Close Schools, No Food

Close Schools, No Food?! What? MSNBC is running a story along with several other web and mainstream media talking about various fallout from the winter storms that have hit the Maryland/Virgina/D.C. area.  Living in Western NY, it is somewhat difficult for me to understand how 2-3 inches of snow can close an area down. (I don't bother to shovel the driveway until we get 6 inches of snow!) With that said, this storm dropped more than 2-3 inches; it left 30-35 inches of snow on areas that are not geared to deal with it. That much snow is a show stopper no matter where you are. But the snow is not the point of today's post.

Among the various secondary impacts is the fact that schools are closed and therefore, kids are going hungry, leaving families without any food.

"The two snowstorms that pummeled the region, leaving more than 3 feet of snow in some areas, deprived tens of thousands of children from Virginia to Pennsylvania of the free or reduced-price school lunch that may be their only nutritious meal of the day...."

I can understand the need for reduced price or free lunch programs and support the effort. However, I have to ask how this situation is possible...if you don't go to school, you don't eat?! This snowstorm was predicted well in advance and nobody took the time (knowing they need the supplemental food from schools) to act in advance? To be even a little pro-active...just a little?

The article goes on:

"...about 43,000 children are eligible for free or reduced-price lunches. Some also get breakfast, dinner and bags of staple foods to take home for the weekend."

Okay, I can buy the fact that poverty in America is worse that most would like to admit. But to say that kids and by extension, families, will go hungry because the schools are closed is almost unbelievable...I said almost.

So, lets ask a few questions...

• What do you do when a kid is sick and stays home from school? No school, no eat. Right? 
• There is no mention of routine absentee rates or drop out rates in the schools. A quick Google search indicates that, if you're not going to school you're not eating...there must be a lot of hungry kids. Even before the snow storm hit. 
• How about this...What the heck do these kids do during school breaks and summer vacation!?

I'm sure to get some interesting emails on this story, so let me be sure to state some level of understanding that this storm would be equal to an earthquake occurring here in Rochester, NY. It's simply not an eventuality we worry about...just like 30+ inches of snow is not on the top list of threats in the State of Maryland. Yet, I have to wonder why a predicted snow storm can close a major, well funded, well outfitted city, like Washington, D.C., for two weeks...shouldn't we be able to recover a little better?

I also wonder what will happen when the money dries up and the public assistance goes away? Where would this go if it were a prolonged (months, not weeks) worth of natural disaster...Haiti style. But that can't happen here. What all this leads me to is an in-your-face reminder about the population living on the edge here in the most prosperous nation in the world. It's also a reminder that the Ripple Effect of a situation can be just as bad, if not more devastating that the original catalyst event.

When it comes to domestic preparedness in this country, we should point to the map and say "lets pretend this is a country in need of our assistance..."

Swine Flu Numbers

These numbers brought to you by the letters H and N

The debate on weather or not Swine Flu will be a factor as we continue into 2010 continues. Here are the current estimate numbers from the CDC. The cumulative estimates for the 2009 Swine Flu (H1N1 for those wanting to be politically correct) indicate that nearly 11,700 people have died from H1N1. This includes 1,180 children. Keep in mind that seasonal influenza kills 35 to 40,000 each year in the United States. The bigger impact may be the number of illnesses related to the virus...an estimated 57 million (out of about 300 million population) Americans have been sickened.

Doing Decon

There have been several instances in late 2009 and early 2010 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 location poses untold risks to the health care provider, the facility, other patients, and the community. A recent such event at a walk-in urgent care clinic 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.

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. 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.

So, 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.

Now the question becomes; 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. First, 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.

Second, 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 have not. 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.

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

BOTOX: The next bio terror agent

Several mainstream media outlets have been talking about BOTOX...the cosmetic version of Clostridium Botulinum or botulism as the next possible biological terrorist weapon. Also within the past few days, I've recieved dozens of emails looking for information on BOTOX...many asking if this cosmetic botox could be used as an actual biologic agent. So, I thought this would be a good time to review.

What is bioterrorism? Simply put, bioterrorism is the use of microbes or toxins to cause illness or death, or poison the environment. Microbes such as bacteria and viruses could be used as well as toxins. BOTOX is a toxin. Remember, bacteria and viruses cause an infection while toxins result in inTOXication. Bacterial examples include anthrax, plague, and Tularemia. Virus examples include Smallpox, and hemorrhagic fevers. While toxins include botulism and ricin.

