Why you should read history

Learning lessons from historical case study

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I've been a fan of using historical case study in emergency response and domestic preparedness for many years, and until recently, thought I was the only one. Just the other day I read a post on another emergency management blog that noted the significance of the MGM Grand fire in fire code and code enforcement change (Thank you, Todd Jasper -if you haven't visited his blog, click here).

• What is a case study?
• What makes case study valuable today?
• How can we apply case studies to our current environment?
• Where can we find good case studies?

What is a case study?
According to Dictionary.com, a case study is

"...a study of an individual unit, as a person, family, or social group, usually emphasizing developmental issues and relationships with the environment, especially in order to compare a larger group to the individual unit."

While the above definition is fine for generic use, I'd rather think of a case study (as it pertains to emergency management as the following:

• an historical record of something the really happened - an after action report
• a synopsis of the situation
• a review of positive and negative outcomes from the event
• an honest review of the lessons learned from the response

A case study should include all of these elements to be useful. It's our job to apply them to today's situations. 

What makes case studies valuable today?
Wouldn't it be nice to learn an important lesson without having to pay the price of error to learn it? Of course it would. And that is the value of relevant case studies...you can learn the lesson without paying the price!

 Reading a case study is just like reading history. It's an event that really happened. People actually responded to the event and had to make decisions. Making a case study valuable to your situation is up to you and you'll have to do a bit of work to find a case study that's good for you. That work includes:

•  defining what your needs/threats are - is there a specific situation you're preparing for or are you looking to explore you Hazard Vulnerability Assessment?
• finding a case study or situation that is similar to those needs/threats - finding an event that is similar to what you're preparing for means you'll have to apply the outcomes and lessons to your situation.
• applying the lessons from that case to your situation - understand where and when the case took place, then compare the outcomes/lesson to today's world and your needs.

How can we apply case studies to our current environment?
Think about what happened in the case. Look at the end result and ask "what would we do?" Would we respond in the same way? Do we have a similar hazard with the same potential? How can we avoid the situation? These are all questions you need to ask yourself while reading a case study.

You'll also need to take into account any changes in operations, personnel, or threats that have been put into play since the case took place. Reading the lessons learned section of an after action report or case study can be the catalyst for training and thinking.

Where can you find emergency response case studies?
United States Fire Administration - Technical Report Series
FEMA - Keyword search Case Study
Centers for Disease Control and Prevention (includes NIOSH)- Keyword search Case Study

Just remember; it can’t happen here.

The time is just before noon on April 20, 1999 and the teachers and students of Columbine High School are going about their business as they would any other day. In fact, it is just that; any other day in Littleton, Colorado.

April 20, 1999 was not an ordinary day for two students Columbine High. Tragically this day would become one of the darkest days for domestic terrorism in our Nation. It would also become the day the parents of thirteen children dread…the day their children were killed.

Can anyone remember the act of domestic terrorism at Columbine High School way back in 1999? In case you’ve forgotten let me give you a review.

Two juvenile students of Columbine walk into the school that late morning after killing two students at the entrance. The offenders continue to fire-at-will killing another 11 people and wounding over 160. The semi-automatic guns were not the only weapons of the day. These juvenile home-grown terrorists deployed or possessed over 100 incendiary and explosive devices in an anti-personnel fashion.

Nobody saw it coming. Nobody was ready.

But, that can’t happen here. Dozens of firefighters and paramedics tell me so every month.

Fast forward to January 31, 2006 were we find the first two of three events that underscore our vulnerability to such events. A student of Webster Shcroeder High manages to get a small caliber handgun into the school with a population of 2000 students. He’s caught and peacefully disarmed of the gun and the knife he had hidden in his locker. On that same day at 7th grader at Geneseo Middle School is arrested for compiling a “hit list” from his 536 classmates and attempting to conceal a “fake” bomb.

Editors Note: Don’t let the term “fake” fool you. “Fake” bomb is just another name for one that will not go off. There is a fine line between a bomb that fails to detonate and one that is a “fake”.

February 2, 2006; the 840 student population of Franklin High School in Rochester, NY in lockdown mode, reportedly a student has a loaded gun.

January 31 and February 2, 2006. Two days just like any other.

Here we are nearly seven-years after the Columbine High School attack. Are we better prepared for such an eventuality here?

We’ve broken our collective arms patting each other on the back at various simulations of chemical attacks and aircraft crashes. We’ve written for grant dollars and purchased shinny trucks. So, we must be prepared. Aren’t we?

The sad fact is that we are not prepared. For all the hard work and planning that goes into planning a full-scale functional exercise, many of the lessons that should be taught and learned simply aren’t. We’ve failed to glean all we can from these training sessions because they are WMD or hazardous materials or airplane crash scenarios…not school shootings.

We have to shift our focus to training in the all-hazards mindset. The commonalities among these large-scale events; mass casualty, haz-mat and so on, can be translated to almost any situation.

Can anybody remember April 20, 1999 at Columbine High School? The lessons that should have been learned from that day at Columbine were lost just as the lessons from Y2K, SARS, and any number of natural disasters have been.

Our response community suffers from the worst preparedness shortfall; we still think that the worst thing that we’ve ever encountered in our career is the worst thing that will ever happen…

Just remember; it can’t happen here.

