Do it in your Sleeve

Here is a nice public education video on the topic of respiratory etiquette. Its lighthearted and factual. Check it out here: http://www.coughsafe.com/media.html



Thanks to Mitigation Journal reader/listener, Ted Lenze, for sending this in.

Of Chicken and Expectations

OK, you've got to see this video! When watching, do so from an emergency management standpoint...that is, substitute antiviral agents, antibiotics, masks...for the word "chicken".

Also, change the question "how do I feed my family?" to "how do I protect my family?". How about instead of Popeyes...we use [insert your organization/community name here] ? Are you prepared for the onslaught?

How does simply changing from "chicken" to medication/masks (or whatever) impact this situation? What will changing from "feed my family" to "protect my family" do to social unrest and public health?

Is this a snapshot of what we can expect when the community expectation is not met?! These people are not actors, they are actual citizens with actual expectations...reacting when those expectations are not met.

Imagine your point of distribution running out of medication...or the neighboring jurisdiction running out of medication and how that will impact your community. If people react in the manner displayed on this video over a chicken combo special, what do you think they will do when we run out of antivirals, antibiotics, masks...or whatever?

I can hear it now..."What do you mean you didn't order enough antiviral medication and masks?! You knew this flu was coming two months ago!"

Special thanks to our Director of Apocalyptic Thinking, Officer Sundquist, for sending me this video and bringing this potential to our attention.

I await debate and comment!

Selected Reading on the Flu Situation

Here are a few of the many articles I've read in the last few days on the topic of Swine Flu and flu in general.

Avian Flu Research Sheds Light on Swine Flu
"...A new study by University of Maryland researchers suggests that the potential for an avian influenza virus to cause a human flu pandemic is greater than previously thought. Results also illustrate how the current swine flu outbreak likely came about..."

Is Swine Flu A Worldwide Threat?

Pandemic Flu Vaccine 6-Month Lag Time
"...the first wave of pandemic flu may be over before people are vaccinated..."

On the topic of N95's

Some questions about fit testing for N95 masks have come up.

Fit Testing...is it worth the time?
http://www.upmc-cbn.org/report_archive/2008/12_December_2008/cbnreport_12192008.html

and here is a joint NIOSH/OSHA/CDC study
http://www.cdc.gov/eid/content/13/5/700.htm

Don't Expect Too Much from N95
http://www.iom.edu/CMS/3740/32033.aspx
http://www.medicalnewstoday.com/articles/42502.php

OSHA comments on stockpile of masks
http://www.upmc-cbn.org/report_archive/2008/05_May_2008/cbnreport_05302008.html
...and http://www.medicalnewstoday.com/articles/69826.php

Flu virus is airborne...suspended in air - need for more stringent precautions?
http://www.upmc-cbn.org/report_archive/2009/01_January_2009/cbnreport_01222009.html

Don't expect much from facemasks
http://www.medicalnewstoday.com/articles/42502.php

What NOT to do for Flu

Here is some good info in the setting of flu from TIME/CNN: The top five things NOT to do in a pandemic situation -

1. DONT go to the hospital
2. DONT be afraid to eat pork (and yes, I think we should continue to call this SWINE FLU)
   
3. DONT hoard anti-viral medications (lets add to this one...DONT take antibiotics...they wont work on flu - antibiotics are for bacterial infections, flu is viral. Taking any medication...antibiotic or antiviral...when you're not sick can lead to the development of resistance, too)
   
4. DONT leave your home if you feel sick (lets add to that if you have fever and respiratory symptoms...or symptoms suggesting cold/flu of any kind)
5. DONT panic (its Swine Flu...not an IRS audit)

And now for a few of my own...