What is Botulism? Botulism toxin has several forms; toxin A - G...they are all some variety of Clostridium Botulinum. The cosmetic BOTOX is the toxin A variety and its estimated that it would take a huge amount of cosmetic BOTOX to cause serious biological threat. With that in mind, we have to reinforce the fact that BOTOX is BOTOX...cosmetic grade or pure strength. The symptoms are the same and the lethality is always a potential. In fact, there have been several deaths related to cosmetic BOTOX in the United States. We should point out that there are other medical uses for this toxin. BOTOX can be used to treat muscular diseases. In fact, a tragic case in California has highlighted the dangers of medical botox as a seven-year-old girl who was undergoing botox treatments for her cerebral palsy has died, attributed to the toxin treatment.

Alright, what are the symptoms of botox intoxication? First, you've got to remember that botox is botox...medical, cosmetic or pure toxin. If used improperly, with an incorrect dose, poor injection/administration technique, or intentional exposure to the pure toxin...the symptoms are the same. The general incubation period is 24 to 36 hours after exposure. By the way, estimates are that a single  gram pure botulinum is enough to kill one million people. Botox in general causes weakness, descending flaccid paralysis and eventually respiratory failure. Botox enters the nervous system via the bloodstream, binding to the receptors of peripheral synapses.  Again, all forms of Botox act in the same way...making the point that all forms of Botox have the potential for intoxication and the same set of neurological symptoms. The binding to peripheral synapses stops the release of Ach and the production of AchE.

The specific symptoms are:

• Diplopia or double vision
• Dytharthia, difficulty walking secondary to descending paralysis of skeletal muscle
• Dysphonia or trouble speaking

There are other symptoms that should be addressed; most seriously is the respiratory failure that occurs when paralysis reaches the phrenic nerve and paralyzes the diaphragm. Of note, the Botox intoxicated patient remains afebrile and fully conscious.

Care is mainly supportive...not good news. Ventiliatory support, feeding support and mechanical ventilation may be needed for as little as 6-8 weeks or as much as 7 months.

With all that in mind, Botulinum Toxin being the most deadly toxins known is certainly capable causing thousands, maybe even millions of deaths, with a very small amount. The question then becomes one of production, availability, and dissemination.

Read Fatal Botox Reaction on MSNBC.com
Read Botox as next bio terror weapon in the Washington Post

'Fun-Size' Terrorism

'Fun-Size' Terrorism is not a term relating to an attitude toward terrorism. No, not at all...let me explain;
Have you ever been out on Halloween? Of course. You dress up in costume and go out expecting to get a variety of candy. Sometimes you get back and find out that the candy you got was not exactly what you expected. People dump those fun-size candy bars in your bag, not quite the event you expected but gets the point across.

Well, with that in mind, lets look at our expectations and preparations for acts of terrorism or intentional events. We've been told what it means to live in the "post 9/11" era and how we must be prepared for the next terror attack. Nobody will tell you what the next attack will look like and so we believe and plan for what we've seen in the past...another 9/11-style attack. In short we've fallen into the trap of believeing the biggest or last major event we've experienced is the worst we will ever see. Nothing could be further from the truth! In short, we're preparing (and have been) for the wrong type of event...that's my opinion anyway.

I think we're going to see another attack on the United States and many other sources believe it will be in the not too distant future. While I'm not willing to commit to a time frame, I am comfortable relating my opinions as to what the next terrorist attack will look like. No, I don't think we'll see another attack on the same size and scope of September 11, 2001, rather I think we'll see a "fun-size" smaller and coordinated multiple simultaneous attacks version.  I would also predict that these smaller, coordinated intentional events will be aimed at soft targets...those locations of infrastructure that lack defensive protection or deterrence.

Specifically, I'm talking about locations such as shopping malls, ground transit hubs, health care facilities, sporting events, and hotels and coffee shops. The impact of bombings or other events on these locations...especially if they're coordinated in multiple locations across the country...will have a significant death toll as well as a devastating ripple effect. These smaller attacks will be harder to predict and intercede on. The impact on a community and economy will be huge. Consider the possibility of mass casualty events coupled with a lack of surge capacity or total loss of local hospitals.

The failed attempt to bomb an airliner on Christmas Day, 2009 is an indication that independent individual attackers are a potential threat. Often referred to as "Lone-Wolf" attackers, these individuals may have a loose affiliation and training with well-funded, established terror groups. They may also be individuals with no affiliation but share an ideology or sympathy with terrorist groups. Smaller than coordinated terrorist cells, these lone-wolf attackers could easily infiltrate soft target locations and carry out attacks with conventional explosives, chemicals or even biological materials. As an aside, while the impact of an explosive attack will be huge...the impact of a biological attack (biological bomber style) is almost unimaginable.