Links:
Franklin H.S. lockdown: http://www.13wham.com/news/local/story.aspx?content_id=52F7165B-88D2-4322-A360-F839E5F5F446

Geneseo student “hit list”: http://www.13wham.com/news/local/story.aspx?content_id=1DF9C978-6764-4009-B733-9CDC331ECC3A

Webster student brings gun: http://www.13wham.com/news/local/story.aspx?content_id=66946445-AD9E-45E7-9D2F-29DB9C59A915

Mas Shootings

Check out this article on Mass Shootings from Government Technology online magazine. Read the You might be interested to listen to my commentary on Mitigation Journal Podcast (see Mitigation Journal #90) as to why hospitals and shopping malls are soft targets and need their own MCI plan.

4 pitfalls to avoid in your biologic planning

Think you'll have access to everything you'll need? Think again. 

This plan is your plan, this plan is my plan. Not.
Emergency service agencies and healthcare systems have spent countless hours and dollars on the planning process yet, few if any of these plans integrate with each other. There is little if any continuity between traditional response groups and healthcare systems. Failure of any agency or service to adopt or even recognize the existence of the national incident management system or NIMS will be the cornerstone of failure during a large scale event. Scant few services, either public or private, address planning needs or participate in any level of joint training. This unfortunate situation is perhaps the least expensive and easiest to implement, yet remains ignored. 

Four things you shouldn't count on in a biologic crisis

1. Communications

Each plan assumes that there’s going to be the ability to communicate and that communications will be undisturbed throughout any given event regardless of the length or scope of that event.  Case studies of numerous large scale events indicate the communications will be among the first piece of infrastructure to be compromised. When communication systems have failed or are compromised alternate means of communication will spring up; and it is these alternate means of communications that will lend a false sense of communications security and ultimately yield unreliable and inaccurate information unless they are planned and tested.

2. Power and Transportation

The reliance on public energy and public transportation are critical weak link in the disaster and emergency planning process. Power and transportation are linked together in the disaster planning setting. If we have and reliable and hardened power infrastructure capable of producing climate control, light, and maintaining critical operations in a given facility we can reasonably assume that facility will remain habitable and functional during crisis. If the power supply is threatened or lost we will no longer be capable of sheltering in place throughout the crisis and the decision will have to be made concerning evacuation or alternative sheltering. Should the need arise to evacuate a given facility, especially a healthcare facility, there will be our reliance on emergency medical service (EMS) and public transportation to make it happen. EMS transportation vehicles may or may not be available in such a situation. One must understand that all traditional response groups, including emergency medical services, will have their resources stretched to capacity and beyond. Air and ground transportation units will be subject to the same problems of fuel, power, and communications disruptions as fixed facilities. Alternate means for power supplies and shelter in-place needs must be addressed by fixed facilities in addition to hospital evacuation contingency and 96 hour planning.

3. Personnel. 
Another fatal flaw in emergency planning is the assumption that personnel will in fact report to work. This consideration must be taken without regard to the status of roadways and transportation. A survey study conducted by Columbia University in September, 2005 demonstrates possibility of personnel, who are otherwise unaffected by crisis, refusing to report to work. In this study, health care workers were asked to indicate if they would be able to report for work or willing to report for work in the event of a mass casualty incident. 81% said that they would be able to go to work if there was an environmental disaster, yet only 69% said they would be able to go to work during a small pox epidemic. The study goes on to note that the willingness to report for work would only be 48% of health care workers during a SARS outbreak. Further, only 57% of health care workers would return to work in the setting of a radiological event. The fallacy in this stage of planning is to assume that Healthcare workers who have a perceived obligation to respond will, in fact report to work. Numerous sources have noted that the willingness to report for work in any situation may be impacted by concerns for the safety of the responders family. It is important for employers of public and private organizations to understand that the family care can be as vital as responder care. Workers fears will impact their willingness to work and administrators and company leaders must talk to their workers about these concerns regarding exposure and contamination and reassure them by planning to assure family and dependent safety. An example of such contingency planning would be the setting of highly pathogenic flu or other biologic event. It is estimated in such a situation that nearly 30 to 40% of the American workforce would become stricken or ill and unable to report for work of any kind. That percentage includes persons engaged in critical infrastructure such as traditional responder and healthcare providers. 

4. Surge Capacity
Another important point to consider is that of the lack of surge capacity in the concept of ripple effect deaths. Surge capacity is a specter of imagination as many Healthcare systems operate above capacity every-day. Just as the traditional response groups will continue to respond to the routine calls for service during a large scale event, routine medical emergencies will continue to arrive at local hospitals. Lacking surge capacity will almost certainly cause some of these otherwise routine patients to destabilize and become critical or fatal. This can add to the death toll of any large scale event and further destabilize community infrastructure.

Its Summer. Do you know where your plans are?

Summer months are the time to exercise your pandemic plans

We’ve been looking down the barrel of a loaded “pandemic gun” for some time and you've been meaning to do something meaningful about biological preparedness for a while now. Lets face it, a mild winter and lack luster flu season has taken biologic preparedness off the radar.  Here it is Summer time and were guided ever so gently by the media away from flu (avian or otherwise) and pointed towards gas prices, immigration, and politics of all sorts. Although not without good reason and some value, we’ve forgotten about the “pandemic gun” or maybe just because the weather is warm here we figure that gun is no longer loaded.

