Mandate the shot or not?

Debate over mandated vaccination continues

Voice your opinion, take our informal poll located in the right sidebar. 

What rights do I forfeit to work in health care?

Do health care workers have a "duty" to be vaccinated against seasonal flu? 
The answer to that question is "yes" ccording to the New York Times  who published an article suggesting that health care workers "should know better and anyone". The article cites a recent survey conducted by the CDC and claims that while doctors and nurses are "getting the message" about flu vaccination, mid-level providers and other health staff are not. They goe on to state that "Vaccinations of health care personnel should be required, either by state laws or by employers" and further notes that compliance is 95% when flu vaccination is mandated by an employer.

Should health care employers "mandate" workers to be vaccinated?
According to an opinion published in Medscape, Why Hospital Workers Should Be Forced To Get Flu Shots, by Arthur L. Caplan, PhD, the answer to the question of mandated flu vaccine is clearly affirmative. Correctly noting that seasonal influenza impacts high risk groups such as extremes of age, immune-compromised, and those living in long term care facilities, he states -

"Ethically, your first obligation is to do no harm. If you are there to do no harm and that is your primary obligation, then you cannot put your personal choice or your personal reluctance to get that shot above doing harm. And you are likely to do harm to others if you do not get that shot."

He goes on to say -

"...every code of ethics that I have seen -- medical, nursing, and others -- says that we put patient interests first. It is not in the patient's interest for you to not get a flu shot. If we are putting patient interests first, if that rhetoric is what we believe in our codes of ethics, what we teach in our medical and nursing schools, there is no excuse for not getting a flu shot."

Can a seasonal influenza vaccine be mandated as a "condition of employment" be enforced?
New York State attempted to mandate vaccine during the 2009 H1N1pandemic for all health care workers. The vaccine mandate was made by then Governor David Patterson despite a lack of vaccine, a sustainable mass vaccination program or a declaration of public health emergency. There was also considerable debate as to who, exactly, was considered health care workers. Most studies overlook non staff health care professionals such as EMS providers, firefigters and other public safety responders who contact the public in and out of the hospital setting.

Should we include environmental/support service staff or provide for blanket inclusion of anyone who would walk into a hospital?

Not everyone agrees with vaccine mandates.
New York State Nurses Association vigorously opposed the vaccine mandate in 2009. (See NYS Nurses Opposes Mandates for Vaccine) In June, 2010, the Centers for Disease Control and Prevention issued a statement saying they would not endorse mandated flu vaccines for health care workers for that year. The announcement by the CDC was a reversal from their controversial stance in 2009 that anyone working in a hospital must be vaccinated against the H1N1 Swine Flu. The full text of the CDC's statement can be found here.

Can vaccination be mandated without a formal declaration of a public health emergency?
You may recall that the United States Army (2003) had to resort to disciplinary action against soldiers who refused mandated Anthrax vaccine in preparation for deployment to a area with a credible Anthrax threat. The Army Anthrax vaccination program was eventually halted by federal court in 2006.  

If the Army cannot mandate vaccine soldiers in the presence of a credible threat, can anyone mandate civilian health care workers to be vaccinated in the absence of public health emergency?

If health care providers are mandated to be vaccinated today, what will be mandated tomorrow? 
What do the experts say? The opinion of the CDC is echoed by other infectious disease. The Society for Health care Epidemiology of America (SHEA) has released a position paper endorsing mandated vaccination with endorsement from the Infectious Disease Society of America. According to the SHEA media release:

"...influenza vaccination of health care personnel [is] a core patient safety practice that should be a condition of both initial and continued employment in health care facilities."

More than one controversy in this situation.
There is no doubt that flu vaccination will prevent the spread of flu, seasonal or otherwise. Public health history reminds us that viruses like Smallpox can be eradicated by a staunch vaccination effort. But can we expect to vanquish Type A influenza by mandating seasonal flu vaccination?

Don't listen to me! Recording without consent in healthcare

Is recording without consent a real concern?

 Are you being recorded without consent? Imagine your reaction when you discover a patient or family member has been secretly recording your interactions with them. A MJ follower recently had such a discovery and was (not surprisingly) concerned...

T.U. is an RN from Central New York and writes:
"...I was appalled to find that a patient had coordinated with family to record interactions with their health providers. A family member recorded (our voices) on a smartphone by simply leaving it on the table while another filmed encounters on another phone. All this without the nurses knowing about it. We found out about it only when a recording was accidentally played while a housekeeper was cleaning the room."

