A Nuke in the Future

Is there a Nuke attack in our future? According to a recent poll, when it comes to a terrorist use of nuclear devices, 17 percent think it unlikely they'll detonate a nuclear weapon and just two percent  believe it’s not going to happen...at all...ever. This is in contrast to fifty-eight percent of adults who believe it is at least somewhat likely that there will be a major war involving nuclear weapons in next century...with twenty-six percent who say nuclear war is very likely.

There are also divisions among party lines...but few other demographics are given in this posting from NewsMax.

So, is there a nuke in our domestic future? Who knows. The point is that preparedness for such an event is not constrained to nuke attacks. This type of preparedness, with basic ideas, can be used in a variety of situations.

There's no escape chutes in ambulances

There's no escape chutes in ambulances...and even if there was, EMS providers wouldn't use 'em.

Mainstream media and the web are abuzz with the story or JetBlue flight attendant Steven Slater. By now you've heard about his exchange with passengers, grabbing a beer or two, and jumping ship via the aircraft escape chute. Who many of us in EMS have wanted to escape our ambulance from time to time?

I read a recent article that expounded how unhappy people were when the board aircraft; becoming rude and obnoxious. The passengers "expected" to be treated better (by what standard, I don't know) and the flight attendants were there to serve every need. On the other hand, the article tells us about how hard and stressful the job is and that flight attendants take the brunt of these difficult passengers and it is they who deserve to be treated better.

Lets compare this situation to emergency medical service. I've dealt with difficult patients, family members, and bystanders (like every other EMS provider). Not unlike an aircraft, the back of an ambulance strips people of their feeling of self-control and sprinkles in a bit of helplessness. Add to that the stress of a major (or minor) illness/trauma and you've got all the makings of a quite stressful environment. How many times have I wanted to pull the ambulance to the side of the road and get out...simply get out and walk away...to another line of work? How many times have you felt this way? The numbers might be hard to count and in hindsight, maybe it wasn't all that bad. But at the end of the day what counts is that you (and I) didn't pull over and get out.

Ambulances don't have escape chutes...

The Problem with PODs

Points of Distribution, or PODs, are the hub of pandemic planning in some communities. PODs are set up at certain locations and used to distribute oral or injected medication. Despite urging from the emergency response community, many jurisdictions have hung onto the POD plan as the only distribution method for pharmaceuticals in the setting of pandemic. Although not entirely a bad idea, the POD system has a number of faults that should be addressed and considered in the planning and contingency process.
What is a POD? As mentioned, a POD is a site designated for the distribution of medications or supplies in the event of a crisis or emergency. The pubic gathers at a give location or locations and materials are handed out.

Why was the POD system developed? In short, the current points of distribution model is based on an earlier process used to receive, break down, repackage, and distribute materials/supplies from the National Pharmaceutical Stockpile (NPS). The idea was further refined for the use in the setting of SARS and later, H5N1 Highly Pathological Avian Flu.

So, whats the problem? The first problem is in the planning assumptions made with POD Establishment. The assumption has been made that "we'll know" when a given pathogen is threatening and have time to medicate/vaccinate our public. That assumption was based on experience with SARS and predictions of H5N1 and is totally dysfunctional. To assume there will be a "lead-time" when we know a pathogen is coming is a terrible mistake. As we have seen with H1N1 in 2009, the disease was present in various states with little or no lead-in. In that situation, we have to plan for the disease spreading beyond any given boundary...simply by virtue of our modes of modern travel. So, to bring otherwise healthy people together into a central location(s) may actually increase exposure.

The next assumption we have to deal with is that a vaccine or medication may not be available in the amount we need...we could run out of medication. Running out of medication leaves us with people standing in line and not getting protected, perhaps being exposed. And speaking of standing in line...managing the que and providing sanitation services, shelter from the environment, food, and medical care at POD locations can be an event in itself. These continence's are not often included in POD plans. As one pubic health emergency managed told me; "the people in line are not our problem..."
That brings me to the problem of civil unrest and disobedience. Dealing with uncooperative persons, people with special needs, and those intent on causing problems is often beyond the scope of those working in a POD. Understand that the unrest can turn into a riot and become violent quickly...especially if you run out of medication.

In recent experiences, some PODs were overwhelmed with people and had delays of several hours while other locations remained nearly silent. Why? Because people did not know where to go, under what conditions to go, or did not understand direction. We cannot plan on people following direction. We can expect that once the media announces that site "A" is running with a ten-hour delay, many people will flood site "B".