Experts are warning of the biologic implications of the London Olympics. Now what?


Its Summertime, do you know where your plans are?
Just because we’re out of the typical flu season is no rationale whatsoever to put planning and training for such an event on the back burner. I’ve been asked a number of questions recently pertaining to planning, preparedness and response capabilities. The sad fact is that, despite effort and dollars, most pandemic and biologic event plans fall short of functionality. The overtone seems to be that the healthcare community and public health are going in one direction and traditional response groups are not going anywhere at all when it comes to planning for a biological event.

Each of the plans I’ve reviewed share a number of pitfalls by assuming:

1. The ability to communicate will remain intact and accurate/factual information will flow
2. Power and transportation will be readily available
3. Personnel will be healthy enough and willing to report to work
4. Civil obedience will be maintained both in the community and at healthcare facilities
5. Patients will be able to be evacuated to neighboring facilities or regions.

In addition, these plans do not mention the fact that every-day emergencies will continue to come to hospitals expecting treatment.

If you want resiliency, stop doing this one thing.

When we place a term on an issue, that term becomes imprint in our mind. 

Terrorism and weapons of mass destruction (WMD) are terms arisen out of the September 11, 2001 attacks that have been imprinted on us. Although not entirely new terms for many in the traditional response group of emergency medical service (EMS), fire service, and law enforcement; terrorism and WMD became the language defining events of national crisis. Highly paid “experts” have become obligatory content in any number of trade journals and conferences. Emergency service organizations have received millions of grant dollars to purchase training/education, equipment, and supply all to be brought to defend against terrorism/WMD.

The sad  reality is that much of the training conducted has been lacking context to what is encountered and managed every day. There is little, if any, ability to apply theory or skills from terrorism training to the real world. We need to take the all-hazards approach to training and relate the material to the daily events that  paramedics, firefighters and healthcare providers deal with.  are just a few examples of the threats outside of the traditional terrorism training we've been given. 

 Doing so will keep the skills and knowledge fresh and usable. If we continue to wrap this material up and say “don’t open ‘till terrorist attack” we will not be able to access it efficiently or use it properly.  Lets make terrorism training part of the greater Civil Preparedness/Resiliency that includes naturally biologic events, chemical suicide and technological failure.

Civil preparedness is much more than readiness for an intentional event - its not about being a Doomsday Prepper, either. Its a way of identifying through analysis and assessment the hazards we're likely to encounter and the potential impact of those threats. We have to blend what we’ve come to know as terrorism/WMD training into the “basics” of public emergency service and healthcare response. To do so is simple because of the similarities between the intentional events and haz-mat accidents, mass casualty events, and natural disasters.

What do accidents, man-made events, and natural disasters (ice storms, hurricanes, earth quakes, floods) have in common?

Here's the short list of commonalities:

From the web. I do not own this.

• little or no warning
• large numbers of civilians needing assistance
• multiple casualties and fatalities
• protracted operations
• limited resources

The Civil Preparedness Mindset looks at preparing us for a multitude of potentials. Not everyone has to be ready for a blizzard or a wildland fire, but we should all be aware of the hazards we're likely to face based on our Hazard Vulnerability Assessment. We all need self-protection, working knowledge of the incident management system, triage and casualty/fatality management, for example.

The labels of terrorism and WMD may have been a great disservice to emergency responders, healthcare providers and citizens. Those terms imply an event that most people don’t believe will ever happen to them. There is much more to preparedness than terrorism.

Let’s try to change our thinking.

Updated/edited. Original 11/05

Nuclear KODAK Moment. So what?

Highly Enriched Uranium, yes. How much of a threat?

Mainstream media and blogs are alive with the discovery of a nuclear reactor at Eastman Kodak Company (EKC). Enchanting headlines lead us to believe that there is and was a conspiracy to keep the reactor and its contents, 3.5 pounds of enriched uranium, from public knowledge.

 Knowledge of the reactor, its contents, and location had been limited to a small group of employees until an ex-employee recently outed the reactors existence. Supposedly nobody in Rochester/Monroe County, NY government knew about it. The community at large was not informed.  Its interesting how just a few years ago I found two containers labeled "radioactive" sitting unsecured in the back of a truck and nobody seemed to care but, now we're supposed to get upset over a small amount of material that has been safely operating since 1975.

Background
The EKC reactor, a Californium Neutron Flux multiplier (CFX), and associated material had been kept quiet since the mid-seventies. Only two reactors of this type were ever produced and according to documentation, EKC was issued a Special Nuclear Material License by the Nuclear Regulatory Commission in 1975 for the use/operation of the CFX. The reactor was housed a concrete labyrinth outside the Northwest corner basement of EKC building 82. This building is well known as Kodaks research and development area. Researchers used the CFX reactor for chemical and radiological testing, manufacturing process studies, and investigation of new chemicals.

The reactor was shut down in 2006 with the fissile material/fuels, Uranium/Claifornium (Cf) 252, removed and shipped to the Department of Energy (DOE) Savannah River facility in Aiken, GA.