 Discovering you've been recorded without your knowledge or permission stirs emotion and puts us on the defensive. Why would a patient or family want to record our actions? Are they upset about our care or waiting to catch proof of a mistake? Perhaps the family just wants to have a record of the conversation to remind themselves of our instructions. Those who provide care outside the hospital environment may be more aware of the potential for being recorded. EMS providers and firefighters frequently provide care in public locations and are always in a position to be recorded by bystanders. Radio transmissions are also recorded and often are played on various websites.

Recording devices have come along way

While there are many reasons why someone would record (audio/video) we often jump to the negative conclusion...a reasonable defense mechanism when were recorded without our permission or knowledge. If nothing else, finding out you've been recorded without your knowledge or permission, taints the environment of care.

The ever increasing popularity of smartphones and other portable devices makes covert recording an almost certain eventuality.  And here in New York, its perfectly legal to do. Okay, disclaimer time - I'm not a lawyer, I have no background in legal matters and Mitigation Journal is not (emphasis not) a blog for legal opinion or recommendation.With that in mind, lets move on...

Recording your healthcare providers conversation without consent is perfectly legal in New York and many other states. There are only 12 states with "all-party" legislation that requires consent for recording. That being said, I think its important to take a calm approach to the situation.
 
Upsetting as the situation may be, recordings made covertly (or overtly, for that matter) may not be of benefit during legal proceedings. While medical records are seldom questioned for authenticity, recordings made by patients and families may be. They can be edited, tampered with and it may be difficult to prove exactly who is talking on the recording.

Here are a few articles that I found helpful:

Be Careful Who and What You Are Recording

When Patients Audio Record Without Your Consent

Family may use secret recording in medical negligence suit

Secretly recording conversations with doctors... Is it legal?

 

MJ Podcast 239 West Nile Virus

Special joint podcast episode with the MedicCast and This Week in Virology

What is it about West Nile virus that has everybody talking? Do the number of infections and deaths from WNV this year make sense? Is this hype or example of emerging infectious disease threats to come?


Join me, Jamie Davis (MedicCast/Nursing Show/Insights in Nursing), Dr. Vincent Racaniello and Dr. Dickson Despommier (This Week in Virology) for everything you wanted to know about West Nile virus and more!


In this episode:

• Where did WNV come from? 
• How did WNV get to the United States? 
• What's driving the 2012 epidemic and is this really the worst ever? 
• How can we apply current knowlege to other emerging infectious diseases?

See also WNV Hype or Threat (Mitigation Journal 8/2012)

Subscription links (iTunes)
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This Week in Virology
MedicCast

Click player below to listen now or direct download here

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Schools fail bio preparednes 101

U.S. Schools receive a failing grade in pandemics

If a biological agent targeted schools and children would try to prevent it?

Despite the global awareness of biological terrorism, emerging infectious diseases and the impact of diseases such as influenza, a majority of schools in the United States remain unprepared for a biological event. Only 40 percent of schools have updated their infection control/pandemic preparedness according to a study published in the American Journal of Infection Control. The study, conducted by Saint Louis University suggests that many schools in the United States are not prepared for a biological event despite experiences from the 2009 H1N1 pandemic event. As the threat from naturally occurring infectious disease and intentional acts of bioterrorism grow, the importance of community preparedness will increased. We know that one of the keys to a successful outcome in disaster situations is the preparation of local response agencies. Traditional responders and non-traditional responders (public health, hospitals) are the primary responders in any community during times of crisis. Unfortunately, hospital and public health preparedness may still be lacking. Schools should be included in the non-traditional responder group, considered part of critical infrastructure and as such, should be given direction for biologic preparedness according to their role in a biologic event. Best media coverage from Science Daily (http://www.sciencedaily.com/releases/2012/08/120830105323.htm)

• For biologic agent details, see Understanding Flu and Biologic events
• Need help writing your biologic response plan?
• Planning tips: What good plans have that bad ones don't
• Avoid these four pitfalls in biologic planning

Could school preparedness be any worse? Yes.
These findings question the general preparedness of critical infrastructure. The Saint Louis study looked at responses from about 2000 school nurses encompassing only in 26 states. If the results truly represent the biological preparedness efforts (or lack thereof) the school preparedness situation could be much, much worse and equate to greater risks. Closing schools during a biologic or pandemic event will not replace preparedness as studies have shown that kids don't often stay home.

