Under the premiss of Homeland Security and preparedness, New York State Bureau of Emergency Medical Services (NYSBEMS) undertook an aggressive initiative to arm EMS providers with auto-injectors to be used to treat people exposed to certain types of chemical agents. As the expiration dates on these materials begin to come due, NYSBEMS, citing budget constraints, has no plans to replace these auto injectors.
If auto injectors for chemical antidotes were so important three years ago,
why aren't they important now? The fact is that having auto injectors
on ambulances is not an important component of preparedness now. They
never were. And the situation leaves a problem of perception. This situation is the latest example of unrealistic resources being put into play without a sustainable plan under the failed model of Homeland Security. It's an issue of poor planning, of being reactionary - rushing to do something in the name of Homeland Security,
in this case, putting auto injectors on ambulances where they'd most
likely never be used by EMS personnel who, by an large, lack the
personal protective clothing to operate safely in a chemical
environment.
Chances are that public service organizations and public health departments in your state are facing (or will
face) budget issues that will force similar decisions. New York is not
alone, and New York State Bureau of EMS is not at fault for these items
expiring without replacement.
The new post 9/11 era message to emergency response and public health: we're out of money...pay for preparedness yourself or don't do it at all.
This issue goes beyond any single item, it's and issue of sustainable preparedness. Was it ever
realistic to place chemical agent antidote injectors on ambulances
in the first place? Probably not. And, now that they're not going to be
replaced, gives the impression that this initiative is no longer
important or the threat is no longer present.
What we're seeing now is the result of a steady, predictable
decline in preparedness funding, planning, and operation. EMS has never received an amount of preparedness dollars commensurate with their function and this de-funding of EMS preparedness will continue to hasten the eventual collapse of public health.
The term Homeland Security does a disservice as
it brings to the public mind an image of guys with guns and scanners at the
airport or big shinny fire trucks...leaving public health, healthcare systems, and Emergency Medical Services poorly funded, trained, prepared.
When nothing happens, nothing happens. And nobody wants to pay when nothing happens.
PumpIt!, Ivory Wave, and Bath Salts are just a few of the label names of synthetic drugs that are causing intoxication similar to Ecstasy and methamphetamine. These synthetics are often sold in convenience stores, on line, and in your neighborhood may also be labeled as an enhanced plant food...some printed with the warning "not for human consumption". Few, it seems, are heeding that warning as the Centers for Disease Control (CDC) and National Institute of Health (NIH) are calling attention to the growing numbers of emergency department visits, hospital intensive care admissions, and deaths linked to use of Bath Salts. As a example to their popularity, YouTube hosts hundreds of videos on this topic.
Not unlike other drugs, these materials are being swallowed, snorted, smoked, injected or otherwise consumed by a growing population that crosses age, economic, and social barriers.
From K2Incenseonline.com
What's in this stuff?
Common chemical ingredients include:
Cathinone - a monoamine alkaloid that is similar to ephedrine and amphetamine. Cathinone has toxic side effects of anorexia, anxiety, irritability, insomnia, hallucinations and panic attacks. This chemical is also known as Khat and is found in plant food.
Mephedrone - a substance known to produce methamphetamine-like reactions in rats.
Patient presentation
Bath Salts, PumpIt! and similar drugs have been compared to a combination of Ecstacy, cocaine and methamphetamine. According to both CDC and NIH consumption of these and similar products results in symptoms resembling stimulant overdose. Since these drugs often lack an immediate effect, users frequently increase their intake resulting in overdose situations with neurological and cardiovascular dysfunction including acute myocardial infarction (AMI). Rhabdomylysis has also been reported.
The major psychiatric componant associated with these materials is a psychosis that can last for days. psychotic symptoms may include:
loss of contact with reality
false beliefs
hallucinations/delusions
disorganized thinking and speech
Patients testing positive for Bath Salt use often test positive for other substances. Be on the lookout for indications and side effects of polypharmaceutical overdose!
If all that's not good enough, intramuscular injection of Bath Salts is linked to aggressive cellulitis and necrotizing fasciitis or flesh eating soft tissue infections. For more on the link between cellulitis/necrotizing Fasciitis see this report from Z6Mag
Its like methamphetamine, cocaine, and Ecstasy...not exactly.
Image from Z6Mag
Like meth, Bath Salts cause a spike in dopamine levels causing users develop a craving quickly. "Dopamine burnout" is a factor in the abuse potential.
Like Ecstasy, there is an increase in serotonin. With continued use, an eventual inability to react to serotonin develops and is related to increased use and binging.
Like both meth and Ecstasy chronic use increases the risk of personality disorders and AMI
PumpIt! has an added twist. This product contains Methylhexanamine, a chemical created in 1944 as a nasal decongestant/vasoconstrictor. Side effects/toxic effects are similar to caffeine and stimulant overdose and include the discussion above with the added increased risk of hyperpyrexia due to a strong thermogenic properties.