Kodak Building 82-a mixed industrial/residential area

What should we have known?
The CFX reactor is not a nuclear power plant. Its no Three Mile Island and its no Chernobyl. Should the public, emergency planners and responder shave been informed of the CFX reactor operation? Absolutely. Not because the CFX was dangerous, but because its one more threat that we should have been planning for...just in case. The Greater Rochester region has a robust nuclear response plan in place for the Ginna Nuclear Power Plant. The Ginna plant came on-line in 1969. In 1982 the plant leaked a small amount of radioactive steam. The 93 minute leak resulted in a disaster declaration. Nuclear and radioactive materials is nothing new for this area, and it is inconceivable that the local government did not know of the Kodak CFX reactor existence.

What is the Potential Threat?
If we'd turned on the news today and heard the Iran had obtained 3.5 pounds of highly enriched uranium (HER), I'd be concerned...the revelation of Kodak operating a nuclear reactor doesn't really bother me.

Kodak CFX Reactor

Despite headlines claiming Kodak could start a nuclear war or was sitting on a nuclear bomb, there is little threat to be found here...as long as everything goes as planned. 3.5 pounds of HER is roughly 1.5 Kg of material. The Little Boy dropped on Japan carried approximately 64Kg of HER. With today's nuclear weapons technology, it would take 15 to 25Kg of material to produce a true nuclear weapon.

A major potential for harm comes not from the Uranium but from the lack of knowledge that it exists. Most reports have indicated that local officials were unaware of the reactor. I find this hard to believe since, as noted above, EKC was issued a Special Nuclear Material License by the Nuclear Regulatory Commission. However, I’m certain that the responders who protected that area were not aware of the reactor...and there is the danger.  If planners and responders are not aware of a hazard, proper actions will most likely not be taken - the response outcomes will suffer.

Theft or sabotage are the larger threats. Even a small amount of HER or Cf 252 could created a significant dirty bomb threat.

You can check to see how many nukes you are within range of by going looking at the Nuke-O-Meter

Biologic Effects of Radiation
For more on the biologic effects of radiation that covers the basics of radiation as well as the phases and syndromes associated with radiation exposure. You can read the three-part series on Mitigation Journal. Part one is an overview of radiation sources, measurement, and an introduction to the biologic effects, part two covers biological effects, acute radiation sickness and associated symptoms and syndromes, while part three reviews the details of Acute Radiation Sickness (ARS)

School-Based Health Centers, not your average nurses office

HHS tags $75 million for school-based health centers

Image: Seattle School Based Heath

Funding for the school-based health centers capital (SBHCC) program is contained within the Affordable Care Act with an earmarked total of $200 million.  SBHCC will receive $75 million spread out over an estimated 150 grants in 2013. The purpose of SBHCC grants is to help create jobs and improve child health by either implementing a school-based health center or improving an existing school health center. Like retail health clinics and walk-in care/urgent care centers, school-based healthcare centers are (or can be) part of the public health safety net. Children and adolescents will have improved access to healthcare resources while attending school. Kids with special or chronic care needs will also benefit from increased access to care.

According to the Health Resources and Services (HRSA) website:

School-Based Health Center, in general, means a health clinic that

• is located in or near a school facility of a school district or board or of an Indian tribe or tribal organization;
• is organized through school, community, and health provider relationships;
• is administered by a sponsoring facility;
• provides through health professionals primary health services to children in accordance with State and local law, including laws relating to licensure and certification; and
• satisfies such other requirements as a State may establish for the operation of such a clinic.

These clinics will provide care and improve overall health and wellness through health screening, promotion and disease prevention.

Opinion
The "off label" benefit to a community will be increased disease surveillance and additional healthcare resources. These clinics will almost certainly meet the routine health needs of children and adolescents who may otherwise end up in an emergency department. In times of crisis, such as severe flu/pandemic, or other emergency, the school-based clinics could play an important auxiliary role (much like retail healthcare) in the distribution of pharmaceuticals and screening exams.

Podcast 236 Prepare like its 1999 and London 2012 Olympic Ground Zero?

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This is a big week for us on the blog and podcast. Co-host Matt Comer is back this week as we discuss a couple of interesting and thought-provoking topics. As if that weren't enough, Mitigation Journal is coming to you from the West Coast and the Great State of Alaska!  I'm headed to Alaska to present at the South East Region EMS Symposium in Ketchikan, AK. I'll be talking about a variety of topics; from Culture of Preparedness and flu/biologic events, to school bus rescue. I'll be posting updates to FB and Twitter as well as daily blog posts reviewing the events. We're going to try to squeeze in a podcast, too!

This week on Mitigation Journal Podcast:
Is it time to prepare like its 1999? I think so. This week Matt and I rehash Y2K and consider the ramifications of a technological failure today. Our conversation is based on a Mitigation Journal post Y2K Planning Like its 1999 - this post ignited dozens of emails and mentions on Google+ - clearly a topic of interest.

Also this week we talk about the potential for a major biologic event at the London 2012 Olympic games. Some people have said London could be a biologic "ground zero" for the next pandemic. While the possibility is there - Matt and I shed a little light on the other possibilities...and what we can do about the threat of a naturally occurring biological event.

Click the player below to listen on the blog page or click here for direct download.

Decontamination and the Chemical Suicide

Decontamination and the Chemical Suicide

How were they exposed and what was the chemical? 
Those might be the first two questions you ask when confronted with a chemical suicide or consumer level hazardous materials event. They're also the most important. Figuring out the how and the what can be difficult but is vital to a safe mitigation of the situation. Incident indicators such as product containers and patient symptoms can help with identification. (see Concerns grow as chemical suicide evolves)

Key Point:
You should not rely on your senses to identify chemical products and determine exposure.