Traditional elementary and high schools draw students together from a variety of social, economic, and cultural background. Bringing a student population together to share ventilation systems, food, water and sanitation, in close quarters, provides opportunity for disease spread. With this in mind, school systems must be a leader in educating students on proper hygiene and infection control measures. Non-pharmacological  interventions are vital to prevent the spread of disease and include hand hygiene, respiratory etiquette and appropriate social distancing. These simple measures are important for everyday health promotion but could be even more important in preventing or limiting the spread of influenza.

• Three things everyone should be doing to get bio-event ready

By the numbers, per the Saint Louis study.
According to the Saint Louis study, less than one-third of the sample schools maintained a supply of personal protective equipment (PPE). Even more concerning is the over 20% of the staff in these schools have no members trained in the schools disaster plan. Infection control training for students was reported by only one third of schools and conducted usually once a year or less.

The study also asserts a positive note, finding that nearly 75% of school nurses have recieved seasonal flu vaccination.While this is good news, its only a drop in the bucket. One person (school nurse) vaccinated for seasonal influenza will do little to stop the spread of the disease. When it comes to emerging diseases and intentional biologic releases there may be no vaccine and we'll need to rely on those non-pharmacological interventions.

Test all Baby Boomers for Hepatitis C. Really?

CDC: Boomers need HVC testing

Baby Boomers make up about one-third of the United States population with a startling number of Hepatitis C (HCV) infections. In fact, the Centers for Disease Control and Prevention (CDC) believe that the Baby Boomers, those born between 1945 and 1965, should undergo one-time testing for HCV. Previously, CDC recommended testing only if risk factors such as IV drug use, blood transfusion, or organ transplant existed. Testing for those in healthcare or other high risk occupations (including EMS and nursing) should be tested.

Given that as many as 2 million baby boomers are infected with HCV and many of the 15,000 Americans who will die from the disease are boomers, risk-based screening is no longer enough. According to the CDC -

"...newly available therapies that can cure up to 75 percent of infections, expanded testing – along with linkage to appropriate care and treatment – would prevent the costly consequences of liver cancer and other chronic liver diseases and save more than 120,000 lives." 

  Why are baby boomers at such increased risk for HCV? One theory attributes the increased risk to past behavior, suggesting boomers participated in activities that placed them at risk for HCV. 

HCV can be contracted by occupational exposure. I wonder what the ramifications will be for those baby boomers, who by definition now have increased risk of having HCV, have an undocumented occupational exposure in their past? 


http://www.medscape.com/viewarticle/769361
http://www.cdc.gov/nchhstp/Newsroom/2012/HCV-Testing-Recs-PressRelease.html

Has public alerting technology made warning sirens obsolete?

Is hanging on to your siren warning system worth it? Many of the alerting siren systems are aging and becoming difficult if not impossible to maintain and operate. Siren systems have limited ability to do anything more than make noise. They can't tell the public what they need to know in order to take meaningful actions. In other words, for a siren-based alerting system to truly be functional, the public must know ahead of time what the activation means. Is there an storm coming or is there a meltdown at the local nuclear power plant? Is this simply a test activation? The cause may not be that easy to define but the fact remains that the public needs to know the message prior to the activation because the activation will not be able to give that message. We also like to convey  to the public what actions we'd like them to take based on our warnings. Do we want them to shelter in place or evacuate? We'd ideally like to be able to tell them or have them know ahead of time. Not only do communities need to know their role in advance of crisis, they need to pay attention and react to the situation - and the alert or warning.

So far, we've outlined some of the shortcomings of a siren system that a web-based or cellular messaging system might be able to fix.

Back to basics
A warning system has to be able to be get the job done in time of need. It has to be maintained and tested. The public has to be educated on what the alert or warning actually means. These things are universal regardless of the system used. Awareness and alert meaning are usually the result of emergency management public education public education efforts. Engaging the public is key.  A warning system must be able to do a minimum of three things:

1. Tell the public why its been activated or what hazard is expected
2. Tell the public what to do and why
3. Tell the public how long they have to do it

These three simple items are asking a lot for even the best of siren-based systems. Should siren-based alerting systems be discarded in favor of web-based or cellular text alerting systems? Some people would argue that they should. New technology, social media, SMS/cellular messaging systems can solve the problems of awareness, notification, and meaning. New technology can produce real-time alerts, provide updated information on expected actions and hazards. Technology can even help educate the public. 