McVeigh, Rudolf, and Kaczynski  are all names in our domestic terrorism history that we should keep in mind and even study as a means to appropriate pre-plan and train for what might be ahead. We should also keep in mind the ever-present threat posed by domestic groups; hate groups, supremest groups and Ecological groups. Keep in mind that multiple smaller attacks will be just as devastating as a focused single event.

Yes, but what if it DID happen here?

Yes, but what if it DID happen here? For years I've based training and teaching on this simple question. The idea has always been to overcome complacency and Optimism Bias. When we think "...it can't happen here" or that it "won't be as bad as they say it will be". Were 'IT' becomes the last or worst crisis we've encountered and we don't believe 'IT' could ever happen again...we're victim to Optimism Bias. The challenge is to not only believe that we're vulnerable but also to acknowledge the need for pre-incident planning and training.

With that, there are still a large number who believe that it can't happen here. And until recently, this issue has seen limited attention from mainstream media. Until recently. The earthquake in Haiti and results of relief efforts have spurred an uptick in the number of those asking "what if it DID happen here"? In my opinion this is an important indicator of change. Perhaps swinging our preparedness pendulum back to center from way over on the terrorism end of the scale.

A snapshot of this is illustrated by numerous articles and one such example can be read in Newsvine and coming from MSNBC.com. So, lets take a look at a few quotes from that article and relate comment:

"The White House and the Capitol have been destroyed. Congress and critical government agencies overseeing finance, health and other domestic services have been critically impaired. Many of the government employees who used to work in those offices are dead."

This is an important point and underscores the need for local government self-sufficiency. States will be in competition for  Federal resources. Those resources will have to be triaged...if they would be available at all...States, cities, towns, communities, and individual families will be on their own. Probably for months.

"The U.S. Interstate highway system has been destroyed (there never was one in Haiti), and travel by road is arduous."

The ability to get aid into the areas effected may not be possible. Travel in and around those areas may not be possible. Refugees may not be able to get out. Local responders will not be able to provide relief.

"There is no FEMA. The well-financed network of local “first responders” that Americans take for granted is gone. "

Well, no FEMA might not be a big deal. Loss of the first responder networks...another story. 

"The entire air traffic control system has been destroyed. "

Air travel may be the only way to bring relief materials to states in need or provide evacuation...and in the scope of impact seen in Haiti...where would you evac to?

"The infrastructure to handle marine cargo has been destroyed at the major seaports — New York, Los Angeles, Houston."

OK, we won't get supplies that way either.

"As much as one third of the population (in the U.S., roughly 100 million people) are without food, water or shelter and limited means of acquiring it."

Knowing that a majority of Americans do not have supplies of food or water on hand and that there will be no supermarket to run to magnifies this problem. The loss of water and sanitation will exponentially compound this problem. And no shelter? The lack of Civil Defence style preparedness will force entire communities into the elements. The ripple effect will be huge.

"Millions of survivors are in need of urgent medical attention; many simply won’t receive it — even if relief efforts proceed flawlessly. Most local hospitals have been destroyed. The ones that remain have no supplies. Doctors have resorted to using hacksaws and vodka in place of surgical instruments and alcohol."

When will it be it be time to change from a standard of care to a sufficiency of care? How will we make triage decisions? Who will get care and who will not? Forget surge capacity...no hospitals. Everyone should take a First-Aid class.

Two Chemical Events, Two Deaths. Many Lessons

Two recent chemical events have claimed two lives and provided some valuable lessons to be learned or reinforced. First, an man in his 30's died hours after ingesting some type of hazardous substance. As if that is not bad enough...twenty-four people at the clinic where he had gone for treatment were either deconed or quarantined.  Buest guess at this point is that the man ingested selenomthionine in the industrial environment he worked in. It is not known if the ingestion was an accident or not. The article interchanges ingestion and inhalation...we know the route of absorption is important...but is unclear in the new article.  The victim came home from work, changed clothes, and went to an InstaCare clinic (walk-in health care/urgent care). As a result, the clinic was shut down for twenty-four hours with eight people undergoing decontamination on site...none complained of illness. In this case decon seems to have been more pro-active.

In another, unrelated event, a fire department in Iowa responded to a "person not breathing" call at Mercy Medical Center to find that what seemed to be a routine event was actually a hazardous materials event. Sodium Hydroxide...a laundry additive...was leaking. Responders began working on the victim then noticed the leak. Four other civilians who were in the area and several firefighters were evaluated in the emergency department as a result. It is not clear if the leak caused the victims death.