Was it accidental or intentional? 
The answer to that question indicates intent and potential secondary hazard. Chemical assisted suicide situations are intentional events  carried out by mixing a variety of chemicals to form a lethal combination. We often think of Hydrogen Sulfide in these cases but Cyanide and other materials have been created as well. Consumer level hazardous materials situations most likely fall outside of an intentional event and may be accidental. We should also consider that chemical exposure can be the result of illicit chemical use - chemical bomb creation or drug production. Regardless of the intent, the cause or the chemical, we have to consider emergency decontamination at these event. (see Managing the Chemical Suicide)

Key Point: 
You may have to search for source of the chemical - at the event location or at prior locations the person has been at  - and send the appropriate resources.

Not all contamination is treated equally

While all contaminated persons should be considered for some level of decontamination, internal and external contamination situations require different approaches.

Example of emergency mass decon

Internal contamination is hard if not impossible to decontaminate. The product may/may not be known. Secondary exposure risk is not a "scene only" hazard. The potential threat persists into the transport and hospital phase of care. Once a person has ingested a chemical the risk of secondary exposure to that agent (exposure of other responders/hospital providers) increases substantially once the person has vomited. Vomiting can release the chemical and produce symptoms in those exposed.

Exposure may be in the form of off gassing from internal contamination or exposure to liquid from vomit. Prior to vomiting the chemical is contained within the body with the possible exception of exposure via exhaled breath.

External contamination has the potential for immediate secondary contamination and exposure to responders and health care receivers. Because of the variety of chemicals that could be used, the actual product may not be known. Atmospheric monitoring may be helpful to identify oxygen limited or other toxic environments. Treatment may be determined by the situation and hazardous conditions as access may be delayed while the patient is removed from the toxic environment and decontaminated.

Keys to Decontamination:

• Decontaminate as soon as possible
• Use properly trained and protected responders
• Removing outer clothing of victims may remove > 90% of contaminated material
• Bag contaminated clothing/items appropriate overpack drum or container - may be evidence - consider chain of custody issues. 
• Control run off whenever possible -  paramount with radiological materials
• Don't bring containers or contaminated materials (even if contained) to hospital - take a picture - or video
• High volume/low pressure water streams may be the fastest and most effective means of emergency mass decontamination
• Be prepared for outcomes resulting from:
• environmental conditions
• privacy and media issues



Sources of information

•  casualty care issues of hypothermia/re dressing/re warming

Conclusion: Decontamination Points to Remember

• Decontamination prior to treatment or transport - must be done on site
• Exposed persons will flee the scene prior arrival of rescuers - contaminated self-referrals pose a risk to hospitals and staff should be on the look out for contaminated persons arriving in the ED
• Casualties should be triaged to receiving facilities that are equipped and prepared for secondary decontamination
• The fire department should be involved in decontamination operations at scene and hospital
• Be prepared for events to take place at non-hospital health care locations - walk in/urgent care centers

Managing the Chemical Suicide

Chemical Suicide: Situational Awareness

What's at stake when a person decides to carry out their chemical suicide in a public location and has desire to intentionally injure others? 

There are no rules concerning chemical suicides. Chemical agents, delivery devices, and locations are as variable as the people who attempt suicide by chemical means. A person who wants to carry out a chemical suicide is only limited by their resources and imagination. (see Concerns Grow as Chemical Suicide Evolves, MJ April, 2012)

The risks of multiple patients and potential for additional casualties dramatically increases when the desire to harm others is part of the suicide plan.

• Japan - Laundry detergent with liquid cleanser in an apartment building. Hydrogen sulfide is created and sickened 90 other people in building.
• Arizona - one individual manufactured hydrogen cyanide instead of hydrogen sulfide.
• Oregon - man mixes chlorine, bleach, ammonia and Drain-O and heats on Hibachi grill in a hotel room.
• Boston - Sodium azide is ingested and subsequently forms  Cyanide causing the evacuation of the building and the quarantine of several responders.

What does a chemical suicide look like?

The first indication of a chemical suicide or consumer level hazardous materials event may come from the caller or dispatch information. The presence of strange odors or the smell of rotten eggs may be reported depending on the chemical used. While some materials give off pungent odors others may have no olfactory warning whatsoever. 

Chemical containers in or around the location may be present. Remember, these containers may be from every-day Consumer Level Hazardous Materials purchased at a local grocery store or garden center. Any unusual cluster or amount of empty cleaning product containers, even if they're same products you see on store shelves every day, should be taken as a warning. There may also be a container used to  mix various products such as large pans or buckets. Pressurized tanks, the size you'd find on a gas grill, may be present if a simple or systemic asphyxiant gas is used. The presence of commercial size containers (pressurized gas or liquid) should be a warning, too.

Chemical suicides can take place in any venue. Many cases have involved a vehicle parked in a public place while others are carried out in residential locations including apartment buildings. Selecting vehicles, residential bathrooms and other small spaces allows for a small amount of gas to quickly reach lethal concentrations. Signs indicating the intent and chemical presence may be used...or not. While confined spaces seem to be the norm, the situation can quickly become a much larger threat if a chemical suicide were to be attempted at an indoor public location as the hazardous materials will escape the immediate area, increasing the potential for unintended persons to be exposed. 