Treatment
Treatment is mainly supportive and based on symptoms. Sedation, benzodiazapine, and anti psychotics may be used (refer to local standards). Because of the risk of polypharmacy use, treatment and recognition may be difficult. Scope
As reported in Morbidity and Mortality Weekly Report (MMWR), May 2011, and in numerous other publications, the scope and severity of this situation is increasing. According to the MMWR report, in a sampling of 35 patients who reported to a Michagan emergency department had the following findings:
symptoms similar to stimulant intoxication
32 patients had neurological symptoms
27 patients had cardiovascular symptoms
many tested positive for other drugs
Hospital admits were to the ICU, medical floors, and psychiatry
Operational Considerations
There is an increased risk of multiple patients becoming intoxicated with these substance when used in groups. There may be risk for multi patient events. Be on the lookout for commonalities in patient complaints and presentations.
Physician Shot in Baltimore Hospital...Reminding us that hospitals are Soft Targets.
A lone gunman entered Johns Hopkins Hospital and became upset over his mothers condition. According to CNN.com, the man pulled out a pistol and shot a doctor. He returned to his mothers room and is believed to have shot her, and then shot himself. Also, according to the original CNN.com article, the hospital gets 80,000 visitors and has at least 80 doors that makes security difficult.
We've talked about Soft Targets many times before. Anyplace that lacks deterrents to an attack and holds value as a target (ie place of critical infrastructure) is a soft target. Hospitals are locations of critical infrastructure.
"It's important to understand that open structures with multiple access/egress points, isolated utility and services corridors and large crowds are potential target hazards for multi-patient, mass casualty events. Remember, we're not just talking terrorism here...gang activity can cause collateral damage as well as structural collapse, fires, panic situations, and of course, intentional events." (Hospitals, Hotels, Malls - Soft Targets December 2, 2008 Mitigation Journal)
I wrote the above quote almost two years ago in response to an attack in India (see Why hotels are easy terrorist targets in MSNBC.com). The reminder has to be that we continue to have locations of critical infrastructure that are open buildings, lacking any deterrent. That is, they're a soft target. Violence against health care workers has been an issue of growing concern for several years. Most cases of violence in hospitals occur in the emergency department, while other less predicable events can occur on any floor.
The recent shooting of a physician at Johns Hopkins Hospital underscores that unpredictability. According to a follow up article from CNN.com, the shooters mother was paralyzed as a result of recent surgery. It was that bit of bad news that caused the man to shoot the physician, his mother, and himself.
The Johns Hopkins event is only the latest in a growing trend of hospital violence. According to this MSNBC.com article, most physicians do not feel safe in their workplace. The rate of attacks and violence is particularly disturbing in emergency departments as noted by MSNBC.com in Assaults on ER nurses rise as programs cut.
While there are no simple answers to the growing violence problem, there are non-intrusive countermeasures. We spoke with representatives from Net Talon on Mitigation Journal Podcast (listen to MJ# 187 here) talking about active shooter situations and solutions. You can also read my posting Active Shooter Brief in Mitigation Journal Blog, July, 2010.
The bottom line on all this is that we must harden our soft targets...including hospitals...no matter how difficult the task. As tragic as the Johns Hopkins and other events are, they could be much, much worse.
How do you decide when to evacuate your hospital or healthcare facility? Who makes that decision and what resources are called into action? Chances are these things are covered in your emergency management plans. But how do you know when its time to activate those plans? Your 96 hour plan can help identify trigger events and make the evacuation decision.
Part one of this series on 96 hour planning discussed the Joint Commission on Healthcare Accreditation
(JC) requirement for emergency planning on the part of hospitals and
healthcare facilities. We discussed the need to have
an operational plan that sustains the facility when access to external
resources are no longer available. Commonly known as the 96-hour plan,
healthcare facilities must prove that they've considered the
possibilities and impact on operations when they become cut off from the
rest of the world by some catastrophic event. 96 Hour planning may be
seen as something of a fuel gauge to manage inventory and as a means to
survival for the facility. The process includes an assessment of
materials on hand and consumption rates. Like other disaster plans, the
96-hour plan must integrate the facilities Hazard Vulnerability
Assessment (HVA), existing community response plans and identify the
ability to sustain communication, resources and
assets, security and safety, staff, utilities and patient care.
The decision to shelter in place or evacuate is not a one-time-only event. This critical decision requires continual reevaluation and situational awareness. While keeping tabs on the external situation or crisis at hand is vital, it is equally important to understand how long you can safely remain in your location and continue to operate. These points are actually the premiss for doing an self-evaluation and creating a 96 hour plan. The value of this process is seen when you realize how the amount of supplies and materials you have (or don't have) on hand and how long your stockpile will last. In other words, given your occupancy rate, how fast will you consume these materials. One way to start this process is by asking how bad can this situation get or what if it did happen here?
This same process can be used to make the switch between standard of care and sufficiency of care. Let's define standard of care as the way we do business every day, with our normal resources and operation. With the normally available resources limited only to what we have stored (no resupply) how long will they last during normal operation? Chances are you'll recognize that you cannot (nor should you) maintain the standard of care (normal operation) when you access to outside resources are cut off the resupply becomes impossible. Switching to sufficiency of care means you'll do what you can or the minimum needed to keep the situation from getting worse. You may be faced with the burden to decide who lives and dies during disaster. Based on the findings of your 96 hour planning process you may:
Choose to conserve in-house resources early
Supplement with community resources if availble
Close to new patients (if that's possible) or redirect incoming people
Maintain staff for extended operational periods
Consider limited or full evacuation
The 96 hour plan as part of your larger emergency management plan and can help on your search for preparedness. These plans must include assessment of agreements with vendor/suppliers as well as a means of monitoring and reporting on the status of in-house materials.