• Call 9-1-1 only if you need to...remember, ambulance crews are limited and calling an ambulance will NOT guarantee you get a hospital bed any faster (if at all)
• Wash your hands...all the time
• cover you cough/sneeze
• practice appropriate social distancing
  

FEMA Preparedness Guide 101

The final version of the FEMA Comprehensive Preparedness Guide 101 is available. You can download the entire 176 page PDF here: http://www.fema.gov/about/divisions/cpg.shtm

I read the draft a while ago and used that as a template for the Planning Series on the Mitigation Journal Podcast. I think it is a solid document with many good features for civilian and responder alike. My biggest joy from this document comes from an apparent return to a civil defense approach...something I am a BIG fan of...throughout the document.

I just hope someone at FEMA or DHS reads it.

Anthrax? Not. Lessons Learned? Not.

Check the story here...good video, too.

Envelopes containing the dreaded "white powder" have been found in numerous locations Sebring, Fl. Some of the envelopes were found on cars in the parking lot of a hospital, some at the town hall, others in various mailboxes throughout the area. In at least one instance, a person who found the item on their car, took it back into the hospital...a lock down and default quarantine followed...
Of course, responders in PPE and SCBA collected samples that later turned out to be "non-hazardous" to humans.
What strikes me about this situation is not the fact that someone did it...its how the public and media responded to it. We know that, of the three varieties of Anthrax, inhalational anthrax is not spread person-to-person, we also know that it is difficult to manufacture is quantity and distribute. Why, in today's culture, would you take a substance back into a hospital?

Yet, we don't seem to get the lessons from prior events. Emergency managers should be informing the media about the reality of inhalational anthrax and responders (with appropriate caution) need to be realistic about responses...not every white powder event is NIMS laden, large scale disaster event.

We knew this before 9-11-01, we knew this after 9-11-01, yet we keep reacting to white powder events as if we've never seen it before.

Sabotage: Back to the Stone Age

An act of sabotage in Santa Clara, Ca. has disrupted communications and left 52,000 without telephone, cellular phone, or internet communications. According to the National Terror Alert and MercuryNews.com someone got into (an unsecured)utility man-hole and cut four or five fiber optic lines. The disruption impacted not only "land line" service, but cellular service, ATM's, and emergency communications.

Although sabotage is the suspected (obvious) cause of this event, the MercuryNews.com report notes that the contract between AT&T and the Communications Workers of America (CWA) had expired at 11:59 (problem identified at 2am)...

According to both reports, the situation was noticed when an emergency communications center discovered they had lost phone service. Officials have given some interesting quotes published in both the National Terror Alert and MercuryNew.com...

"We've never to this extent in recent history had this kind of phone outage,''and It's kind of like an earthquake" are two that stand out.

According to MercuryNews.com:

"The Santa Clara County Emergency Operations Center has been activated; the Santa Clara County Fire Department has moved more firefighters to south county fire stations; the county sheriff has increasing staffing and patrols; and additional ambulances have been positioned in the area."

Overall this is a good tactic. However, you have to consider that loss of communications is a precursor to another event in another area. If you move resources into the effected area, make sure other areas are also well supported.

A couple of things to point out, and this is what I'd be thinking if I worked in this areas emergency management:

• Soft Target/Hard Target...communications service is part of critical infrastructure...protect it! Open utility vaults/man hole access are soft targets when they contain communication equipment, power supply access, water supply distribution and so on. They should not be soft targets...they need to be protected.
• Despite the almost obvious link between AT&T/CWA contract negotiations, don't jump to conclusion that this situation was perpetrated by a member of either party. Keep in mind that people that want to do us harm read the paper, too. The contract negotiations may be just the cover an individual(s) would want to try an act such as this...bottom line, think deeper. Also, it wont take a lot of imagination to figure out what to cut/destroy to cripple a system like fiber optic communications. I think anyone with motivation could do it.
  
• Consider that this act may be a probe, a test simply to see how a community responds to such an event. Although significant, this could be the tip of the sabotage iceberg.
• Consider also that destruction of communications ability may be the heralding event for something else...disruption of communication may be just the start, with the primary event taking place later. Crippling of the emergency service communication and the public ability to report an event would signal trouble for responders...and increase the scale/impact of a concurrent event.
  