Want another snapshot view...see Mitigation Journal Of Chicken and Expectations from May, 2009 to see what I'm talking about. Points of Distribution sites are difficult to manage and plan for...they are a part of pandemic planning, but only a part. Putting all our eggs in the POD basket puts us at risk of failure to meet the expectations of the public. Not meeting expectations will be disastrous.

MJ Podcast #182: The Problem with PODs, Flu Season Preparation, and Prescription Medication Abuse.

This week on Mitigation Journal Podcast edition #182

I received a number of emails this week about a comment made on edition 181 of Mitigation Journal podcast...I was talking about my support for the United States Postal Service pharmaceutical delivery program the lack of functionality and failure potential of points of distribution. Leading off edition 182 is a discussion A few listeners/readers wanted to know why...nobody disagreed with me...just wanted more information on my opinion. One podcast listener actually wants me to write an opinion for their superiors and deliver some training on the topic of comprehensive biological event planning.

Matt and I also discuss the need to revisit flu season planning. Who knows what we're in for this flu season, but this is a good time to develop (or encourage) those good non-pharm infection control practices; respiratory etiquette, hand hygiene, and appropriate social distancing. Its also a good time to revisit your services infection control plan...review, update, train on it.  This segment of the podcast expands on several recent blog postings. For more on these topics check out these postings in Mitigation Journal blog CDC: Vaccine not a requirement, Forward Thinking for Flu  , and CDC Drops N95 Requirement

And finally this week, we talk about the importance of a medication profile and history in the pre-hospital environment. Medications and medication history are important but never so important as they are today. Prescription medication abuse is increasing faster than meth use and the rate of emergency calls due to abuse is rising. EMS responders must add medications and medication history to the list of things-to-do. I also encourage everyone to have a field guide that lists medications, indications, and side effects. I recommend the EMS Field Guide and Field Guide app for iPod/iPhoneTouch from Informed Publishing.

CDC: Vaccine not a requirement

The Centers for Disease Control and Prevention have announced that it would not endorse mandated flu vaccine for health care workers. The CDC states:

"In 2009, CDC posted on its Web site Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel. At the time it was posted, uncertainties existed regarding the novel H1N1 influenza strain, and the vaccine was not yet widely available. As stated in that document, CDC planned to update the guidance when new information became available. Since then, circumstances have changed. A safe and effective vaccine has become widely available, and is being included in the 2010-2011 seasonal influenza vaccine. Further, we now have information about the number of cases of disease, hospitalizations, and deaths caused by 2009 H1N1, which can be compared to historical seasonal influenza data. At this point, an update of the guidance to address current circumstances is warranted..." Click here for the full text of the statement from CDC...pay close attention to the definition of healthcare settings and healthcare personnel...

Although it sounded like a common sense thing to do, mandating flu vaccine for all health care workers caused quite a bit of debate. In fact, the NYS Nurses Association came out hard against the requirement while many health care facilities threatened discipline or termination of any provider who refused to be vaccinated.  See my post NYS Nurses Association Opposes Mandates for Vaccine for more on this topic. EMS and other traditional responder groups were left in limbo, at the whim of the situation...do EMS personnel who are in and out of various hospitals meet the requirement for mandated vaccine? Nobody knew for sure. Despite it all there was not enough vaccine to go around.  

Forward Thinking for Flu

 It's that time of year again. Time to be forward thinking for flu.

As we approach another flu season it remains unclear what, if any, role H1N1 Swine Flu will play. Will there be another Type A influenza strain that will impact us? Will we see Swine Flu back as a seasonal visitor? Or, will we simply continue to have the various seasonal flu wax and wain throughout the season? I'm safe to say I don't know, nor will predict. Equally safe is the bet that nobody knows for sure.

Despite the less-than-glamorous remarks I get from some planners and responders, I continue to hold the position that flu; seasonal or novel strain, is a naturally occurring biological event. Look at the situation in that frame for just a second or two...If you knew there was going to be a biological event occurring in your community in the next few months, would you begin preparing for it now? I certainly hope so.

We know that seasonal influenza kills 30-35 thousand people in the United States every year. And we also know (now) that vaccine production and distribution in the event of a novel (or, perhaps intentional) biological event will be slow and sparse. So why wait until flu season (with or with a novel strain or variant) to begin preparing to meet the demands this naturally occurring event will place on your public and your service? I'd like to offer my list of things to consider when reviewing/planning for the 2010 flu season:

First, start or renew your infection control practices now. Get in (or back in) the habit of disinfecting your apparatus at the beginning of each tour, after each patient, and at the end of each tour. This includes wiping down all surfaces in the patient care compartment of ambulances, equipment that comes in contact with patients, and the cab of the vehicle. Don't neglect the place were you ride! Wipe down or disinfect the cab...with special attention to door handles, radio microphones, and the steering wheel.