Warning signs if any, may/may not be obvious. If the warnings do exist should we trust them? The potential for additional threats should also be considered. Incomplete chemical reactions, residual products, and flammable/explosive or oxygen deficient atmospheres should be anticipated.

What to do about it

Your first decision may be the hardest...you'll have to decide if this is a rescue or recover? Once that decision has been made the remainder of decisions have to progress accordingly. The actions of the first-arriving units will dictate the progression of the event and the safety of responders and the public. (see First In? Think First, MJ July 2010)

Anyone who enters the space without proper protection may quickly become a part of the problem rather than part of the solution. (see EMS Exposed to Acid, MJ August 2010) Approach to the situation should be cautious, with a high degree of situational awareness. Be prepared for multiple exposed patients. Unintended victims (or intended victims) could be exposed to liquids or gasses depending on the materials used or created as a result of a mixture of materials. Liquid and gas exposures should be handled differently. 

Victims exposed to a gaseous product may not be efficiently decontaminated by mechanical means and initially may pose less risk of secondary (off-gassing) contamination. Those exposed to liquid chemicals may have exterior contamination and require decontamination. Removing clothing of  may remove as much as ninety percent external contamination. Secondary contamination of a rescue crew, ambulance vehicle, or hospital emergency department has to be avoided. All exposed persons and victims of chemical suicides who are receiving care or being transported must undergo the appropriate decontamination. Incidents occurring in public places may call for mass casualty decontamination.

Personal Protective Equipment...what will work, what will not

Standard body substance isolation materials used by EMS or in hospitals will provide little, if any, protection from a chemical hazard.  Air purifying masks and respirators should only be used if the they are compatible with the chemicals used in the event. Filter masks, canister masks, and air purifying respirators will be of no use in an oxygen deficient atmosphere. Self-contained breathing apparatus (SCBA) with structural firefighting clothing should be considered the minimum level of PPE for initial operations or rescue of verified, live victims.

Additional Recommendations:

• Atmospheric monitoring should take place as soon as possible. Ideally, monitors that are capable of detecting simple and systemic asphyxiants, blood agents, and choking agents should be used. 
• The most appropriate treatment facility may be one with chemical decontamination and isolation facilities. The facility should be notified well in advance of patient arrival. Fire department units capable of providing or assisting with secondary decontamination should be deployed to any hospital emergency department prior to the arrival of victims.
• Specialized treatments such as traditional cyanide antidote kits or the Cyanokit should be available as well as a variety of other "tox med" medication. (Cyanide antidote kits will be discussed in a later post). 
• Chemical suicide events may occurs with or without a hazardous materials team available. You might find yourself responding to, or receiving patients from, these events without the ideal resources...take the responsibility for situational awareness yourself. 

Concerns grow as chemical suicides evolve

Chemical Assisted Suicide: Agent Review

Chemical assisted suicides continue to change and challenge emergency responders. Recent cases have demonstrated the ability to utilize various products and expand that challenge to health care facilities and providers. While we've focused much of our attention on Hydrogen Sulfide, cyanide and numerous other chemicals with high hazard potential have been used. For more, follow this link for background information on Chemical Assisted Suicide. In this series Mitigation Journal continues coverage of chemical suicide/blood agent suicide that began in 2008.

Recent Cases:

New York City - a man was found in a running car with an open bucket containing about 10 gallons of unknown chemicals. The car was parked near a "big box" home improvement store. We can only speculate based on media reports, that the open container of chemicals played a role in the death. This situation may have been one of many that mix various chemicals to form Hydrogen Sulfide.  

Boston - a woman ingested sodium azide and subsequently metabolized a form of Cyanide resulting in her death, causing the evacuation of the building and the quarantine of several responders.

Florida  - a man ingests a pesticide, malathion, and was transported to the hospital by EMS. The man vomits, exposing the ambulance crew and hospital providers to the effects of this organophosphate/cholinesterase inhibitor material. (see Are you ready for nerve agent exposure? Mitigation Journal)

The locations are different as are the chemicals used but, they're all part of a growing trend that poses extreme risks to civilians, responders and healthcare facilities.

Review of Chemicals

Various chemicals are used in suicide attempts and can include:

• Simple Asphyxiants - carbon dioxide, methane, and propane - displace oxygen in an enclosed space, promoting asphyxiation and suffocation by causing an oxygen deficient atmosphere.
• Systemic Asphxiants - carbon monoxide - exclude oxygen from the red blood cell by altering hemoglobin, decreasing the oxygen carrying capacity of the blood and resulting in hypoxia/hypoxemia .
• Blood Agents - Cyanide/Cyanide forming compounds, Nitrates, and Sulphides. Hydrogen sulphide, hydrogen cyanide, cyanogen chloride are major concerns. These materials interfere with cellular respiration and result in cellular hypoxia. Each of these products are toxic and can lead to rapid death. 
• Choking Agents - Chlorine and Phosgene - stress the respiratory system and the respiratory tissues. Exposure to choking agents results in mechanical compromise as well the potential for chemical damage that may result in pulmonary edema. 
• Consumer Level Hazardous Materials -  hydrogen peroxide, acetone, drain cleaners, and bleaches - can be combined to create toxic environments. Commercial pesticides may become contain hazards similar to chemical never agents.