National Infrastructure Protection Plan

I've just received this link for the new National Infrastructure Protection Plan. We'll be reading it over in the next few days and reporting back here and on the podcast.

Until then, give the Plan and associated documents a look. All documents are available in PDF.

The updated document replaces the 2006 document...I think that one was over 200 pages...the update is only 188 pages. Your thoughts and comments are important. If you take the time to review the NIPP and documents, please let me know what you think.

Chemical Suicide in Cars

Information is circulating on the topic of chemical suicides. We've talked about them a number of times on Mitigation Journal and here, in the blog. I've added some links to the podcast and blog postings on the topic of chemical suicides...see the links below.

There have been numerous cases in Japan of people committing suicide by mixing various chemical products with the end result being Hydrogen Sulfide. The situations in Japan have occurred at an alarming rate, and due to the living conditions, created a number of MCIs and ripple effect casualties in apartment buildings.

Two cases are being talked about recently...both in the U.S and both involving people sitting in parked cars (sometimes sealed with tape on the inside) and mixing chemicals. By reports I've been reading, the chemicals are different from the types used in Japan and other places, but the end result is the same.

I have been aware of this type of activity for a while now and reported about it on the podcast and blog. I am aware of two events within the last 6 months or so (Georgia and California) where people have locked themselves inside their car and mixed chemicals. I am also aware of at least one other similar event in Portland, Ore, where a guy used chemicals heated by a hibachi in a hotel room to do the same thing. In many cases there is hydrogen sulfide (H2S) created. Chemical suicide has been a growing problem in Japan...these situations have caused MCI's in apartment buildings and numerous deaths. It would seem the trend is continuing and moving toward us.

Mitigation Journal Podcast #72
Mitigation Journal Podcast #64
Mitigation Journal Podcast #59
Mitigation Journal Blog

More to follow...If any readers have better intel on this, please write in or call the voicemail line 585-672-7844.

Stand by for the Ripple Effect

One out of every four people said they're (or someone in the family) is putting off getting medical attention due to cost. Another 50% admit to over-reliance on folk remedy and over the counter medications in lieu of seeking prescription drugs and doctors office visits.

EMS providers hang on to your EKG leads! The combination of prolonged reliance on over the counter medications will lead to increased medication interaction and more severe disease. Sprinkle in a bit of denial and delayed access to care, and we'll be seeing sicker patients with masked symptoms. The situation reported by MSNBC should also be a warning for use to look ahead for the Ripple Effect...in this case, the Ripple will be surge on hospitals and EMS with patients who have been under treated or have been non-compliant with treatment. Also, responders have to be ready for the prescription / OTC interaction and complication of history and exam.

Keep an eye on this one.

Protecting Nuke Plants from Air Attack

Shouldn't we have done this already?
You and I may have thought that nuclear power plants have been evaluated and made safe from threats on the ground and in the air. We're wrong. A story being run on CNN.com states that new construction of nuclear power plants will have to be protected from dive-bombing aircraft.

Just think, it's only been seven years since the September 11, 2001 attacks on the WTC...and we're just getting to the protection of our nuke plants now!? To make matters worse, the requirement put forth in the article notes that "...require any future nuclear power plants to be designed to withstand strikes from commercial jetliners..." What about the current plants? Shouldn't we be doing something with them as well? I have to honest here, I thought that they were already protected to some degree from this scenario...guess not.

Once again we demonstrate the failure to learn from our emergency preparedness history. Billions of dollars have been spent and much of it wasted in the name of preparedness since 9-11-01. We've failed to make meaningful changes to our attitudes toward preparedness and been mediocre at best keeping up with man-made and biological threats.