 Second, although vaccination is still a great way to protect yourself from getting the flu, non pharmacutical interventions go a long way in stopping the spread of any disease. Remember to follow good hand hygiene practices by washing your hands as often as possible and using waterless sanitizers when soap and water are not available. Practice respiratory ettiquette - cover your cough and sneeze. Do so by coughing or sneezing into your elbow reduces the spray of material that comes out of you and into society. Also, wear a mask and don't be afraid to put a mask on your patient. The Centers for Disease Prevention and Control has recently dropped their requierment for N95 masks in the setting of flu in favor of surgical masks (See my previous Mitigation Journal post CDC Drops N95 Requirement) Also, consider appropriate social distancing...that is, stay home if you're sick. Many employers don't like to hear about this one. It is irresponsible to go to work (especially if you have contact with the public) if you are ill. Those involved in planning must account for the possibility that the workforce will be decreased, perhaps significantly, by members not reporting due to illness. You must also consider the absentee rate to increase due to employees remaining home to care for significant others who are ill or children when schools/daycare centers are closed. 

I encourage everyone to review the Mitigation Journal posting Bio-Event Ready or Die! 3 Thing to do, Today. originally posted August, 2009, for more on this topic.


For a summary of Mitigation Journal blog postings and podcast episodes on flu and flu-related topics, click here

MJ Podcast #181: Acid, Bombing Changes, Flu season on the way

MJ Podcast #181: Acid, Bombing Changes, Flu season on the way...with CoHost Matt and special guest Tom Sullivan, is now available.

This week we tackle a number of important topics as always. Join us as we discuss the not-so-obvious operational concerns in the wake of an assault involving acid here in Rochester. The key point being that decontamination must be accomplished prior to any victims being transported and this and any type of incident involving multiple patients or intentional acts involving hazardous materials must be communicated to all area hospitals in order for them to prepare for the potential of self-referring, contaminated patients. For more on this, see Acid used in Rochester, NY attack in Mitigation Journal August 2010.

Although the mainstream media would have you believe different, would-be bombers can and do test their bombs. On this edition of the podcast, we discuss how the stifled Times Square Bomber did, in fact, test his bombs, change his materials, and conduct pre-incident surveillance. See Times Square bombing details indicate planning, testing posted August, 2010.

Make sure you listen to the podcast, better yet, go to iTunes or click the and subscribe!

Times Square bombing details indicate planning, testing

Bomber had planning and surveillance

"...the bomber decided to substitute higher grade explosives for items that were "more readily available" on the consumer market..."

A recently released article by CNN.com provides some frightening details surrounding the attempted Times Square bombing. According to this report, Faisal Shahzad, who pleaded guilty to the attempted attack on Times Square, also admitted that he had altered the composition of the bomb, its materials and structure to avoid detection. After what seems to be comprehensive surveillance on his part, Shahzad decided to substitute higher grade explosives for items that were "more readily available" on the consumer market. This action indicates surveillance, planning, contingency planning, and testing on the part of this would-be bomber. Interestingly, these steps, now obvious, are the same steps mainstream media outlets have stated would allow an attempt to be detected by officials...making it nearly impossible to carry out an attack.

The most disturbing facts here are that the targeting of a major hotel in a densely populated area on a Saturday night...the intent clearly to maximize casualties.

They only have to work once...

We were lucky. This bomb didn't detonate. It was discovered (noticed...by a civilian who had the wherewithal to say something) before anything could happen. Fortunately the skills of the bomb maker were lacking, but the planning and intel gathering/surveillance work were not; this is exactly why this type of attack got as far as it did ad why they will be successful in the future.We also have to admit to ourselves that this type of individual effort is almost impossible to detect. Not part of a know cell, nobody tunes into their actions, purchases, emails, or cell phone conversations. So, when someone buys guns, propane tanks, fireworks, and fertilizer...they don't raise any red flags. They may be detected, maybe not...but it only has to work once.

MJ Podcast 180: Invisible Bracelet - Great Start for National Preparedness Month

Workable communication is key to managing any crisis...individual emergencies, local events, and large-scale disasters, all need an efficient means of communication. National Preparedness Month is September, 2010 and encourages everyone to be better prepared - Get a Kit, Make a Plan, and Be Informed. A great way to start your personal and professional National Preparedness Month activities is to enhance communication.

Visit Invisible Bracelet

How about a means of improving communications for every-day emergencies and large-scale events? I found an answer with Invisible Bracelet (iB)...an online tool that allows targeted medical information to be available to emergency responders and others involved in health care delivery. iB is not a comprehensive Electronic Medical Record or EMR, its a snapshot of vital information (that you control) available for responders to act on in case of emergency.