The Joint Commission on Healthcare Accreditation (JC) requires emergency planning on the part of hospitals and healthcare facilities. Part of that preparedness requirement is to have an operational plan that sustains the facility when access to external resources are no longer available. Commonly known as the 96-hour plan, healthcare facilities must prove that they've considered the possibilities and impact on operations when they become cut off from the rest of the world by some catastrophic event. 96 Hour planning may be seen as something of a fuel gauge to manage inventory and as a means to survival for the facility. The process includes an assessment of materials on hand and consumption rates. Like other disaster plans, the 96-hour plan must integrate the facilities Hazard Vulnerability Assessment (HVA), existing community response plans and identify the ability to sustain communication, resources and
assets, security and safety, staff, utilities and patient care.
A solid 96 hour plan will help decision making when changing from a standard of care to a sufficiency of care, evacuation or conservation of resources. While the JC does not require stockpiling of supplies for the planning period, the expectation is that advance planning will take place and a process will be created to aid in decision making. Organizations that undertake a realistic approach to this planning will come away with and improved understanding of how resources and assets are used for daily operations. This level of planning is also relevant to other forms of emergencies such as biologic events and other threats.
The Tenent Health decision illustrates the need for 96-hour or resiliency planning for disaster operations and sets a tone of responsibility. Get the full Mitigation Journal two-part review on the Katrina/Tenent decision check out A Message from Katrina. Healthcare facilities must prepare for the following eventualities during a disaster:
Discharges from the hospital will be limited - limitations in travel as well physical damage to roads and residences will make discharge of patients difficult.
There will be a surge in patients seeking care - healthcare institutions will be seen as an area of refuge and people will expect some level of care in the form of shelter and food. At-risk and special needs populations will self refer in anticipation of need as well.
Supplies and materials from fuel to water will be limited if not impossible to obtain from vendors and routine delivery of supplies and materials will not occur. Facilities will be left with what they have on-hand.
Hospitals must be considered critical infrastructure by local government and protected accordingly. With that said, healthcare facilities retain responsibility for the care of patients and support of staff during catastrophic events and must plan to be self sufficient.
A conversation with Emergency Management/Social Media blogger, Todd Jasper
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I recently had the pleasure of speaking with Mr. Todd Jasper on the topic of emergency management myths and realities, social media, and emergency notification. Todd is the Associate Director of the Homeland Security Division of MSA and has added his expertise in preparedness to the social media world through his blog, toddjasper.com.
An introduction to life as a Chief Medical Officer with Evelyn B, Sklair, RN, EMTP
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How would you like to live and work on a cruise ship? That's exactly what today's guest does! Evelyn Sklair, RN, EMTP is a Chief Medical Officer for Holland America Cruise Lines and she is going to share with us what its like to work (and live) in this unique environment.
Evelyn is a Registered Nurse and has been active in EMS as a Paramedic for many years. She was instrumental in the development of prehosptial care at the Eastman Kodak Company and an EMS leader in Monroe County, NY for many years.
The Anthrax attacks that followed in the days after 9/11/01 reminded us of the need for public health emergency preparedness.
Public health efforts have vaccinated millions, crushed Polio, and eradicated Smallpox, and they've done so while operating in the background of emergency management in relative obscurity...until September, 2001. The Anthrax attacks provided a wake up call to the Nation that our public health system was vital to the effectiveness of domestic preparedness efforts. Public Health was thrust into the public safety arena. With emerging biologic threats that jumped off the pages of a novel and into reality, it looked as if public health was destined to remain a part of the new traditional responder group.
Not so fast.
In Ready or Not? 2011, Protecting the Public from Diseases, Disasters, and Bioterrorism, the Trust for Americas Health reports that "key programs that detect and respond to bioterrorism, new disease
outbreaks and natural or accidental disasters are at risk due to federal
and state budget cuts."
We're still searching for preparedness in America. Rather than continuing to support efforts to maintain a durable healthcare/public health preparedness system, we're going to go backwards.
"We're seeing a decade's worth of progress eroding in front of our
eyes," said Jeff Levi, PhD, Executive Director of TFAH. "Preparedness
had been on an upward trajectory, but now some of the most elementary
capabilities - including the ability to identify and contain outbreaks,
provide vaccines and medications during emergencies, and treat people
during mass traumas - are experiencing cuts in every state across the
country."