If IT CAN Happen Here, IT CAN Happen Anywhere

For those of you remaining in the "it can't happen here" crowd; let CNN serve up this story as a reminder. I actually read this a few days ago and forgot to post it. The scenario is that an improvised explosive device was detonated inside a prison during a search. Although no one was injured, it is another reminder of the relative ease of construction and obtaining materials for an improvised explosive device (IED) or homemade chemical bomb can be.

If some motivated inmate, presumably with limited access to materials and under salience, can construct an IED...what makes you think your community is going to remain free from this type of event.

If the term "Domestic Terrorism" is not in your vocabulary...put it there today.
See these Mitigation Journal blog postingsand listen to Mitigation Journal Podcast for more:
Homemade Chemical Bombs
Chemical Fumes Risk
Domestic Terrorism in Aspen

Point and Click Equals Sick?

I found this story in the Orlando Sentinel interesting. The story suggests that more people are turning to the Internet for medical information and becoming "Cyberchondriacs" as a result of diagnosing themselves with a worst-case disease scenario.

Any access to information has to be put into context. Without qualified medical opinion and assessment the medical information found on-line or sought in texts is next to impossible to use correctly. Should we limit public access to medical information? Absolutely not. While a person may over diagnose themselves with a condition they may be just a likely to seek evaluation and treatment earlier. We may actually see a decrease in denial!

In any event, I think we as responders have to recognize the fact that people who call 9-1-1 have access to a great deal of information...and that information may lead them to incorrect conclusions about their health condition or situation. That means a charge in expectation. Responders have to be able to speak intelligently and factually in the face of "Internet self-diagnosis". We have to be able to do this in order to maintain our credibility, elicit the proper information from the patients, make the correct decisions...the list goes on.

If you fail to acknowledge the fact that the public you serve is informed...you may fail to meet their expectations or elevate fears. Both are failures of service.

1 in 5 Quit

Another story being run by MSNBC states that 1 in 5 nurses quit within their first year of service. Once considered a product of the over-worked, under-paid emergency services field, it seems as if the longevity and retention of nurses is reaching alarming rates.

This article is worth the few minutes it will take to read. I think it will open your thoughts to the situation in the Nations emergency departments.

On a final note, things that make you go HHHMMM...

"Many novice nurses like O'Bryan are thrown into hospitals with little direct supervision, quickly forced to juggle multiple patients and make critical decisions for the first time in their careers."

The Cost of Texting

For many, its not the cost of text messaging service that's a problem...it's the loss of communications skills. This recent MSNBC story highlights a concern many of us (especially parents of teens) have about the texting communication craze. The story highlights the possibility of loss of traditional communication skills, use of grammar, inability to use proper sentence structure and so on. Thinking about my own experiences I'm not sure that I fully agree. I know my own writing, spelling and desire to write increased dramatically when personal computers (read: spell check) came to the commonplace . In my case, the use of technology (personal computer...in my case a TANDY notebook) made it possible for me to overcome poor handwriting and spelling. When all is said and done, the personal computer became a way for me to overcome limits and eventually produce Mitigation Journal, one of the finest niche blogs available today.

Can we say the same thing for text messaging or "texting"? I don't know, its far too early to tell. I do think that texting allows us (teens and others) to communicate with others who we'd not normally contact and share immediate thoughts. We've talked about the value of social networking sites such as Twitter (follow Mitigation Journal on Twitter) and Facebook. These sites have value in emergency service and public safety communication as well as message delivery to the public.

To put a public safety spin on it; the question that remains is one of integration. How will the "text" generation communicate with others in an official situation. Let me define that as, for example, communications face to face between paramedic and physician or paramedic and triage nurse. Although we can become concerned with issues of miscommunication or loss of data with texting and the impact of patient care, I suggest that texting posses no more threat to communication between people than poor use of grammar or body language. In fact, texting a brief EMS patient care report or fire ground situation update may improve communication. Texts are usually short and focused and contain the only the needed words to get the point made. How will we integrate texting and other social media into emergency service remains to evolve...rest assured, it will continue to evolve.