Th iB system also tackles communication with family members - simple to program In Case of Emergency (ICE) contact information allows the iB system to send a text message to emergency contacts letting them know you or your loved one has been taken to a hospital.

This week on Mitigation Journal Podcast, I had the opportunity to speak with Mr. Mark Tornstrom, the Executive Director of the National Medic Network for iB (listen to MJ#180). In our conversation, Mark details the functionality of this vital service. Tune in to the podcast as we discuss the role for this technology in every-day and disaster events as well as the benefits to traditional and non-traditional responders. 

Functional, with just the basic information needed to save a life...Invisible Bracelet is a great fit for National Preparedness Month. For more on National Preparedness Month, go to www.ready.gov and for all the details of iB got www.invisiblebracelet.org...and, of course, keep checking Mitigation Journal Podcast/Blog for the latest in emergency response.

CDC Drops N95 Requirement

CDC Drops N95 Requirement...and boy, do I feel good about it! 

N95 - Surgical Mask Just as Good

I've been arguing that the Centers for Disease Control and Prevention (CDC) requirement for N95's was not only expensive but, cumbersome, and difficult to ensure compliance. Pushing my  thoughts on the use of surgical masks over N95's has caused me significant headache...from the 2003 SARS epidemic to 2009 Swine Flu. I've written my opinion of surgical masks over N95 and stood by it for years.  See Bio-Event Ready or Die! 3 Thing to do, Today. originally published August, 2009 and On The Topic of N95s originally published May, 2009.
 .
But now, the CDC has issued opinion that surgical masks can be used in place of the N95.

I've been outspoken in classes; and now, it seems that the CDC agrees with me! The recent document from the CDC Interim Guidance for the Use of Masks to Control Influenza Transmission states the following:

About time they listened to me

"The use of surgical or procedure masks by infectious patients may help contain their respiratory secretions and limit exposure to others. Likewise, when a patient is not wearing a mask, as when in an isolation room, having health-care personnel mask for close contact with the patient may prevent nose and mouth contact with respiratory droplets. However, no studies have definitively shown that mask use by either infectious patients or health-care personnel prevents influenza transmission. In the United States, disposable surgical and procedure masks have been used widely in health-care settings to prevent exposure to respiratory infections, but they have not been used commonly in community settings (e.g., schools, businesses, public gatherings)."

 and further states -

"A surgical or procedure mask should be worn by health-care personnel who are in close contact (i.e., within 3 feet) with a patient who has symptoms of a respiratory infection, particularly if fever is present, as recommended for standard and droplet precautions. "

Non-Pharm Interventions: Only Half the Battle

Non-Pharm Interventions: Only Half the Battle...the other half is doing them correctly!

A recent study from New Zealand doesn't give us much hope the public will practice good hand hygiene or respiratory etiquette; two actions that are vital to prevention of disease spread. The researchers studied the habits of general public over two weeks in late August; a time when H1N1 Swine Flu was a concern and the work "pandemic" was all over the news.
Full article as found at MSNBC.com here.

What they found was 3 out of 4 people at least made an attempt to cover their cough. But, they didn't do a very good job as most people coughed or sneezed into their hands. Contaminating the hands is a great way to spread disease to surfaces or items. They also found that people were in the habit spitting on floors. You'll recall that spitting on streets and public places was implicated in the spread of SARS.

All this should come as little surprise following that a 2007 study noted that one in four adults still do not wash their hands after using the bathroom.

This study leaves me wondering about the impact of public information campaigns and disease prevention strategies. Were public information programs ineffective? Was the message poorly received or not understood? Or, do we still suffer from Optimism Bias...it can't happen to me! In either case, we have to stress that the non-pharmacological interventions; hand hygiene, respiratory etiquette, and social distancing are keys to preventing spread of any biologic agent. These interventions become even more vital when vaccine is not readily available.

Mitigation Journal Podcast #179

Click for Edition 179

Mitigation Journal edition #179 is now available. This week Matt and I discuss several topics for emergency services...our theme this week is situational awareness. In this issue we discuss the need for correct use of non-pharmacological interventions in the prevention of disease spread. It's amazing how many people still do not wash their hands after using the toilet!  In an even more disturbing situation, firefighters respond to a dumpster fire and are ambushed; showered with fireworks by an angry crowd.

We also discuss the latest in medication delivery; micro needles and how they may change the way we give flu vaccine...IF we get flu vaccine. And finally, Matt talks about staging for potential dangerous situations; when we do it, how close we do it...and who makes the decision...and in this case, what can happen when its not done appropriately.  You can see video excerpts from this episode on the Mitigation Journal blog on the VIDEO tab or on YouTube

Unknown Chemical used in Attack in Rochester

Unknown Chemical used in Attack in Rochester...few details available.