History lesson

The Control of Electromagnetic Radiation system or CONELRAD was developed in the cold war era and used from 1951 to 1963. As a radio-based system, it focused on key AM radio stations to deliver messages. AM 640 and 1240 were the designated stations. This system  worked because the AM radio was nearly a universal household item. Most automobiles were equipped with an AM radio, too. People were accustomed to getting their news, information, and entertainment from a radio during that time period.

The next generation of CONELRAD came into use around 1963 and functioned as the familiar Emergency Broadcast System or EBS. The familiar tone alert followed by the statement "this is a test - if this had been an actual emergency..." became well known to many in my generation. The EBS was upgraded for peacetime use to include FM radio and television as well as AM frequency.

In 1997 changes in technology made possible the Emergency Alert System. This system was maintained and tested by the FCC, FEMA, and the National Weather Service. One of the cornerstones of this system was that it claimed to be able to deliver a Presidential address to the nation within 10 minutes.

The Integrated Public Alert System (IPAWS) was designated in 2006. FEMA leads this project along with DHS, FCC, and NOAA. Later, in 2007, FEMA established the IPAWS program management office. With IPAWS, FEMA acknowledged new media as a method of message delivery. This system is estimated to be able to reach about 40% of the United States population during the day. Including new media and technology, the IPAWS system could reach the ever-expanding population that recieves a a majority of information from internet based technology.

An interesting note
Nation-wide emergency alerting systems were not used during September 11, 2001. When siren based systems were activated for more recent natural events, they were largely ignored by the public. Although newer technology was tested on a nation-wide basis in November, 2011, it is not clear exactly how successful those tests were.

West Nile Virus 2012. Hype or Threat?

 Is West Nile virus 2012 a serious public health concern or matter of media hype? 

The Centers for Disease Control and Prevention (CDC) tell CNN that the recent 2012 West Nile Virus outbreak is the largest ever seen in the United States.  Read CNN: West Nile outbreak largest ever.

Really? Worse by geographical distribution? By total number of cases? Fatalities? Not according to the CDC's Statistics, Surveillance, and Control Archive its not...at least not yet.

West Nile Virus (WNV) has hit the mainstream media in a big way over the last weeks of August, 2012. The virus is being dramatically portrayed as spreading, seemingly out of control, from state to state. As of this publication date, the Centers for Disease Control and Prevention (CDC) is reporting 1,118 human cases of WNV with 41 deaths attributed to the mosquito-borne disease. Going by these (most recent as of posting) numbers, the 2012 WNV situation is actually fairly average when guaged against previous years.  See How does 2012 WNV measure up to past years below.

Is the CDC intentionally contributing to the hype or are we missing something?

CDC categorizes WNV into broad groups; neuroinvasive and non-neuroinvasive disease. In other words, a severe form (neuroinvasive) that produces meningitis or encephalopathy and a less severe form. The 2012 data-to-date demonstrate that 56% of WNV cases are neuroinvasive, with 44% non-neuroinvasive or less severe.

Signs and Symptoms
As many as 80% of people infected with WNV will have no symptoms at all. Few may have mild symptoms resembling other viral illness such as influenza. One out of every 150 people infected with WNV go on to develop severe disease  - high fever, various neurological abnormalities, and weakness that may last several weeks. Neurological effects may be permanent.

How does 2012 measure up to past years? 

2012. An average year for WNV?

Looking back at the CDC data from 2011 to 2006 we find some interesting (albeit less dramatic) numbers. For that six-year period there were a total of 11,708 cases of WNV and 477 fatalities. That's an average of 1,951.3 cases/yr and 79.5 fatalities/yr. making 2012 look like an average year (of the last 6 years) for WNV.

Interestingly, the CDCs archived statistics 2003 would reign supreme as the worst outbreak ever. In 2003 there were 9862 reported cases of WNV and 264 deaths spanning 46 states.


According to the CDC West Nile Virus homepage:

• People over 50 at higher risk to get severe illness. People over the age of 50 are more likely to develop serious symptoms of WNV if they do get sick and should take special care to avoid mosquito bites. 
• Being outside means you're at risk. The more time you're outdoors, the more time you could be bitten by an infected mosquito. Pay attention to avoiding mosquito bites if you spend a lot of time outside, either working or playing. 
• Risk through medical procedures is very low. All donated blood is checked for WNV before being used. The risk of getting WNV through blood transfusions and organ transplants is very small, and should not prevent people who need surgery from having it. If you have concerns, talk to your doctor. 