Lessons Learned and Reinforced:

1. Response to medical facilities, including walk-in or urgent care centers, can not be taken lightly or considered to be routine. The additional hazards associated with these locations have to be considered in preincident planning and responders must size-up with a high level of suspicion. 
2. The need for decon may exist wherever people go for help. Many emergency departments have some form of decontamination equipment or facility...few, if any walk-in care/urgent care centers have decon equipment or the trained people to carry out the activity. Expect this type of situation to occur more frequently. 
3. Understand the logistics behind the confinement or "quarantine" of otherwise well civilians...those who do not have any symptoms, yet give you reason to believe they may have exposure. This group to can be difficult to manage as compared to those who actually have symptoms.

Cyanide Suicide

I've been using the term "consumer-level" hazardous materials events to describe everything from mixing household cleaning products to creating hydrogen sulfide and homemade chemical bombs. Noting that these situations are developed out of ordinary, off the products...the kind you find in almost any store...to raise awareness to the severity and potential impact to responders.

A recent story from the Kansas City Star underscores what I've been talking about for years. A man decided to kill himself in his car by opening canisters of cyanide. No warning signs on the windows this time. Responders open the door...instant exposure.

For more on cyanide, check out prior Mitigation Journal Blog posting and be sure to tune in to Mitigation Journal Podcast (edition #143 for 1/3/2010) for the latest on this topic.

Protecting At-Risk Populations

Protecting At-Risk Populations: Here is a great story...perhaps the best way to better hold off the spread of  H1N1 or any other disease. CNN is reporting on a crew of volunteers going out to the streets to vaccinate homeless persons against H1N1. Taking the vaccine to the streets, along with any type of treatments, will almost certainly keep the infection rates down and may prevent spread of the disease.

Lets remember that the homeless population includes many who have issues with addiction or mental illness in addition to co-existing medical conditions. This situation clearly makes the homeless population at greater risk.

Air Terror Attack

I've suspected something of this nature would be happening and have been following events the mainstream media has not been covering. Tonight, 12/25/09 we have striking developments from Detroit...
MSNBC is reporting that a Nigerian man attempted to detonate or ignite a powdery material on a Northwest airlines flight today.

At the same time, CNN is reporting that this incident took place at the end of the flight from the Netherlands to Detroit and involved fireworks or fire crackers of some type.

While the latest Reuters report out of Washington and being carried locally here in Rochester, NY,  has the White House confirming a more serious event...calling it an act of terrorism.

Interestingly, we've been talking about several instances occurring on commercial airliners in the last few weeks. These events seemed to involve threatening or hostile-like actions on the part of passengers appearing of Middle-Eastern dissent. I've called them "probing" events - those events used to test our response to and actions during an event and just talked about them in MJ#140 on the podcast. They have received scant media coverage and what has been covered has received a glossy political correct finish. While supposed eye-witness accounts and the "official" airline accounts differ in degree of severity, its important to note that seemingly everything that can be done to discredit those concerned (civilians) who bring this issue up.  The National Terror Alert is linking to an article published by the American Thinker that you should read. They do a nice job of piecing the commonalities together.

While all the details are yet to be known, we have to ask what type of explosive or device could get past TSA? We'll be increasing our security for sure. More to follow.

Cardiac Arrest Survival: Thirty Years of Change without any Changes

Cardiac Arrest Survival: Thirty Years of Change without any Changes...Yes, you guessed it. I going to take yet another shot at the American Heart Association. UPI is reporting on a study by the University of Michigan that states cardiac arrest survival rates have not changed in thirty-years. This despite all the CPR and ACLS cards issued to and paid for by emergency service responders.

The study concluded the chance of surviving an out-of-hospital cardiac arrest has not improved since the 1950s. As quoted from the original UPI article:

"Increasing bystander CPR rates, increasing the awareness and use of devices to shock the heart and keeping paramedics on scene until they restore a person's pulse needs to occur if we are ever going to change our dismal survival rate," Dr. Comilla Sasson, the study's lead author, said in a statement.

Now lets take a look back...how many CPR changes have we seen...all with a new book ($$) and another class (more $$)...and can someone tell me why we have to PAY for CPR training? How about all the "research" that causes us to change the procedures we do (advanced airway, for example) or the medication changes we have to endure. High dose Epi, Vasopressin, Amiodarone, Verapamil, bicarb or not, Lido or not...in what order...and don't forget...the research (sarcasm) will tell you that everything you know and have been doing will be totally wrong and deadly tomorrow! So run out and take another class and buy another book. Because you can see the results of all the cardiac arrests we saving.