All the media outlets in Rochester, NY are running a story about an assault involving an unknown chemical. One group, armed with baseball bats, confronted another group and then threw some type oc chemical on them. The injuries are reported as minor and the victims include at least one woman and an infant.

This type of attack is becoming more common. There have been several instances of chemical splash attacks and use of homemade chemical bombs in public assaults. 

See Homemade Chemical Bombs in Mitigation Journal August 15, 2006

Points to consider:
It CAN happen here
Decontamination MUST take place prior to transport
EMS must be aware of the potential chemicals and resultant injuries

We'll have more details as they become available.

Rx Abuse. Ready or Not?

Rx Abuse. Ready or Not? That's what we in emergency medical services should be asking ourselves.

Rx Abuse: Accident or Intentional

According to this story from Reuters found at MSNBC.com, prescription medication abuse is rising faster than methamphetamine and marijuana abuse. According to the Substance Abuse and Mental Health Services Administration, treatment and those seeking treatment for addiction to prescription medication has increased 400 percent. This rate was more than meth abuse, which has doubled, and marijuana abuse, which has gone up by nearly one-half.

They go on to claim that nearly ten percent of hospital admissions in 2008 were for prescription drug abuse; this is up from 2.2% in 1998. Pain killers were overwhelmingly the medication of choice; with hydrocodone, oxycodone and morphine are the medications of choice. Interestingly, the abuse included all levels of education, employment, race, and geography.

EVERY responder needs a guide!

A take-home note for EMS responders is that a majority of the people abusing these medications are in the 18-24 year age group. The rationale seems to be an [incorrect] belief that the prescription medications are "safer" than the street drugs. This translates into the need for responders to search out and document all medications found on a scene...not just those actually prescribed to the patient. Yes, I'm profiling and suggesting that the potential for abuse is there with all patients...keep in mind, it could be accidental, but the potential for prescription medication use/abuse; accidental or intentional, exists in all cases. Bottom line - include all medications on the scene in your medication history - make doing so a habit (no pun intended).

A good medication history may make the difference in your working field diagnosis. I also recommend that each responder have access to some kind of field references to identify prescription medications. My choice is the EMS Field Guides from Informed Publishing. A hard-copy pocket guide or the app for iPod/iPhone of the BLS or ALS version is the way to go (I have both on my iPod). Either way, every responder should have one...keeping a copy will help you identify medications by name and provide the insight that might just save a life. Read my review of the BLS/ILS iPod app

Mitigation Journal Podcast #178

Click on my cool logo for download

Mitigation Journal Podcast #178 is a special request edition. Matt and I are planning to record the regular weekly segment shortly, but due to the number of emails...all requesting similar information...I decided to post a bonus edition. Don't worry, the weekly MJ podcast edition will not be interrupted.

So, on this special in-service training edition (MJ#178) you'll hear my talk on Clinical Decision Making in Critical Situations...previously delivered under the title of "When is dead, dead?" this program covers many aspects of interpersonal and scene management from the decision making model. If you're into managing difficult situations (and who isn't) this is the lecture for you. Best of all its recorded LIVE during one of my training sessions. So, hang on for enthusiastic EMS evangelizing!

One note of warning; this lecture was given for a group of firefighters and the analogies reflect fire service operation and themes. Other than that its 100% pure easy-to-understand for any level provider!

I'd love to hear your comments and constructive criticisms; email me at mitigationjournal@gmail.com or call me on the voice mail line 585-672-7844

Closing Schools During H1N1

Closing Schools During H1N. Will closing schools be an effective means of preventing the spread of a naturally occurring biological event?

A recent survey conduced by the Centers for Disease Control and Prevention looked at  214 households after a 1-week elementary school closure because of pandemic (H1N1) 2009. They found that students spent 77% of the closure days at home and 69% of students visited at least 1 other location, and 79% of households reported that adults missed no days of work to watch children.

In May 2009, an elementary school (kindergarten-4th grade) in a semi rural area of Pennsylvania closed for 1 week after an abrupt increase in absenteeism due to influenza-like illness (ILI) and the confirmation of influenza A pandemic (H1N1) 2009 virus infection in 1 student while other schools in the district remained open.

For each day of school closure, respondents were asked for the following information: where the student spent most of the day; whether the student went elsewhere, who watched the student; and whether the person watching the student missed work. Questions were asked regarding the oldest student if multiple children attended the school. Households that reported missed work incurred costs, even if those costs were only in terms of lost vacation or sick time.oldest students spent the days of school closure at home. However, most students left the home at least once during the closure period to visit routine venues (stores, locations of sports events or practices, restaurants).