Many drain cleaners contain sodium hypochlorite (bleach) and lye, an oxydizer/caustic. Chlorine (bleach) mixed with an acid creates chlorine gas and chlorine gas combined with ammonia results in chloramine gas. All of these materials are severe inhalation and contact hazard.

Many cases of chemical assisted suicide, sometimes described as detergent suicide, involve some form of bathroom cleaner (acid), pesticides (sulfur) , laundry detergent (chlorine), and in some cases bath salts (not the synthetic drug type). Hydrogen sulfide is created by combining acids and sulfides with other materials. There is usually some type of mixing container and empty chemical containers nearby.

In some instances, chemicals have been combined and created other materials that have resulted in differing signs and symptoms including those similar to nerve agent exposure with a similar toxidrome.

The details of the chemicals presented in this post are presented solely for the benefit of responders and health care providers. The intent is to increase the awareness to the growing threat of chemical suicide and Consumer Level Hazmat situations.

London Olympics: A Biological Ground Zero?

The 2012 Olympics in London are at risk of becoming the next pandemic ground zero according to research conducted by Maplecroft.

The bad news is that London is only part of the story.
Singapore, North and South Korea, Italy, Germany, Netherlands, Belgium, France, and Spain make the extreme risk of pandemic list, too. None of them are hosting an Olympics, yet are on the same list with the same extreme risk ranking. Confusing? No so much.

Many of the countries noted by Maplesoft are at risk of flu spread as a result of environmental and living conditions. South East Asia is noted in the report as being "a particular risk of emerging strains of influenza" and China is noted as a particular concern. This should not be a surprise. We've been following the development of widely publicized diseases like Avian Flu from these areas for several years. What's different is our level of awareness today. We recognize that global events that bring so many people together from diverse locations brings with it increased disease spread potential.

What makes the 2012 Olympics in London different?
Nothing. In fact, the risk of disease transmission is not unique to  the London Olympic Games in any way. We would be having this same conversation if the Games were being held in Lake Placid, NY or Beijing, China. Mass gatherings have the potential to spread disease, influenza or otherwise. We discuss influenza most often because of the attention drawn to influenza A - H1N1/Swine Flu and H5N1/Highly Pathological Avian Influenza. Although they top the list of notable flu viruses, it's important to remember there are many other diseases of concern. These diseases hold threat potential regardless of the location of the event. The fact is simply highlighted because of the diverse population and environments the athletes and spectators will be coming from. Immune system status, comorbid conditions, and overall state of health of attendees will also be factors in the spread of disease. People will bring diseases as diverse as the culture and health environment they come from...and they'll take other diseases home with them, too. We should also consider the fact that the Olympic Games will be a high-profile event that may be an attractive target for a variety of threats including the biological bomber. Read more: YOU, the biological bomber

What may be different today is our awareness and sensitivity to the biological threat. 
Naturally occurring or intentionally released, a biological agent can be an extraordinarily deadly situation. Perhaps worse than a nuclear detonation, without the big bang, if you will. The good news is that, when compared to other threats, the biological event may be able to be contained and person-to-person transmission limited by simply washing your hands and wearing a mask. The non-pharmacological interventions go a long way to slow the spread of disease and support vaccination efforts. Read more on non-pharmacological interventions.

Technology is a new ally in disease tracking. As described in this video clip from Reuters, public health officials from all over the world are working to improve disease tracking before, during, and after the London Games.

How will the media respond to athletes and attendees at the London Games wearing masks?
This would not be the first time the issue has come up. The United States Cylcling team came under scrutiny for wearing face masks during the 2008 Olympic Games in Beijing. Pollution and air quality prompted the athletes to don the masks and subsequently sparked political issues between China and the U.S. Masks for pollution is one issue. Donning masks to prevent the spread of disease is quite another. Consider the global impact if we were to hear of a "flu-like" illness spreading through London and, at the same time, see athletes wearing N95 masks. It wouldn't take long for the speculation of an outbreak to be spun into the next pandemic.

Preparedness, of course.
There is another side to the threat...preparedness. The widely cited Maplecroft report clearly describes the 10 nations most at risk for pandemic influenza. What is less often noted is that this same report ranks an areas ability to contain a disease. This same research concluded that the U.K. is one of the countries most likely to be able to contain an outbreak:

"...the UK’s strong governance, highly developed infrastructure, well educated population and advanced health system also places it among the 10 countries with the highest capacity to contain a potentially lethal outbreak of a strain of flu." - quoted from Maplecroft.com

What's less clear is the preparedness in other countries. Attendees and athletes will return home with whatever (if anything at all) they've been exposed to. While strong infrastructure adds to resiliency, the lack of that infrastructure will add to disease complication and management. Read more on flu and biological preparedness.

Looking for Preparedness Guidance? Add this to your reading list

Standard to Sufficiency: IOM Framework Paves the Way

Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response has been released by the Institute of Medicine and should be required reading for anyone who participates in emergency preparedness.