Too many systems still gauge effectiveness based on cardiac resuscitation rates. Nothing could set us up for failure more than this unrealistic expectation. Why do we expect responders to show up and correct decades or a lifetime of disease that caused the cardiac arrest? We'll work on a cardiac arrest victim for a while with limited resources in the field and then turn them over to the ED. Yet, if they don't walk out of the hospital...we didn't "save" them. How can this make any sense?  A majority of what Paramedics carry in terms of medications and equipment is aimed at the cardiac arrest patient.

And despite what we know and do, we're not making much of a difference.

Air Medical. At What Cost?

I have the deepest respect for my colleagues who work in the air medical arena. I also have little doubt that air medical transport with helicopter and fixed-wing aircraft have saved untold numbers of lives throughout the Country. In general I support air medical, albeit with some reservation on the use of helicopters.

I've written about the potentials of landing a helicopter at your emergency scene or on the roof of a hospital (a totally bad idea as far as I'm concerned) and you can read my comments in Mitigation Journal http://mitigationjournal.blogspot.com/2008/05/helicopters-and-hospitals.html one persons opinion may be that helicopters and operating with lights and siren are the two biggest contributors to EMS LODD...maybe they should be avoided...and at all costs, keep your helicopters off of and away from your hospitals!


Todays posting is going to look at another, less deadly impact of air medical transport...cost. MSNBC is running an article with focus on the cost of emergency helicopter transport and the health care system. According to MSNBC, the cost of this service can be anywhere from $12,000 to $25,000 and that cost may not be covered by insurance. Sure, we can't put a price on a life...and I would certainly pay that amount and more for any of my family...gladly. I think what is at issue here is the fact that these flights are not always deemed appropriate. Even in the setting of trauma other alternatives to air medical transport my have provided the same outcome at a fraction of the cost.

Another issue is choice. Victims of trauma who are in serious condition may not have the capacity to provide informed consent for air transport. The public is trusting the emergency responders to make the best choice for their care. Transport mode should be a decision, like any other, made carefully and with the patients best interest in mind. In these cases the "customer" has little choice. And on that note, please remember we treat patients...not customers. Read my comments on the word "customer".

So let this one sink in a while. When is air medical helicopter really needed? How can this service be put to best use...when should it be avoided? Patient condition, injury severity, distance to definitive care, and weather conditions are just some of the points to ponder. Now we have to add in cost...or better stated; cost effectiveness. Will air medical transport make a difference in relation to the non-covered cost in relation to ground transport alternatives.  More to follow on this...and I welcome your opinion.

Finding Radiation in the Parking Lot

I happened to go out for a cup of coffee with a friend of mine this morning and found something unexpected in the parking lot. In the space next to mine was a pickup truck owned by a construction company with two containers in the back...labeled RADIOACTIVE. Barely secured with an old chain and skimpy padlock, these containers were just sitting in the open bed of the truck with nobody around.

I'm certain they were legitimate. But in today's society, just leaving them out in the open was a bit odd. Certainly, these materials could be used for some untoward event, like a dirty bomb, but more concerning is the number of possibilities that are more likely to happen.

Suppose this truck were to be involved in a collision, a roll-over or rear-end collision for instance. You find the containers after you approach, size-up and being patient care...or worse, you find the compromised containers only after patients have been taken to the hospital.

How about fire? You arrive to find this truck fully involved. Only after extinguishment you find the melted, compromised containers. Do you have radiation detection equipment available? Would you even think about getting it out?

Finally, what will the average citizen think of this? Two containers left out in the open and clearly marked radiation. Perhaps they'll call 9-1-1, how will you respond?

Bio-Event Ready or Die!

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

Biological events can be natural or intentional. The intentional kind is what you'll learn about in a weapons of mass destruction (WMD) training class and you read about in the papers. The naturally occurring kind...SARS or pandemic influenza, for example...are the kind that go on almost every year and we don't pay much attention to. One is intentional, one is natural. Both can be deadly, both have lessons to be learned. We've seen both types in the last ten years; SARS and West Nile Virus...naturally occurring, Anthrax, intentional. Again, both situations with lessons to teach. But did we learn anything?

Here we are in 2009 and many documents and memos are urging us to "get ready" for pandemic flu, H1N1 or otherwise. SARS hit the world back in 2003...what did we learn? It is way past time to be getting ready, we have to be ready. Its not as hard as you'd think and you don't need dozens of pages of plans, either.