This study bring up some interesting questions. Will school closings have any role in preventing the spread of a naturally occurring biological event if the schools are the only venue closed?I think the answer is no. For social distancing to work, all venues in a given are need to be severely restricted or closed...leaving some schools open while others are closed will lead to disease spread as many households have more than one student going to more than one school.

Also, keeping other venues open; malls, movies and others will encourage people to move outside their home location and may erode the sense of severity in the situation.


Kentucky Study MMWR http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5850a2.htm

Mitigation Journal Podcast #177

This week on Mitigation Journal Podcast - I'm solo from the Basement Bunker! Co-Host Matt had to work  and will be back next week.

Click here to listen to edition #177 of Mitigation Journal Podcast

MJ Podcast Line-Up for Edition #177

Special thanks to long time listener Russ for making a donation and supporting Mitigation Journal and to Kyle David Bates for working on the new MJ Logo.

In this edition we'll discuss the NFPA 2009 Firefighter Fatality Report, how school closings in the setting of H1N1 impacts home and work life, and a snapshot of immediate actions to take at school bus accidents.

Picture This!

Picture This! And do it now.

MJ logo by Kyle David Bates

Emergency service educators from all walks can struggle to make a point stick in the classroom. We've come to acknowledge the use of illustration as a means to "demonstrate" in class. As computer and digital technology has improved, especially for us Mac users (sorry, can't help it)so has the quality of our message to students when we use pictures and graphics that are realistic and meaningful.

I've recently become aware of the talents of a friend and colleague...I should say more aware, rather. I'm talking about Kyle David Bates. I've taught classes with Kyle and you've heard him on several podcasts including Mitigation Journal, EMS Garage, and most recently on First Few Moments. Kyle recently re-worked the Mitigation Journal logo and when I was adding the banner to his site (in the sidebar of this blog) took a few minutes to view his site...and you should, too. 

Here's what you do; go to http://www.kyledavidbates.com/Gallery/Gallery.html and take a look at the Clinical photos. They're so realistic...you'll have to resist calling 9-1-1! Jazz up your instruction and message to your students...check out www.kyledavidbates.com. You can also follow Kyle on Twitter @imagemedic.

Immediate Operations at Bus Crashes

Immediate Actions at Bus Crashes ...there are quite a few to think about. Establishing command and control of the scene is paramount. Today I'll  focus on some points for the responders working on operations and we'll save the C&C for another post.

So, from an operations perspective, especially for those arriving early in the situation. A few "quick tips" if you will:

Size up - don't get tunnel vision and focus only on the bus. There most likely is another vehicle involved. For more on this, see Mitigation Journal post First in? Think first! and tune into the First Few Moments podcast at firstfewmoments.com

The fatality/injury ratio is proportional to the size of the vehicle that hit the bus (or that the bus hit). Keep this in mind when you arrive.

Think about where kids like to sit. Prepare for entrapment or multiple casualties in the back of the bus.

Expect exits will be unusable. They'll be blocked by bodies or debris. Side exits are not usable if the bus is on its side. If you can use existing exits, I recommend doing so. If not, make the exits bigger and use them. As a last resort; make your own openings.

First in? Think First!

We just finished recording the First Few Moments podcast #3 the other night. The topic was So, you're first in...Now what? We had an All-Star cast including Wilma Vinton, Chris Montera, and Kyle David Bates.The discussion was lively...with viewpoints that as vast as the difference between Rochester, NY and Fairbanks, AK. If you haven't checked out First Few Moments, now is the time.

I was asked to chime in and, of course, had my own take on things.

"So, you're first in...Now what?"

1. First of all, know where you're going before you're first in. Pre-plan (FD is real good with this, EMS not so much) - do you have areas of your district that are notorious for bad thing happening? A place where the bad wreck always occurs...a high hazard area, lots of commercial traffic, hazardous materials, or a roadway location that could impact a target hazard building or site? Tunnels and bridges fall into this category as well, as do locations with poor visibility. Areas that change hazards with the changes in the environment should also be considered. Knowing where your going also means knowing how to get there and get out...alternate routes for both! Table talks on these locations make for great "quick drills" for new members and the seasoned veterans. 
2. Do something smart with your apparatus. Placement of first in apparatus can make or break the entire event. You can promote scene safety or put responders at risk. Know what other services are responding with you...fire department, EMS, law enforcement...and have an understanding of their operational priorities. No, you don't need to know everyone's standard operation procedures, just an awareness will do. Doing so may help prevent conflict and keep you from getting blocked in...or out. Also, when it comes to EMS appatus placement, begin with the end in mind. That is, think about how you're going to get out before you get in. 
3. And finally; don't just do something, stand there. Take the time to do a good size-up of the situation and report your findings back to the communication center and other responding units. Resist the urge to rush in - prevent tunnel vision - just take the few seconds needed to gain preliminary situational awareness. To be a little more detailed; use the Two x 360 method...a 360 big circle of the event on the ground and a big 360 that looks above and below the incident. Remember, size up is dynamic...and you have to report changes or your findings mean nothing.