Here are a few examples of the capabilities that will be lost:
10 state labs at risk for losing "Level 1" chemical testing abilities
24 states at risk to lose Career Epidemiology Field Officers
14 universities at risk to lose Preparedness and Emergency Response Learning Center funds
Why? Because when nothing happens, nothing happens. And nobody wants to pay when nothing happens. We've seen concern and hype over SARS, Avian Flu, Swine Flu - and nothing not much happened. Our impression of preparedness is high visibility people with uniforms, badges, guns under the failed approach of Homeland Security. Healthcare and public health operate in the background of preparedness and lack that high visibility until some biologic threat is exposed. Then, and only then, is the value of a durable healthcare/public health system realized...temporally. Katrina reminded healthcare systems to be ready. How can they be if they're not assisted with the same level of resources afforded to other Homeland Security measures?
Preparedness for biologic events, natural or intentional, requires funding to remain constant for healthcare and public health. That funding needs to be on par with other traditional response groups. Without healthcare/public health we will face what it means to live or die in disaster.
Failure to maintain healthcare/public health durability will worsen the ripple effect from biologic events by increasing strain on traditional responders and healthcare systems and by worsening the impact on special needs and at-risk populations. These things add up to poor outcomes from natural or intentional biologic events. Poor outcomes that can be predicted, and prevented if we'd change the way we think.
The Center for Biosecurity of UPMC has released their latest app for iOS. The Clinicians Biosecurity Resource (CBR) App covers the basics of several diseases with feature rich content for further leaning. CBR easily overpowers their prior offering, BioAgent Facts app. Click here for my review of the BioAgnet Facts app.
Disease list on iPad
The CBR app covers six diseases with enough detail to make this a worthwhile reference to assist in the recognition of a naturally occurring or intentional biologic event. The information for each pathogen is broken down into categories and is referenced to fact sheets from the Centers for Disease Control and Prevention (CDC) and he Center for Biosecurity. The value of the CBR app is increased substantially by the addition of sections for each pathogen on naturally occurring states, post exposure prophylaxis, personal protective equipment (PPE). The content is digestible, concise, and easily accessed through the apps interface. Images of x-ray findings are included (see Anthrax below).
Access to Biosecurity News
Notification option
You can also access Clinicians Biosecurtiy News (CBN), published twice monthly, directly from the home screen. Clicking on the wrench icon on the CBN page provides an option to be reminded about CBR updates. The information icon (i) links to the 'about' page containing a disclaimer, developer credits and additional links for reference.
Typical bioagent page layout shown below (Anthrax page as example)
The Clinicians Biosecurity Reference (CBR) will be useful for emergency medical service professionals, nursing, as well as physicians. The layout/design and feature rich content take this app above and beyond. Navigation and user interface are simple and CBR runs smoothly on iPhone/iPad running iOS 5.0.1. The color scheme is much easier to read than BioAgent Facts. I highly recommend the CBR app.
Final Score 0-5: The CBR app gets a 4.5 Content: 4.5 Solid information from a trusted resource, easy to access and scan. External links to CDC and Biosecurity News add value. CBR app can go a long way being used as reference and learning tool. Dumping the Zombie section (as seen in BioAgents Facts) and adding sections for Naturally Occurring, PPE, and Post Exposure information is a major improvement.
Aesthetics/graphics: 4.0 Detailed graphics and color combinations that are easy on the eyes.
Ease of Use: 4.5 I
found the tabs/buttons easy to navigate. Text is clear with pleasing color combinations. Stable on an iPhone/iPad (iOS 5.0.1)
there is no clear support/FAQ available.
Wishlist for CBR:
Allow screens to rotate. This would be especially helpful for iPhone.
Enable gestures. Again, a big advantage for iPhone
The Joint Commission says fatigue risks patient care
The Joint Commission has issued a position warning healthcare agencies to fight medical errors by fighting fatigue. Citing the link between health care worker fatigue and adverse patient care events, the Joint Commission revisited the issue of extended shifts and fatigue in a recent Sentinel Event Alert.
Fatigue resulting from an inadequate amount of sleep or insufficient quality of sleep over an extended period can lead to a number of problems, including:
lapses in attention and inability to stay focused
reduced motivation
compromised problem solving
confusion
irritability
memory lapses
impaired communication
slowed or faulty information processing and judgment
diminished reaction time
indifference and loss of empathy
In 2007, the JC noted that strong evidence exists linking medical error, fatigue, and extended duration shifts. The findings indicate that exteded shift and night shift workers make 36% more serious preventable adverse errors than others and have a 61% more needlestick or sharps injuries.
The take home message is that healthcare organizations need to assess the shift work/hours worked environment in their institutions for patient and provider safety. Key to reducing errors is to provide a culture of proactive safety. Staff should be able to express concerns about fatigue in the same way they would express concern if a colleague were impaired by intoxication.
Can these findings be applied to prehospital care? Certainly. While not be the norm in prehospital care, many services do work 24 hour shifts. It's far more common to find EMS professionals who may work far more than 24 hour shifts between multiple jobs. That is, work 12 or 16 hours at one EMS agency then go work another 8 or 12 at a part-time gig. Part-time work and other "off duty" work is not addressed by the JC in terms of healthcare providers. The fact remains that many EMS professionals do work more than one job. There is, of course, the dreaded "late call" that threatens to turn you 16 hour shift into much, much more.
