My opinions on Hospital Emergency Preparedness are nothing new

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

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

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

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

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?

 ...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

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

 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

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

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!

See Something Say Something goes to Wal-Mart

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)

MJ 214: Angelo's Podcast

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

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

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

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

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

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

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

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

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

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

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

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

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.

Subscribe to Mitigation Journal podcast...free...via iTunes.
Subscribe to Mitigation Journal blog...free...use our email subscription in the right side-bar.

Pharmaceutical Shortage

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.