When disaster strikes changes have to be made. Planning has to turn into action. Public health, emergency medical service, and hospitals will be faced with tremendous pressure to do the best for the most with what they've got. I call this situation switching from a Standard of Care to a Sufficiency of Care - the latest publication from the Institute of Medicine (IOM) calls it Crisis Standard of Care. The Tenent Health/Katrina decision reinforced the health care planing message...IOM tells us how to do it -

IOM defines three levels of care:

1. Conventional Care
2. Contingency Care
3. Crisis Care

Overview

Crisis Standards of Care document totals over 500 pages divided into easy to digest volumes that target key pillars of Hospital Care, Public Health, Out of Hospital Care, EMS, and Emergency Management/Public Safety. The standards are built on a platform of ethical considerations and legal authority that segue into other critical, but often ignored, components such as community engagement and creation of incidents and triggers for action.

A key to this document being noteworthy is the detailed incorporation of emergency medical service, out of hospital care and public health.While most preparedness documents clump these disciplines under the health care umbrella, IOM takes a refreshing stance by giving each of these disciplines receives appropriate attention and legitimate planning guidance. The quality doesn't stop there; IOM goes even further, including at-risk populations, palliative care, home care, and walk in/urgent care centers as contingencies for planning.

Planning

Template from IOM document

Hospitals have a "duty to plan" and the framework for planning and plan development is exceptionally easy to follow. Step-by-step guidance is given in terms that are easy to understand with a process that has a natural flow and will be a nice addition to your 96-hour planning. Based on my experience, this process with integrate well into existing planning workflow. Following the IOM planning template may also help you avoid my 7 Surefire Tips for Emergency Plan Failure. I also recommend a review of the 6 items that good plans have that bad ones don't.

Training

Recommendations are made for the inclusion of tabletop exercises (TTX) as a means to testing plans created under this framework. TTXs are my favorite training exercise; they are fantastic activities that can be accomplished with a reasonable amount of preparation and very little funding. Follow these links for more on  tabletop exercises and exercise design. See also my five tips that will enhance your exercise design program.

Review
The IOM Crisis Standards of Care -

• includes template guides for palnning
• includes EMS, public health as major players 
• accounts for mental health, palliative care and at-risk populations
• call for tabletop exercises

Includes recomendations for -

• establishing trigger points for switching between conventional, contingency, and crisis care
• modifications for protocols/authorized use of CSC in planning
• guidance for liability protection and reimbursement

Recommended areas of focus -

• Volume 3: EMS
• Volume 4: Hosptial
• Volume 5: Alternate Care

How ready are you for a nerve agent exposure?

Latest Chemical Suicide Attempt Prompts HazMat Response

Consumer Level Hazardous Materials (CLHS) continue to prove their devastating potential. Chemical suicides and chemically contaminated persons may cause evacuation and closure of your emergency department. Unfortunately, these situations and their potential continue to go largely ignored.

FOX News is reporting on a situation in Florida involving a person who attempted to take his life by drinking a chemical pesticide. The man later vomited, releasing the chemical and causing paramedics to become ill and the emergency department to be closed for hours.

What would happen in your health care system if just one emergency department was closed from chemical contamination? 

Suicide by blood agent, often called chemical or detergent suicide, has been growing in popularity for years. These situations continue to be a threat and have evolved with the use of various chemical products. Hydrogen Sulfide is one of the main chemicals of concern as are cyanide and phosgene.  These events are often carried out by mixing the requisite chemicals in a vehicle parked in a public place. Follow these links for more on chemical suicide in cars and chemical suicide in general. Cyanide was used in a Kansas suicide in 2010.

 

The chemical used in the Florida event was the pesticide Malathion, an organophosphate/cholinesterase inhibitor that can cause a toxidrome similar to that of chemical nerve agents.  Organophosphate nerve agent exposure can result in a variety of symptoms including the "Killer B's" of bradycardia, bronchospasm, and bronchorrhea. Nerve agents in this class block the effects of acetycholinesterase (AChE) and result in hyper-stimulation of effected body systems. 

In contrast, blood agents (Hydrogen cyanide, cyanogen chloride, and hydrogen sulphide) interfere with cellular respiration and result in hypoxia. They are highly toxic materials and result in rapid death. Chlorine and phosgene are known as choking agents and stress the respiratory system and cause edema in the lungs. 

You don't have to wait for a terrorist attack to think about these chemicals. 

I discuss all of these materials in Maintaining a Culture of Preparedness - a talk designed to draw parallels between terrorist attacks and everyday Consumer Level Hazardous Materials events. 

I encourage everyone to:

1. Review their agency policy on decontamination and chemical protection  and inventory
2. Review your hospital emergency evacuation plan - is it realistic? 
3. Review your plans for mass fatalities and management of chemical casualties
4. Have your plans reviewed by an independent evaluator and test your plans with preparedness  exercises. If you'd like help with plan review and exercise design, contact me 

Follow this link for a summary of Mitigation Journal podcasts about chemical suicide.
Special thanks to Mike for sending the original article

Is your Preparedness Expiring?

Who should pay to prepare? 

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. 

Bath Salts: stronger than dirt

A new "Ivory Wave" of synthetic drugs

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.

Further Information
The following links were helpful:
Centers for Disease Control and Prevention (CDC) www.cdc.gov
Morbidity and Mortality Weekly Report http://www.cdc.gov/mmwr/
National Institute of Health (NIH) http://www.nih.gov/
YouTube > search keywords: Bath Salt, Spice, K2, Ivory Wave, PumpIt! Power Drug

Healthcare Providers Targeted by Violence

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.