Read The Joint Commission News Item/Action Alert: Click here
Direct Download Sentinel Event Alert: Click here
Welcome to 2012 and another year with Mitigation Journal. This weeks podcast is a summary of the challenges we face for planning and what we can do about it! Rather than give my predictions (as good as they are) I'd like to share a to-do list - a list of items that will help prepare for large scale events as well as the every day events.
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Planning, decontamination, proactive response is needed.
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Riot control agents are
considered “less-than-lethal” but they possess the potential to create
multiple patients, decontamination issues, and respiratory hazards to the
responders. Although usually not deadly, exposure to riot control agents stress the respiratory and cardiovascular systems. Like many other respiratory irritants they exacerbate a
variety of respiratory and cardiovascular medical conditions and cause
hypoxia resulting in critical patients.
Exposed persons with liquid product remaining on the skin or clothing is another concern. Certain types of chemical mace and pepper spray can cause skin irritation and burns. Ocular exposure can result in loss of sight. Persons who remain contaminated with product also threaten secondary contamination by exposing responders to off-gassing. If exposed, contaminated persons are allowed to get into an ambulance or worse, into the hospital, without proper decontamination, the risk of significant secondary contamination and potentially hinder hospital efforts. Along the same theme is the risk of self-referring victims. People who have been exposed to a riot control (or any other irritant liquid or gas) may leave the scene prior to being decontaminated and triaged. Victims self referring to hospitals or urgent care centers pose a significant threat of secondary contamination. This risk is even greater when the local health care institutions are left out of the pubic service information loop.
When encountering a situation involving riot control gases, I recommend the following:
Never assume the obvious threat is the only threat; other potentials should be considered. When someone tells you "its only pepper spray", don't believe them. Consider the potential of other agents such as cyanide, hydrogen sulfide, nitrates, chlorine, and phosgene can cause similar signs and symptoms to riot control agents.
Proper personal protective equipment and atmospheric monitoring devices must be used. This should include respiratory protection for responders. Canister masks or self contained breathing apparatus may be the appropriate level of protection. Atmospheric monitoring and non-invasive monitoring of patients should also be considered to help identify the agent.
Anyone with reasonable exposure to the material should be assessed and decontaminated prior to leaving the scene. Little can be done for the internal exposure a gas. Those with exterior contamination, those who have residual agent on the skin or clothing, must undergo emergency mass decontamination prior to transport.
Local health care systems, including urgent care centers and walk-in care centers, must be informed of a chemical event occurring in their area. Health care systems must be able trigger their Emergency Operations Plans as soon as possible in order to prepare for the possibility of contaminated self-referring victims.
Fire and EMS resources should be deployed to appropriate health care locations in effort to assist with secondary decontamination efforts and management of contaminated self-referrals.
Priority must be given to pre-planning at areas of critical infrastructure. Schools, hospitals, government buildings, and sporting venues are examples of soft targets that may also be considered critical infrastructure. Collaborative planning
and training efforts between traditional and non-traditional responders
(ie: EMS/Fire and school officials) will pay big dividends during
crisis.
Response plans must be tested,
practiced and revised. Tabletop exercises are a great low-cost way of
doing this. Plans should be general in scope with annexes for specific
threats. Planning for school events must include accounting for weather,
media, dispersal of victims prior to arrival and site security. Don’t
forget to build in communication with local hospitals.
Concern over too much school security has asserted
that school security measures are a result of paranoia and not actual
potential for an event.
My stance is that schools are facilities of critical infrastructure by
virtue of occupancy and potential impact of an attack/event. A natural
disaster such as an earthquake or a Columbine-like attack will yield
panic and disruption in any community. We cannot simply dismiss an
event, any event, involving health care facilities, schools or other areas of critical infrastructure. They are soft targets and should be
hardened and protected.
A study published in the New England Journal of Medicine indicates that four medications cause the most adverse drug reactions resulting in hospitalization of seniors. According the CDC study and Medscape article, two thirds of the 100,000 hospitalizations of seniors each year are caused by Adverse Drug Reactions (ADR) involving anticoagulants and diabetic medications.
According to the CDC website, four medications, used alone or together, accounted for two–thirds of the emergency hospitalizations:
33 percent, or 33,171 emergency hospitalizations, involved warfarin, a medication used to prevent blood clots.
14 percent involved insulins. Insulin injections are used to control blood sugar in people who have diabetes.
13 percent involved antiplatelet drugs, such as aspirin or clopidogrel, which prevent platelets, or pieces of blood cells from clumping together to start a clot.
11 percent involved diabetes medications that are taken by mouth, called oral hypoglycemic agents.
The Centers for Disease Control and Prevention define an Adverse Drug Events (ADE’s) as a serious health problem, and have published the following Key Facts on Medication Safety:
It is estimated that:
82% of American adults take at least one medication and 29% take five or more [1];
700,000 emergency department visits and 120,000 hospitalizations are due to ADEs annually [2];
$3.5 billion is spent on extra medical costs of ADEs annually [3];
At least 40% of costs of ambulatory (non-hospital settings) ADEs are estimated to be preventable [3].