Despite the intent, there are similarities between intentional and naturally occurring biological events that we can use to our preparedness advantage. Even the traditional WMD training can be translated to natural event readiness. Unfortunately, most of the WMD training has been a waste of time and preparedness dollars spent on big, shinny things and security cameras.

Traditional responders and the health care system is marginally better prepared today than it was on September 10, 2001. After Anthrax, after SARS.

Recently, the Centers for Disease Control and Prevention (CDC) has predicted that 40% of the United States population will become sick with 2009 H1N1 Swine Flu. That's 40% of the average population. Not to mention those in health care, emergency response, and those with risk factors. And considering the disease as it is today...not accounting for any antigenic drift. Keep in mind H5N1 or Avian Flu continues to lurk and there has been a strain of H3N2 found to be undergoing change.

By way of review, the H's and N's stand for proteins on the influenza type A virus. There are several types H's and N's that, in combination add up to tricky business for vaccine procedures. Influenza vaccine has to match the H and N combination. If not, the vaccine is not effective.

My top three things to do to Be Ready for a natural or intentional biological event:

1. Train your people on infection control and personal protective equipment (PPE) more than once a year. This is the time to develop good habits for regular cleaning and disinfection of our vehicles. Also, several studies have pointed to practice with masks...getting proper fit and know how to put them on properly...as being more important than annual fit-testing. By the way, numerous sources have also indicated that the N95 mask may be no better standard surgical masks for protection against viruses.
2. Promote the safety and health of responders and their families. That means getting appropriate vaccine or other medications available for your personnel and at-risk family. Identify those who can't get vaccinated or take medications and take steps to isolate them from infection. Numerous self-report surveys have concluded that one key to keeping your personnel coming to work in a biological event is provide for the safely of the family.
3. Prepare a Can't Go Home Plan. Stock you stations and facilities with food, water, hygiene products and ready additional bunk areas to keep personnel in-house during extended operational periods.

As always, I look forward to comment and debate. If you have something you'd like to add to the list...email me at mitigationjournal@gmail.com

It's Only Pepper Spray!

Just a reminder here that those non-lethal or less-than-lethal weapons can cause serious issues. Recently, an REI store had to be evacuated due to bear-spray release. Check out the details of the story here: http://www.mercurynews.com/breakingnews/ci_12939095?nclick_check=1

We've been lulled, perhaps by the name, that non-lethal weapons like pepper spray are not serious concerns.

Wrong.

Even when deployed for legitimate reasons and in proper fashion, pepper spray, mace, and other such products can cause a variety of situations. These materials stress the respiratory and cardiovascular systems and precipitate brochospasm. There is also the potential for multiple people to be exposed and in need of treatment. Saturation and prolonged skin contact can cause burns...especially in those hard to reach, moist areas of the body.

Perhaps most important for the responder; remember the need for decontamination. Victims exposed to mace or pepper spray need to be cleaned prior to being placed in a treatment area or in the back of an ambulance. Appropriate removal of outer clothing and water wash should do the trick in many cases. Understand that failing to do so puts the responder at risk of exposure to the material. And just like any other hazardous material event, no patient should be transported to a hospital without being evaluated for need for decontamination.

Lastly, don't forget the psychological impact of these situations. The "worried-well" can clog a system and deplete response resources at a faster rate than actual victims do!

Two Chemical Events...Many Lessons!

Once again proving the point that you don't have to wait for a terrorist attack...

The articles linked below highlight the need for all of us to be familiar with chemical event potential. As I've been saying for years, we don't have to wait for a terrorist attack with a chemical agent to utilize the knowledge/training that we have. When I say "we"...I mean traditional and non-traditional responders...EMS, fire, police, and hospital personnel.

Note to the American Fire Service...I don't buy into the idea the fire department will be too busy to support hospital decontamination/protection efforts in large-scale events. Fire departments must be involved in planning, training, and implementing protective measures at hospitals...even if only one fire officer, to help direct mutual aid companies. Hospitals are critical infrastructure.

The first two links below relate to a chemical event at refuge company. I'm getting the impression that something got mixed in the trash and reacted, releasing an unknown chemical vapor resulting in three critical patients, numerous contaminated, many transported...119 total. The underlying situation is that one hospital was ready with decon...they had drilled for such an event with the fire department. Also, EMS didn't send contaminated patients to the hospital and on-scene decon worked. These articles are preliminary, but I'm thinking this will be an interesting case to follow.

The last link is to an article that is much more disturbing; a situation using a chemical dispersal device, chlorine and an incendiary device were deployed...with intent...with strategy...to a specific target. The mainstream media is calling this a hate crime. I'm looking at it as an act of domestic terrorism.