Think about the use of texting the next time you're giving a verbal report on a noisy fire ground or at a crowded triage station. Texting may be a solution to the "THEY never told me that"...phenomenon that happens to so many EMS providers.

We'll be following this one for a while.

Violence and Duty

We've just learned of an EMT in Jefferson County, New York, who has been shot and killed in the line of duty. We're also getting early news reports about a City of Rochester police officer who has been seriously wounded on duty.

There is a trend of violence towards responders of all uniforms...and yet we don't seem to take it seriously. We've been reporting on what seems to be a continual stream of attacks throughout 2008 and now into 2009. Yet, I have not seen nor heard of any training sessions or in-services being taught on the topic of scene safety. Why is this not a priority? I know, it can't happen here. (Sarcasm intended)

The fire service is full of scene size-up memory aids, COAL WAS WEALTH, WALACE WAS HOT, and others; none of them addressing personal safety. EMS is notable for teaching new EMT candidates to recite "BSI, SCENE SAFE!" upon entering any testing situation. Again, no translation to the actual assessment of a situation and personal safety.

Once upon a time a uniform, any uniform, would grant you respect and a certain level of protection in the community. EMS providers were looked at somewhat differently and could often move in and out of situations with little concern.

Times are changing. If we don't change NOW and start teaching our people to look at every scene for threats and start to size-up the people rather than the building we will invite more assaults and fatalities.

I'm going to challenge every responder to change they way they look at situations and consider all people a threat until proven otherwise. I'm also challenging instructors to begin cross-training with law enforcement on the topic of recognition of dangerous situations and self protective measures.

My commentary on this weeks Mitigation Journal podcast will be about the futility of BSI/SCENE SAFE/COAL WAS WEALTH.

Here are a few related entries from the archives:
Ready or Not (not even EMS) http://www.mitigationjournal.libsyn.com/index.php?post_id=385325

Firefighter shot at fire scene http://www.mitigationjournal.libsyn.com/index.php?post_id=362809

Rochester EMT saves Cop http://www.mitigationjournal.libsyn.com/index.php?post_id=335844

Line of Duty Planning Series with Dan McGuire http://www.mitigationjournal.libsyn.com/index.php?post_id=398987

After the Fire

This is the fire building from the 4-alarm the other night.

After the fire

Duty to Act Policy

Duty to Act; do you have it? Should your service have a policy on the topic? This post on the USFA Blog got me thinking about several issues. How many of us would even think twice about stopping to render assistance to someone in need? Chances are that we all would...

What are your organizational policies, if any, on the topic. The liability and insurance coverage is another matter. Would you be covered...malpractice...injury...the list goes on.

The first part of duty to act should be to protect yourself at all times. Your first duty is to yourself and your family. We often consider the use of PPE for various activities...but how often do you consider protection from legal issues?

Great blog posting - check it out here: http://blog.usfa.dhs.gov/2009/01/duty-to-act.html

Not Alone Against Free Antibiotics

Free Antibiotics Are Bad. We posted on MJ earlier this week about a local supermarket chain here in Rochester, NY, that was jumping on the free antibiotics bandwagon. At the time of the posting there were few voices of warning. There were even fewer who wanted to remind the public (and maybe the Big Box Stores) that antibiotics are not going to help against the flu...think difference between viral and bacterial infection...and antivirals versus antibiotics.

Here is another opinion from Medical News Today about how free antibiotics are not a good idea for public health.

Nice to know you're not alone.

Less Sleep, More Colds

A recent study has me thinking. One of my changes for 2009 (not resolution, mind you...just a change) is to add more sleep. That is more sleep each night and more each week. A number of studies have looked at the effects and the toll of lack of sleep. It seems that from cardiovascular to immunologic systems are among the two at most risk. See Sleep Habits and Susceptibility to the Common Cold as published in The Archives of Internal Medicine.

