus on our planet. The decision to destroy the remaining samples has been pushed back for further discussion until 2014. A target date for destruction set for 2016.

Smallpox exists today at the CDC in the United States (frozen in nitrogen and under heavy guard) and in Russia (under similar circumstances, we hope). They're safe. They're secure. That's what the Japanese thought about their nuclear power plants before an Earthquake of historical magnitude redefined disaster.

Smallpox could easily redefine disaster for Planet Earth...

"What would happen if an Earthquake or other natural disaster of historic proportion struck the CDC in Atlanta? How safe would those Smallpox samples be?"

Smallpox has been around for over 3,000 years and was removed from nature by the efforts of science and vaccination. Today, it is that same claim of science that is keeping the stockpiles in the United States and Russia from being destroyed. The claim is that we have more research to do. See Biological Events: Smallpox (Mitigation Journal, Dec. 15, 2010). You can hear my commentary on Mitigation Journal Podcast #191 Smallpox get stay of execution.

I'm not buying it.

We've been researching Smallpox for over forty-years. The virus has 49 identified strains, the genome is known, and we have a vaccine developed. What more study do we need to do? The United States and Russia claim that we need more research to build new antivirals, create new vaccine. Create new vaccine by 20114? We can't keep routine medications in stock today! What makes you think we'll come up with a new Smallpox vaccine?

How much more are we going to learn about Smallpox between now and 2014?

We have all the data we need.

The Smallpox virus has been responsible for an estimated 3.5 million deaths in the 20th centurry. The death rate from the virus is about 30% (depending on the form) and surviving the pain of having Smallpox means permanent disfigurement. In today's terms, the deaths would be even greater because of the vulnerability of our society and the greater number of people living with compromised immune systems or co-morbid conditions. Worse still, we're a society of anxiety, not preparedness.

We humans have no protection from this virus. In the United States, we discontinued routine vaccination against Smallpox in the late 1970's. Those who were vaccinated may have little protection against the virus today. Those not vaccinated have no protection. In my Maintaining a Culture of Preparedness program, I tell people that one case of Smallpox (anywhere on the planet) is a global health emergency. I usually tell attendees that after I've asked: where do we see smallpox today?...the answer, by the way, is usually given as some third-world country. As responders, we still have a lot of learning to do about this virus and the potential impact. While there are many diseases that give us a concerning rash, none are more deadly than Smallpox.

Destroy the Smallpox virus. The threat is not terrorism...it is our own complacency. Destroy the threat.

Not a current thinker and proud

2011-06-16T05:01:00.002-04:00

I've never responded to a statistic.

I've never been called to help a recent study get up off the floor.

I've never been there to calm the family of dying data.

I respond the needs of my community, the needs of people. And so should you.

Apparently, I'm not a current thinker in emergency medical services. I was told that recently. I was also told that paramedics of my generation aren't relevant because we don't see the bigger EMS picture. We're not in tune with the what is happening in the big cities...what the real EMS systems are doing.

That's crap.

In recent conversation the topic has come up again and again about how large multi-center..."studies show"..."data indicates"..."statistics prove"...the list goes on. What so called current thinkers in EMS are saying when they use these terms is that we would rather let other people think for us rather than think for ourselves.

Don't get me wrong; studies, data, and statistics are important information for us in public service if the information is used correctly. In my opinion, correctly is defined as taking the information presented and applying a healthy dose of critical thinking to it. Decide what (if any) of it actually applies to your location.

Studies done in big cities or multi-center research is great...great for the area that conducted the study.

But we're not here to meet the needs of a "study". We're here to meet the needs of our communities. Only the people who serve that community, those who truly know that community are in a position to decide how to best serve it and meet its needs.

Applying the results of a big city study to your hometown ~~blindly~~ without critical thinking forces your service into a cookie cutter formation that just might not meet the needs of your community.

I found it on the internet...so, it must be true. I read about it in a big city study...so, we'll be cool if we do it too.

Have we ~~gotten lazy~~ de-evolved to the point where we want others to think for us? To tell us what is best for our community? I think so. But, then again, I'm not a current thinker in EMS.

Not a current thinker and proud.

I'd rather read the 'data' and consider the use and impact to my community, to my personnel, to my region before implementing unrealistic changes.

So, go on and implement change based on what works well for Dallas, L.A., D.C., NYC. Chances are you current thinkers won't notice anyway. They've stopped thinking.

Homeland Security: a failed model for preparedness

2011-06-14T05:00:00.001-04:00

Its a war on terrorism...the real war is against complacency.

(I can hear the black helicopters over my house already)

Homeland Security...that's the name of the game. The objective of the game is security. Thus, a majority of funding dollars have been dedicated to law enforcement-type agencies; from CIA and FBI to your local police department. All in the name of security. To a lesser degree, Homeland Security dollars have been allocated to other places; CDC, Public Health, USFA and FEMA.

How's it working for us?

I've been critical of the term Homeland Security. I've been critical of the term because "security" implies people with guns, badges, and secret surveillance are needed to make us safe. I've been critical of the logic that makes law enforcement the top recipient of funding at the expense of other public services...EMS, for example. To be fair, I also think the much of the funding and grants that have gone to the fire service in the name of Homeland Security have been poorly allocated if not wasted. Where has Homeland Security improved our response to natural disasters - Katina or more recent floods and hurricanes?

I've been criticized for my views. Recent reports, however, are indicating that I might just be onto something.

One such report indicates that our National intelligence agencies are no better prepared for counter-terrorism than they were on 9/10/01. Other reports indicate that the growing threat of ~~Homegrown Terrorism~~ domestic terrorism is not able to be managed appropriately under the current counter-terrorism structure of the CIA, FBI, or the Department of Homeland Security.