A few thoughts on the vehicles involved in a crash: You should always note the type of vehicle and fuel source. Fuel/power sources are always important but even more so when we consider alternate fuels such as hydrogen and hybrid/multiple power sources. Consider also the potential for ancillary hazards...guns, bombs,  and other hazards. Keep in mind that terrorists don't build the bomb at the place they're going to blow up...they make it someplace else and bring it to the target. So it is possible you'll find yourself with an MVC toting an IED!

NORAD v. Cessna

Dear NORAD,

This is a CESSNA: 

This is a RUSSIAN STRATEGIC NUCLEAR BOMBER:

I was reading last week about how many "incursions" Russian naval and aviation forces have made near or into the United States over the last several months. Russian nuclear subs in international waters off both coasts, and bombers flying through U.S./Canadian airspace. Real Cold War stuff. Now, when I think of Cold War "incursions" by the Russians, I hear horns and klaxons and imagine fighter pilots racing across the tarmac, jets scrambling...the kind of thing you'd see when Godzilla was sighted...and backyard bomb shelters; you get the idea.

But, not so in today's world. The North American Aerospace Defense Command, NORAD, commander Adm. James A. Winnefeld Jr. is quoted in a recent Washington Times article:

"...beginning a couple of years ago, Russian strategic aviation forces began stepping up training flights of nuclear-capable Tu-95 Bear bombers near or through U.S. and Canadian airspace..."

And that means...?

"They are trying to show the world that they are a powerful nation, and we're not giving them the satisfaction … ."

So, do we do anything about it? Like in Top Gun; have a US fighter pilot flip 'em off or something?

"If we intercept every single flight that comes out in our direction, then we're really just feeding into their propaganda," 

No, really. What do we do?

"So we intercept them when we feel like we ought to, and we have various criteria that we use for that, to include just rehearsing our own skills to be able to do that."

Oh, OK. Is there anything else NORAD can do?

"we just leave them alone,"...[the Obama administration has] "done a good job of trying to hit the reset button with these guys, and sooner or later they've got to respond." Above quoted taken from the Washington Times on-line article.

Sooner or later they've got to respond!? Respond with what!? Anyone else see the problem here? Can you immagine where we'd be if we took this stance during the Cuban Missile Crisis?

But this situation is not all that has me wound up. Another story posted by CNN tells us the NORAD actually scrambled two fighters because a CESSNA violated "Obama airspace" over Las Vagas, Nevada. Okay, I can see the point of that. We've seen what kind of damage a civilian single-engine Cessna can do to a building...remember the kook who flew his plane into the IRS building in Austin, TX back in February, 2010 in an act of Domestic Terrorism? Oh, wait..it wasn't terrorism. Just a criminal act. (so that means we scramble fighter jets for the "criminal act" of violating Obama airspace...?)

Dear NORAD,
The point of all this is:

This is what a CESSNA can do to a building:

And, this is what a RUSSIAN STRATEGIC BOMBER can do to the Nation:

Next week: Building your own bomb shelter.

EMS Points to Remember

Just a couple of points to remember...for anyone who delivers emergency medical service:

1. If the person is unconscious, lay them down and open the airway. Its called putting them supine and its the beginning, not the end of care. But don't hold them up because it looks more natural...they're unconscious for a reason and probably don't care how they look.
2. If the person is having trouble breathing, don't let them lay down. Especially if they are tired. Sit them up. This is called Fowler's position and you have some choices; low- semi- or high-Fowler's. It will make it easier for them to breath and easier to assess. 

And think about it, it only took 25 years for me to figure this out. 

The First Rule of Preparedness

Re-wright the textbooks. Change all the PowerPoint slides. Alert the TSA and wake-up someone at DHS...I am changing the First Rule of Preparedness!

The First Rule of Preparedness is: Make sure you love your God, your country and your family more than being popular...



Add this new First Rule of Preparedness to the growing list of Mitigation Journalisms...

• Rule of Outcomes
• Optimism Bias
• Know Your Job, Do It Well

More on this to follow.