The numbers of adverse drug events will likely grow due to:
Development of new medications
Discovery of new uses for older medications
Aging American population
Increase in the use of medications for disease prevention
No predictions! - Four actions for preparedness in the New Year
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Like many of you, I like to make predictions around this time of year and, like many others, these predictions fall short of reality and are forgotten in a few weeks. We can do better! For 2012 I’m not making any predictions...I’m giving you a to-do list! A four point list of actions to take that will make you, your agency, and your community more prepared for naturally occurring disasters and intentional events. Take these items one at a time...and take your time with each. You’ll be surprised how fast you’ll be able to improve your preparedness.
Conduct a Hazard Vulnerability Assessment (HVA). Some might call this a hazard vulnerability inventory (HVI). The Hazard Vulnerability Assessment (HVA) examines the occurrence or potential occurrence of a given hazard(s) in your community. The impact of the hazard(s) should be measured in terms of impact or threat to life and health, physical damage, and damage/disruption to critical infrastructure. Your HVA should also account for economic and social factors that will increase vulnerability to any given hazard. The Hazard Vulnerability Assessment is not a prediction but an analysis designed to answer questions or “what if” scenarios.
If you’ve done your Hazard Vulnerability Assessment, great. Then add a review and validation of that assessment to your To-do List for 2012.
Work on your Pre Incident Plans. Pre planning can be a never ending chore. Hazards change, threats increase and decrease, and capabilities may also change. The general basis for pre planning emergency and disaster situations is to maintain a certain level of preparedness and interoperability. Your pre plans should include regional and local response to biological events, both naturally occurring and intentional acts. Consider incorporating regional plans into your local pre planning as well. I’d also suggest a review of any plans to receive assets and resources during crisis situations. One such area to consider is a plan to receive assets from the Strategic National Stockpile or other supply. Consider including or updating pre plans that are specific for public information, explosive events, and active shooter events. Click here for more on Pre Incident Planning.
Define your Target Hazards. A target hazard can be defined as a location or area that poses an increased level of interest or attraction to an intentional event. Target hazards can also be identified as those areas or locations that have increased life hazard or secondary risk associated with them. Locations of critical infrastructure should be on your target hazard list as well. Critical infrastructure includes any location or service that, if lost or compromised, would limit or stop your ability to provide service. Power generation, water treatment, hospitals, public service should all be considered areas of critical infrastructure. When defining your target hazards, don’t limit yourself to those locations within your community. You should consider the high value/critical infrastructure locations in neighboring jurisdictions as well. Doing so will increase your preparation and effectiveness during mutual aid responses.
Combine your Hazard Vulnerability Assessment (HVA), Pre Incident Plans, and Target Hazard Identification into training. Use the Exercise Design Process to build realistic training opportunities. Don’t be afraid to start small or call on an outside expert to help construct your training activities. Build on what you do now...start with small seminars to summarize the training objectives and raise awareness to the situation, then conduct a tabletop exercise to add an element of stress yet provide a safe training environment. After you’ve built your training base, move on to a series of drills that test one or two elements of your plan. You can then move on to conducting functional exercises testing large plans in realistic field scenarios. For 5 tips to improve your exercise design click here.
This is final segment of our four part series on the topic of Cold Weather Emergency
Incident Rehabilitation (EIR). In this segment we'll discuss the importance of planning and pre planning for EIR. We also discuss the role of the
incident safety officer and Incident Action Planning that includes EIR. Joining me
for this series is Dr. Jeremy Cushman, Medical Director for Monroe
County, NY.
Cold Weather Emergency Incident
Rehabilitation was produced for emergency responders off all
disciplines. Health care professionals who may treat responders in the
hospital environment will also benefit from this background
information. For more on cold weather emergencies, click here.
Click the player below for the audio from all four parts in this series.
This is part three of a four part series on the topic of Emergency
Incident Rehabilitation. In this segment we'll discuss the importance of "pre-hab" and physical fitness. Joining me
for this series is Dr. Jeremy Cushman, Medical Director for Monroe
County, NY.
In part one we reviewed the need for rehab, in part two we discussed special
logistical considerations. Changing weather conditions and the use of
Incident Action Planning in relation to rehabilitation operations are
covered in part four.
Cold Weather Emergency Incident
Rehabilitation was produced for emergency responders off all
disciplines. Health care professionals who may treat responders in the
hospital environment will also benefit from this background
information. For more on cold weather emergencies, click here.
;
Click the player below for complete audio version.
This is part two of a four part series on the topic of Emergency
Incident Rehabilitation. In this segment we address the special logistical considerations for establishing Emergency Incident Rehabilitation in cold weather. Joining me
for this series is Dr. Jeremy Cushman, Medical Director for Monroe
County, NY.
In part one we discussed the need for rehabilitation. In part three we'll cover the importance of "Pre-Hab"
and physical fitness. Changing weather conditions and the use of
Incident Action Planning in relation to rehabilitation operations are
covered in part four.
Cold Weather Emergency Incident
Rehabilitation was produced for emergency responders off all
disciplines. Health care professionals who may treat responders in the
hospital environment will also benefit from this background
information. For more on cold weather emergencies, click here.
Click the player below for complete audio version.