Tune into Mitigation Journal Podcast for more details...look for edition 118 (expected release 8/5/09)

Unknown gas injuries in MA
http://www.projo.com/news/content/NEW_BEDFORD_INCIDENT_08-04-09_TQF9B2N_v17.3b42d27.html

Emergency Decon Drills Paid Off
http://www.southcoasttoday.com/apps/pbcs.dll/article?AID=/20090804/NEWS/908040324/-1/NEWSMAP

Chemical Attack Hate Crime
http://www.kold.com/Global/story.asp?S=10835087&nav=menu86_2

NYS Nurses Association Opposes Mandates for Vaccine

Representing over 37,000 nurses, the NYS Nurses Association (NYSNA) has spoken out against a new regulation making flu vaccine mandatory for all people who care for patients in health care...including nurses. Under the new regulations, nurses would be mandated to get a seasonal flu shot as a condition of employment. No shot, no work.

My first thought was: how could anyone be against this?! But, after reading the testimony, I can understand it...moreover, there are a number of Ripple Effect points to consider. After reading all the material, I think NYSNA has a number of valid points.

The first point is: Can this be mandated when no current public health emergency exists? The NYSNA is clear that they fully support and encourage nurses to get flu vaccine. Most would agree that getting a flu shot is good preventative action. When working in health care, what rights do you give up? Consider all the issues the military had mandating Anthrax vaccine not too long ago. Keep in mind you can still decline to get a HBV series and work...

I'll be talking about this in detail on the next Mitigation Journal Podcast (Edition 118 expected release 8/3/09). In the meantime - I've talked about the three best things you can do - now - to prepare for biologic events now, without vaccine...you can hear my recommendations on Mitigation Journal Podcast Edition 117.

Below are the links to the NYS Nurses Association press release and testimony.
Medical News Today story: http://www.blogger.com/post-create.g?blogID=18608016
NYS Nurses Association Press Release: http://www.nysna.org/news/press/072309.htm
NYS Nurses Association full text of testimony delivered by Eileen Avery, MS, RN, Associate Director, NYSNA Education, Practice and Research Program to the State Hospital Review and Planning Council, July 23, 2009, New York, NY.

Paramedic Future

What role will technology play in the future delivery of out-of-hospital care? I once believed that an increased use of technology would increase the scope and duties of paramedics. Today I'm not so sure.

I'm now starting to believe that implementing technology may actually decrease the need for paramedic treatment and, dare I say, speed critical patients treatment.

I learned to read 12-lead EKG's over twenty years ago. It was not common for EMS to "do" a 12-lead and the technology wasn't there to support us doing so. Years later the technology became readily available and is in wide use today. Many seasoned paramedics looked down on the computer interpretation and some, including me, would not read the interpretation until after reading all the leads and making a diagnosis.

Luckily, the technology has grown and become far more trusted. That is trusted to a point where we can question if the middle-man is needed. That middle-man, of course, being the paramedic. I don't know how I feel about this; on one side, any EMT could attach the leads and obtain and transmit the readings to the hospital making 12-lead EKG readily available, sooner. But on the other hand, technology can't consider the patient as a whole and put all the assessment pieces together like a skilled paramedic can.

Like any other technology, once we become accustomed to it, we become dependent on it...try going a without your email or word editor and hand-write a few letters...get the point. 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?

Anyway - here is a cool article on the use of Blackberrys and EKGs
http://www.theglobeandmail.com/news/technology/heart-attack-help-the-blackberry-solution/article665450/

Is there a Nuke in your neighborhood?

Is there a Nuke in your neighborhood? Check out Nukeometer at http://nukeometer.com/

Just enter your city and country to find out how many nukes are within range of your city! The breakdown is given by potentially offending country and by delivery...ICBM, submarines, short range missile...these guys thought of everything!

Here in Rochester, NY, we're in range of 6404 nuclear warheads...2347 from the USA and 3684 from Russia, 192 from UK, 121 from China. 2490 of those can be delivered from ICBM and 2771 by submarine with only 1143 available by bombers.

By contrast, Denver Colorado is within range of 8127 warheads and Washington DC 6404 warheads. Tune in and find out where your location stands...pleasant dreams.

Failure

When we fail to train together and understand the same goals and priorities...


ParamedicTV is powered by EMS1.com


ParamedicTV is powered by EMS1.com

Thanks, Mike for sending these in...