Heat Ready

We're all ready for the warm weather. But what about severe heat? The effects of a prolonged heat wave can be devastating to all of us. Emergency responders can find that simple "bread and butter" events can turn into extended incidents quickly...with the need for added personnel and effective rehab.

One of the best things we can do for the public we service is to keep ourselves ready to respond. That means we:

• Stay fit and healthy all the time, as best as possible. Remember, how you live off duty will effect your abilities on duty. 
• Hydrate, and then hydrate some more. People ask me about the type of fluid to drink all the time. The best answer is...Water, the drink of champions! That's it...water, just water.
• Eat. Fruits and veggies...put them in the freezer or keep them cold.
• Review your rehabilitation program and equipment. Be familiar with your stuff before you have to use it...in hot weather I recommend early set-up of a rehab unit. Be proactive. 

These are also good times to test your special needs contact information. Give those you've identified in your special needs planning a call or visit. Simple phone calls and visits can identify problems early and provide a tremendous boost to your public support.

The public will also turn to emergency service for tips on staying well in the heat. According to the American Red Cross, civilians should:

• Listen to a NOAA Weather Radio for critical updates from the National Weather Service (NWS).
• Never leave children or pets alone in enclosed vehicles.
• Stay hydrated by drinking plenty of fluids even if you do not feel thirsty. Avoid drinks with caffeine or alcohol.
• Eat small meals and eat more often.
• Wear loose-fitting, lightweight, light-colored clothing. Avoid dark colors because they absorb the sun’s rays.
• Slow down, stay indoors and avoid strenuous exercise during the hottest part of the day.
• Postpone outdoor games and activities.

Heat Wave

We're having a heat wave in the North East...even here in Rochester, NY. No, really, it can get hot here...sometimes it can snow here in July or at least be fifty degrees and rainy. We here in Rochester, NY complain when we get cool weather in the summer. Apparently we complain when it gets too hot as well. 

The weather man tells us that there is an Air Quality Alert and we're under attack by ozone. So, its not the heat, its not the humidity, its the ozone!

Below you'll find some of the research on ozone and your health...But lets make another point...air quality and ozone may also impact the responder. I think we'll include that in our PRE Habilitation plan and talk more about it in future posts and podcast episodes.

What does this all mean - well, here it is:

Air Quality Alert -  as defined by News 10 in Ohio Issued during times (usually on hot, summer days) when ground-level ozone and/or fine particle concentrations unexpectedly reach, or are approaching, unhealthy levels in your area based on monitored values. Sensitive groups are urged to limit their exposure outdoors.

The following is from a great website; AIR INFO NOW Consider the following selections from Air Info Now and check there for more details.

The properties that make ozone a powerful cleaner, disinfectant, and bleaching agent also make ozone dangerous to living tissues.

When it comes in contact with living tissues, like our lungs, ozone attacks and damages cells lining the airways, this causes swelling and inflammation.

Some have compared ozone's effect to a sunburn ... inside your lungs.

Other health effects include: ·         Irritation of the airway: a cough, an irritated throat, or an uncomfortable feeling in your chest. ·         Reduced lung function: you may not be able to breath as deeply or vigorously as you normally would. ·         Worsened Asthma: ozone can aggravate the effects of asthma (see Asthma below). ·         Potential health effects: ozone may aggravate the effects of emphysema and bronchitis, and may reduce the body's ability to fight infections in the respiratory system.

High ozone levels can affect anyone.

Some groups of people are particularly sensitive to ozone.

Sensitive Groups ·         Children They spend more time outdoors, are more active, and their airways are not fully developed. ·         Adults exercising outdoors Healthy persons engaged in physical activity breathe faster and more deeply. This increases the amount of ozone flowing into the lungs. ·         People with respiratory disease Ozone can further irritate the airways of persons who already have diseases of the lung or airways.

 

Summertime can be ozone time.

First, there may be more ozone around. During the summer months high temperatures and bright sunshine lead to increased ozone formation. Second, people may spend more time outside engaged in physical activities.

Asthma and ozone.

Ozone can irritate the already sensitive airway of someone with asthma. When ozone levels are high, more asthmatics have asthma attacks that require a doctor's attention or the use of additional medication. One reason this happens is that ozone makes people more sensitive to allergens, which are the most common triggers for asthma attacks. (Allergens come from dust mites, cockroaches, pets, fungus, and pollen.) Also, asthmatics are more severely affected by the reduced lung function and irritation to the respiratory system caused by ozone. 

Referenced sites:
http://forecast.weather.gov/wwamap/wwatxtget.php?cwa=usa&wwa=Air%20Quality%20Alert
lhttp://www.10tv.com/live/content/weather/stories/story_weather_meanings.html
http://www.airinfonow.com/html/ed_ozone.html