This is part one of a four part series on the topic of Emergency Incident Rehabilitation. In this segment we'll discuss the need for rehab at all situations - truly a "sector for all seasons". Joining me for this series is Dr. Jeremy Cushman, Medical Director for Monroe County, NY.
In part two we'll discuss special logistical considerations, part three covers the importance of "Pre-Hab" and physical fitness. Changing weather conditions and the use of Incident Action Planning in relation to rehabilitation operations are covered in part four.
Cold Weather Emergency Incident Rehabilitation was produced for emergency responders off all disciplines. Health care professionals who may treat responders in the hospital environment will also benefit from this background information. For more on cold weather emergencies, click here.
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Using multi-media and internet strategies to reach today's health care and EM students.
I stumbled on this topic while reading one of my favorite blogs, Life in the Fast Lane. The post, Peer Reviewed Lectures, really caught my attention. As a semi-pro blogger and podcast host, I truly appreciate (and honestly believe in) the incredible value of multiple instructional strategies and web-based interaction. Traditional topics will find new life when a "new media" twist is applied. All you have to do is embrace the New Media delivery!
Continuing education becomes cutting edge and lecture content can be taken at-will or on demand to satisfy specific needs. This New Media approach also reaches out (and grabs on to) the Millennial Generation as well as those who want that convenience offered by this media. In the video below, Danielle Hart, MD (Hennepin County Medical Center Department of Emergency Medicine) outlines the learning style differences between various generations and how this non-traditional instructional tool bridges the educational gap.
The following anonymous comment on Paramedic Future (Mitigation Journal July, 2009)
Anonymous wrote: Thank you for your post. Examining your argument that
technology will eventually replace the need for the paramedic I find
some flaws. I feel like your argument is similar to saying why teach
long division now that we have calculators. However, the computer
diagnosis on the 12-lead is horribly unreliable. I don't know how many
911 calls I've made for "ST wave abnormality" on perfectly good
12-leads. As providers and educators we need to push for solid physical
assessment skills and diagnostic skills. The ability to read and
interpret a 12-lead is still a paramount paramedic skill. I currently
work one of my jobs at a teaching hospital and while moving a trauma
patient a physician shouted, "the patient is in v-tach!" the physician
reached for the defibrillator without question as one of the medics
explained that the alarm on the monitor was merely artifact from
movement. If we've learned anything it is that common sense isn't common
at all. We need to continue to educate and trust the interpretation of
skilled providers over technology.
My response:
I don't believe that technology will replace paramedics. In fact:
"...technology can't consider the patient as a whole and put all the assessment pieces together like a skilled paramedic can."
In the original piece I bring up the possibility that reliance on technology may not be a good thing:
"...Like any other technology, once we become accustomed to it, we become dependent on it...In the case of EKG's I'm afraid we'll eventually decide we don't need to teach reading them any longer...what will we do when technology fails?"
The point is that technology may put appropriate diagnostic tools and treatment possibilities in the hands of more responders and may make it possible to speed treatment in the field, improved triage of limited (and costly) hospital specialty care services, and pave the way for advanced practice paramedics.
In the 1950's, CPR was a physician-only skill. Defibrillation was a paramedic skill until the 1980's. Today, both CPR and automated external defibrillators make it possible for almost any member of the public to improve survival from cardiac arrest. We have to think forward to what the next "AED" will be.
E. Coli on the list of nasty bugs in your contact list!
Think about this the next time you put your phone to your face -
A
study published in October, 2011, found that 92% of cellular phones are
contaminated with nasty bacteria...including E. Coli. The cause of the
contamination is people using their phones while in the restroom.
Texting while toileting has been identified as a contributing factor.
According to research conducted by the London School of Hygiene & Tropical Medicine and Queen Mary,
University of London:
92% of phones had bacteria on them.
82% of hands had bacteria on them.
16% of hands and 16% of phones had E. coli bacteria.
How do you decontaminate your phone/handheld device after use in the clinical environment?
7 things you need to know...and why you need to know them
#1. Understand the broad scope of threats and trends in your community. Know what your local responders and emergency planners working on and what your community plans call for.
Why? Best reason why is to be a better prepared citizen, parent, [nurse] [medic]. You’ll be able to carry out your duties (at any level) during times of crisis and add to the success of the response.
#2. Know your internal emergency plans. Know your role within the plan and how crisis situations change the way you do what you do every day. Know what triggers your emergency plans to be put into action and when to shift from your standard of care to sufficiency of care. Consider what will change when you have to shelter in place or evacuate. Why? There may not be time to look things up during a crisis situation and the event will most likely change quickly. Being familiar with your plans ahead of time cuts down on reaction time and contributes to good outcomes. That is, lives saved...yours and your [patients] [citizens] If you’re
#3 Have a basic understanding of the Hospital Incident Command System.
Why? You will have to work within the HICS system during any crisis and you might be put into a lead role at some point. A basic awareness of the HICS and how to carry out the various functional positions within it will go a long way to success in the small scale and large scale of the event.
#4. Know the special resources of your institution and those around you.