More Chemical Suicide

I've been made aware of a case of chemical suicide in Toronto via a memo on Toronto EMS letterhead. Although I've not been able to confirm the validity of the memo or find associated material on the event, it seems as if Toronto has had a case of chemical suicide. The chemicals listed in the Toronto EMS memo are among those on the list of potential chemicals for other events in Japan and the U.S.

When certain chemicals are mixed, Hydrogen Sulfide gas can be created. In some cases the gas has been created in concentrations greater than 2000 parts per million. Hydrogen Sulfide is more potent than cyanide, has a quick "knock down" - causing unconsciousness/respiratory failure - withing one to two breaths.

Chemical suicide events have taken place in hotel rooms, residential areas, and apartments. The latest trend is to mix the chemicals in a car parked in a parking lot. Both residential and vehicle borne events have the potential to cause responder deaths and mass casualty/multi-patient events.

In some cases, people have posted signs on the doors of apartments or windows of cars indicating their intent to commit suicide by chemical agent. Responders need to be aware of any unusual clues such as windows taped shut, open containers of liquids (chemicals have been mixed in small wash tubs), odors of any kind. We should also add a high index of suspicion for any "person over the wheel" calls - don't assume the person in that car is sleeping! If you think there has been chemicals involved in a situation - do not enter, do not open the car. Keep the area clear, create a parameter and keep yourself uphill and upwind - call for FD/hazmat.

Below is a list of links to prior Mitigation Journal posts from the podcast and blog...

Blog Postings:

Chemical Suicide in Cars

Suicide by Blood Agent

Podcasts:
Mitigation Journal Podcast #72
Mitigation Journal Podcast #64
Mitigation Journal Podcast #59

DHS/FEMA Announce Shelter System

I've been expounding this concept for years now...reminding us to get back to the Civil Defence mindset. My meaning has been simple: prepare the individual and the family, provide for save shelters in public areas (a.k.a. Fallout Shelters) to give people a place to go when out in daily life, and we'll greatly improve our ability to mitigate natural and intentional events.

Someone must have been listening...finally.

DHS and FEMA have announced the creation of a Disaster Shelter System to house civilians in the event of a natural disaster. Details are still drifting in, but we are moving in the right direction!
Check the source materials from Los Angeles Times and National Terror Alert.

Homeland Security Secretary Janet Napolitano and Craig Fugate mentioned that we will only be as successful to the level of preparedness of the family - and I agree. September is National Preparedness Month and we should all be making plans, keeping informed and getting involved as best we can to prepare ourselves, our families, and our communities for crisis. Remember - local efforts will save lives!

Now, onto some interesting statements:

Craig Fugate, the new director of the Federal Emergency Management Agency, further stated “We are only going to be as successful as the public is prepared,” and “There are a lot of folks who are going to need very specific help that should not have to compete with the rest of us.”

I agree with the first quote here - public preparedness make for an efficient and successful (as much as can be expected) response to emergencies and disasters. But what is FEMA Director Fugate talking about in the second quote? “There are a lot of folks who are going to need very specific help that should not have to compete with the rest of us.”

Who is competing with whom? Moving towards a shelter system is an excellent idea...but, yet again, we will overwhelm those resources if people are individually prepared! Even the best Nation-wide shelter system will fail under the strain of an uniformed, unprepared community.

Attacking Hemagglutinin and Neuraminidase

Hemagglutinin and Neuraminidase are the proteins of the Type A flu. Hemagglutinin allows the virus to enter a host cell (remember, virus is must have the cellular mechanics of a host) and Neuraminidase allows the virus to reproduce and exit...going on to infect another cell. To date, antiviral agents attack Neuraminidase (Neuraminidase inhibitors). New research outlined in Medical News Today, highlights the possibility of attacking both the H and the N. See the article here: In A New Way Of Treating The Flu, Both The H And N Portions Of The Virus Are Targeted

This would be good news for all of us as virus begin to become resistant to medications such as Tamiflu.

Common Sense PPE

This clip talks about the common sense actions to take during and after encountering any patient with fever and respiratory illness, including influenza like illnesses (ILI) such as seasonal flu or Swine Flu. Hats off to this RN, Paramedic from Paratech Ambulance in Milwaukee, WI, and to the reporter for a job well done.


For more on the topic of flu, type in keyword "flu" in the search box in the upper left header on the Mitigation Journal blog page or into the search box on the right side-bar on the Mitigation Journal podcast page.

Cassandra

Cassandra, in Greek mythology, was given the gift of correct prophecy of forthcoming mishaps and calamities. Apollo, a Greek deity, because of anger, made certain that no one would believe her. Thus, Cassandra has become known as the bearer of evil tidings that no one will believe.

E.L. Quarantelli, 1988