Here is a summary of findings...

• The less a person slept, the more likely he or she was to develop a cold (there was a graded association between infection rate and average sleep duration).


• Participants who slept fewer than 7 hours were 2.94 times more likely to develop a cold than those who had 8 hours or more sleep.


• The more efficiently a person slept (more of the time in bed actually spent asleep), the less likely he or she was to develop a cold (i.e. there was also a graded association between sleep efficiency and rate of infection).


• Participants whose sleep efficiency feel below 92 per cent were 5.50 times more likely to develop a cold than those whose efficiency was 98 per cent or more.


• Feeling rested was not linked to rate of infection.


• These relationships could not be explained by the potential counfounders such as levels of virus-specific antibodies beforehand, demographics, the season of the year, body mass index, socioeconomic status, health behaviours, and psychological variables.

Iron Safety a Hot Topic in Rochester

The University or Rochester and the Rochester Fire Department have teamed up to help prevent burn injuries. A recent article in the Rochester Democrat and Chronicle highlights the efforts between the two agencies to develop a safety campaign to prevent these burn injuries. They are working on two solutions; first an educational brochure to be given to new mothers at the U of R and, second, a physical device to hold the iron flat and protect the sides.

The need for this type of information and protective device are evident based on the stats given by the U of R:

"...Between 2003 and 2007, the Strong Memorial Hospital Regional Burn Center treated 212 children younger than 5 for contact burns. While wood-burning stoves were the most common source, hot clothing irons burned 29 patients."

"Toddlers suffer second- or third-degree burns when they touch a hot iron or knock it onto their hands or face. Some of those burns require skin grafts, a five-day hospital stay and a month of recovery."

Check it out here.

Thoughts on extreme cold weather

Random Thoughts on extreme cold weather...

"evaluate every trauma patient for hypothermia and every hypothermia patient for trauma"

"life safety, incident stabilization, property conservation"

"confine it to the Zip Code of origin and keep it off CNN"

Extreme low temps and brutal wind chill expected here in next 24 hours due to last through the weekend...high temps predicted to be between 2 and 5 above with sustained 25MPH winds. That means wind chills well below zero.

Even small events take more resources and protection of responders can be difficult. Don't forget Emergency Scene Rehab for cold situations (as important as during hot weather) and often forgotten.

Pumps can freeze, lines freeze turn into iron pipes, and the fire scene can turn into an MCI of responders.

"if there is snow on the roof...it can't be too hot inside"

MVC's on highways can become impossible blizzards...think rapid extrication...minor injuries and illnesses will deteriorate quickly.

Retail Health Clinics and Recession

We've talked quite a bit about the potentials of Retail Health Care Clinics on this blog and on the Mitigation Journal podcast. A retail health clinic is a clinic operated and located within a retail store such as Wal-Mart. These walk-in style clinics can be found in other areas like airports as well. Often, these privately operated clinics run within a profit margin and cater to those without health insurance.

Walk-in and retail health clinics are attractive because they are time and cost-effective. There have been questions of quality raised by medical associations in the last year, but no official complaints or awareness of errors have been noted. The trend throughout 2008 has been for these clinics to open and remain stable. That is stable until the shopping season tanked.

This article from Reuters talks about the possibilities of failure and impact on the economy when "big-box" stores decline due to economy and/or recession.

And Here We Are...2009

I've been anticipating this second, this day, this year for quite some time. There is a number of reasons, personal and professional for my focus on this year. If you don't know what I'm talking about; you will...as long as you continue to follow MJ podcast and blog.

Without any resolutions for the year; I've been deciding how to make a few changes in life and activity. How will I do business, how will I conduct myself, how will I simply do all that I do just a little different...all questions that I'll continue to review throughout the year.

I hope you'll similar steps in your life. That is, any steps you take in 2009, may they lead you to where you want to be!

Best wishes for a happy and safe 2009.
Rick