Why? Knowing what specialties services are available gives you an idea of how certain cases will be triage into your system. You may also get an idea of the type of patients you can expect when a specialty hospital (burn unit, trauma or cardiac center) is over-run or has to evacuate. conversely, you can get a head of the decision making for sending your patients out to other appropriate facilities if you know their capabilities.
#5. Know how to prepare yourself and your family for community emergencies...and do it.
Why? The best way to prepare a community for disasters is to prepare the citizens. Well prepared citizens and communities lead to improved outcomes in disaster situations. On the professional side, having a prepared family means that we can continue to go to work and do our jobs better. Keeping staff coming back to work in times of crisis is a major concern. The best way to improve the numbers of people coming back to work is to help them prepare their families to shelter or evacuate as needed during crisis.
#6. Recognize incident indicators, signs/symptoms and heralding events that foretell a problem. In other words, pay attention to what's going on around you...even when you're off duty.
Why? You situational awareness may be all that stands between you and harm. Someone has to be the first to recognize danger signs...don't wait for someone else to tell you there's a problem...
#7. Get better accuainted with your Personal Protective Equipment. Even the stuff you use every day
Why? Some research has suggested that personal protective equipment may not be utilized properly and that annual training is not enough. Without regular and on-going practice, the PPE we have may not be used, or worse, used improperly.
FEMA conducted a never before attempted Nation wide test of the
Emergency Alert System on November 9, 2011. The test included
television, radio, cable, and satellite carriers. Despite the effort on
the part of FEMA, there are many who suggest this was more like a pop
quiz than a test.
This week we complete our discussion with Matt and Jamie talking about the success of the test, role of social media, and the continued need for the Emergency Alert System. We even get into the CDC's Zombie Apocalypse preparedness program.
We're celebrating six years of Mitigation Journal blogging and podcasting. When I clicked "publish" for the first time back in November, 2005, I couldn't have predicted how important this blog would become to so many readers and listeners. Our growth has been tremendous.
From blog to podcast to video to lecture...delivery of material has grown. We've published over 600 blog posts and dozens of videos. More than 6000 people visit Mitigation Journal DOT ORG every month. I've met so many people through Mitigation Journal and I've lost count of how many places I've been asked to visit - to give a talk or consult on a project. I've met so many emergency service professionals through the use of social media. I've had the opportunity to review plans, provide opinions, and teach.
What's next? I can't begin to predict. The only thing I can say for sure is that Mitigation Journal will continue to provide unique perspectives on civil preparedness
and emergency response. I don't like the mainstream way of emergency management thinking and would rather stay off the beaten(down) path.
Through blogging, podcasting, social media, and independent reporting, we'll continue to examine the limitless topics of preparedness and
response for civilians, traditional rescuers and non-traditional
responders.
We'll be reporting on current events, conducting case study,
providing original material sprinkled with commentary. Mitigation
Journal will cover everything from routine incidents to local disaster
and national crisis. Professional responders and concerned citizens will
gain valuable insight into preparedness and emergency response.
With
real world experience and insight, Mitigation Journal will be there
helping you prepare for whatever challenges your role in preparedness
demand...health care, emergency medical service, fire department, public
health preparedness...Mitigation Journal will cover it all.
They are the major effects of cold that are the root of all other problems. These five body changes are the building blocks of system failure caused by cold environmental conditions. They all stress the healthy body.
Cold conditions do not have to be extreme to cause problems. Even mild decreases in temperature are enough to trigger those five major effects of cold can cause increased heat losses through radiation and conduction. Heat losses can increase 25 to 30 times when a body is in contact with a cold or wet surface.
Any condition or disease that involves vasoconstriction, respiratory or neurological impairment places a person at increased risk during exposure to cold. In general, increased cold exposure risk increases with:
age < 1
Circulatory, vascular or neurological disease
Raynaud's Phenomenon
Alcohol, tobacco, caffeine, or energy drink use
Trauma or Hypoglycemia
Prior cold injury
Better health means better performance in cold environments. Exposure to cold decreases mental capacity with increased risk of injury, accidents and errors
While often considered during the hot
summer month, dehydration is a major threat during cold periods.
Evaporation, sometimes referred to as insensible losses, increases with
cold atmospheric conditions. Respiration moisture losses account results
in large amount of fluid loss through evaporation. These
respiratory/evaporation losses increases dramatically in cold environments as the moisture in exhaled breath increases. Dehydration is more prevalent with excessive use of caffeine or alcohol. Prolonged exposure to cold and dehydration are important variables to evaluate as both increase risk for hypothermia.
Environmental exposure to cold is also linked to decreased mental capacity. Reduced mental endurance has been shown to increase the risk of errors and accidents. Responders should be taking this into account when operating in cold environmental conditions for any period of time. Further, the physical discomfort associated with exposure to cold, even for brief periods, may contribute to decreased mental alertness.
Additionally, there is an increased risk of physical injury while operating in a cold environment. Joints and muscles become stiff and strength decreases. These factors lead to sprains and strains and muscular micro-trauma as well as acute injury. These effects can be seen in the well-conditioned person just as easily as in those who are not in good physical condition.
Factors in remaining warm include maintaining good food/nutrition status, adequate fluid and hydration and maintaining reasonable physical fitness.