The McKinsey report on the operations of FDNY and NYPD note that incident command, communications and interoperability were lacking during the 9/11/01 attacks. Keep in mind that the shortcomings were not soely related to communication but to organizational structure as well. NIMS, anyone? While FDNY and NYPD are the cited examples...the same shortfalls continue to exist today at the local level. Yes, I realize some areas have tackled these issues better than others; yet, the point remains that little progress has been made after nearly ten years under the Homeland Security model. Sure we have the Patriot Act, "See Something, Say Something" and, of course the TSA with their pat downs and body scans...but to what success? Our Homeland Security approach didn't do much for our Public Health ability to deal with a naturally occurring biological events...Swine Flu, anyone? Or, how about that fantastic color-coded threat level?

Again, how's all that working?

My solution - Change the name...and change the way of thinking...get rid of Homeland Security and go back to what worked...civil preparedness with an eye toward the all-hazards approach! Civil Preparedness embodies readiness for more than terrorism. Then get the funding (by the way, funding for preparedness is drying up every day) to the local responders who can put it to use for all-hazards - naturally occurring as well as intentional. Under my view of Civil Preparedness, training and funding for civilian (individual families, communities) would take a much larger role. And I'm not talking about just another Ready.Gov style approach - I mean actively engaging civilians and communities to be better prepared and as self sufficient as possible. I believe that approach alone will improve local and state responses to natural and intentional events.

Homeland Security...how's it working for you? Isn't time to try a ~~new~~ old approach to preparedness?

MJ 210: Public Service Lay-Offs Part Two

2011-06-13T09:51:00.022-04:00

Click image for download

Public Service Lay-Offs: Impact on Domestic Preparedness Part Two

Join Mitigation Journal co-host Matt Comer, special guest Alan Bubel, and me as we tackle the ramifications of public service lay-offs and the impact to local preparedness. In part one, Alan and Matt investigated the ramifications from the fire and EMS perspective (MJ Podcast #209 release date 5/30/11).

In part two, I'll examine the larger picture of local preparedness and we'll pull it all together under the All-Hazards approach in MJ Podcast #210 (release date 6/13/11).

School Security goes in wrong direction: Part Three

2011-06-09T05:02:00.000-04:00

School Security goes in wrong direction: Part Three. From Mitigation Journal Podcast.

Click for full audio podcast

The background story can be found here. Several years ago there was a movement to ~~remove~~ decrease the amount of security in public schools. In December, 2006, Mitigation Journal told you about research that indicated school security may actually be doing more harm than good. See School Security Should Go Over the Top (Mitigation Journal 12/06).

We continue to support our position that schools, hospitals, shopping malls and similar locations are soft targets. These soft target locations can also be locations of critical infrastructure and need to be protected. The problem in this situation seems to be that the planning and delivery of the training scenario.

The video from segment 1 and segment 2 of this topic can be found on mitigationjournal.org from our recording of Mitigation Journal #208.

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Pharmaceutical Shortage

2011-06-07T02:00:00.053-04:00

Running out of medications? No pharmaceutical tracking or early waring system in place?

How can we be running out of medication used to treat everyting from cancer to medical emergencies? After 9/11, Anthrax, SARS, and more recently, Swine Flu (H1N1)...how is this possible?
Even more perturbing is the revelation that no early warning system is in place to alert the medical community to an impending shortage?

After nearly ten-years of preparedness, ~~billions~~ ~~trillions~~ a lot of money spent on biological preparedness under Homeland Security we have found (or just awoke to notice) a major hole in our defenses. I must admit that I believed (wrongly) that there was a system in place to detect shortages in raw materials or production. Then again, I must have been blind to it...I remember getting notices from our local EMS system informing us that shortages of epinephrine had occurred almost overnight. I never related the situation to the large picture of ~~Homeland Security~~ Domestic Preparedness. Then again, our obvious inability to ramp-up flu vaccine production should have been a warning, too.

Its one thing to run out of a medication (or any other resource)...its quite another issue to not see it coming. According to media reports, hospitals are postponing or cancelling surgery and delaying cancer treatments due to the lack of medications.

Pharmaceutical shortfalls have been looming for several years. There seems to be several theories as to why, but no firm explanations. With no definition of the problem or cause it seems unlikely that a solution will be found anytime soon. According to 13WHAM (Rochester, NY):

"U.S. Senator Chuck Schumer says the shortages are unacceptable. He is backing legislation that would direct the Food and Drug Administration to give hospitals and pharmacies early warning when there are shortages of certain drugs. He says that would give them more time to find alternative medications."

Legislation (FDA) will not fix this problem. After all the Bioterrorism ~~security~~ preparedness time and money, after all the NIMS training, and after we've been encouraged to "See Something? Say Something" or disrobed, prodded, and felt by the TSA, we have no ability to predict/preempt medication shortages...of medication the health care community uses every day. Imagine what life will be like when some disease gets out of control...naturally or intentionally.

Inhalation Anthrax, for example; can be treated with common antibiotics...if you can get them...but what if antibiotics were in short supply? We've already seen how the media, and by result, the public, response to shortages of medications...real or imagined. For a good reminder about how the public reacts when expectations are not met, review this post from May, 2009. The good news is inhalational Anthrax is not transmitted person-to-person. What if another biological agent (naturally occurring or intentional) like Smallpox? Perhaps a novel Type A Influenza and no vaccine production ability would be another good example.

Would we be able to rely on non-pharmaceutical interventions to prevent the spread of disease? How long would it take to recognize a biological event was unfolding?

We've learned nothing from our experiences with SARS and flu. What will we learn from this little bit of awakening? Will we take some action to prepare ourselves despite the pharm/government failures or hit the snooze alarm...I'll bet most people will remain blind to the fact that pharmaceutical shortages and lack of an early warning system has a major impact on Domestic Preparedness.