Vector control. Key to prevention or hazard trade-off?
The main countermeasure against WNV is to kill the mosquito that carries the virus by way of pesticide use. Substances such as malathion and parathion have been used. Both are organophosphate-based chemicals that can produce illness and cause reactions similar to chemical weapon nerve agents at toxic doses. More recently, the pesticide Zenivex has been used. Zenivex E4 is a skin and eye irritant that contains petroleum distillates and poses an aspiration pneumonia hazard. The NFPA rating is Health: 2 Fire: 2 Reactivity: 0. Zenivex has an oral toxicity LD50>5,000 mg/kg and an inhalational toxicity of LC50>2mg/L (4-hour).

First-In Actions will dictate outcomes of large vehicle events

Initial Operations at Large Vehicle/School Bus Events

Initial Operations at School Bus Events  are, like those at any other event, are critical to the successful mitigation of the event. We know the actions of the first-due units can make or break any situation; and large profile events will magnify that point. When dealing with an event involving a school bus, mass transit bus, or commercial over the road bus, we have to  remember the physical resources needed may easily overwhelm existing services and carry the potential for surge capacity impact on existing health care systems.

In general, school bus incidents should be treated as multi-patient events or mass casualty incidents. It may be appropriate to consider these events in the same way we look at a target hazard location; sending multiple units and dispatching special call equipment on the initial assignment. Sufficient resources should be sent on the initial assignment based on a jurisdictions Hazard Assessment, rather than waiting for first arriving units. While this may seem contrary to conventional response plans, these events hold high potential for rapid deterioration, need for personnel rotation, additional specialized tools and equipment; and of course, an effective Emergency Incident Rehabilitation program.

Size-up should work in concert with established per-incident plans based on a hazard assessment and include 360-degree assessments on the horizontal and vertical. Bus and large vehicle incidents frequently involve other vehicles. The injury-fatality-rescue ratio will depend on the size of the other vehicle involved. You may wish to consider the other vehicle as a separate event with an entirely separate response and resources.

Triage has to be completed both on the bus/large vehicle and in the crowd. Keep in mind that those able to self-rescue will do so and will scatter into the crowd. Some may even self-refer to area hospitals or home. Accountability for all passengers will be difficult. Although we're accustomed to the priorities of triage and treatment, it must be understood that the first people out of the vehicle may not be the most critically injured...removal of walking wounded or non-injured persons should be done to reduce exposure to further injury and create space to assess and treat others. This also includes removal of deceased.

Keep in mind that there may be persons with special needs on the vehicle. Once these people are removed, they cannot be left unattended.

Bus Rescue: Interior

Front windows may not be an easy exit

For gaining access and ease of evacuation, remember three simple points: Use existing openings, enlarge existing openings, or make your own opening. The example used in this series is a full-size school bus has been turned on its passenger side. The side exits and passenger side windows have been rendered inaccessible leaving the front, rear, and roof as access points.

In Through the Roof we concentrated on gaining access and enlarging existing opening. Exit at the Back of the Bus demonstrated the need to open large areas for extrication. In this installment of Bus Rescue, we'll focus on interior operations that create space for extrication and disentanglement.

Side door access blocked by seats

Above: The side rescue door now sits at the top side of the bus. Access from the exterior can be difficult. Don't forget that access to this door may be difficult from the inside as well. Here we see two seats that will impeded the use of this exit door. These seats can be quickly and easily removed.

Hydraulic tools cut seat posts quickly

Above: Hydraulic cutting tools can be used to quickly remove seats by cutting the posts. Remember to cut the posts as low as possible, close to the floor. Gasoline power generators for hydraulic cutting tool systems must be positioned outside and away from the bus to prevent the introduction of carbon monoxide.

Below: A battery powered saw can accomplish the task of seat post removal. All tools must be well maintained with replacement blades readily available as well as batteries as needed. Hand tools and power hand tools are instrumental for arming additional work teams to speed the seat removal evolution.

hand tools are instrumental for arming additional work teams

Bigger is not always better, some cutting tools are too big for efficient interior operation

Above: Larger hydraulic cutting tools can be used but take more space to operate and may be too cumbersome inside a bus. It may be wise to monitor air quality inside the bus whenever gasoline powered hydraulic tools are used.

Reaching the interior door from the inside may be difficult

Above: Firefighter Lisa Coia-Bubel (City of Rochester Fire Department) demonstrates the difficulty of accessing the side interior door from inside a bus turned on its side. Note seats have been removed allowing for ladder placement into the bus. Roof or straight ladders can be placed into the bus via the side door for quick evacuation of minimally injured occupants.

Below: Further illustration of the side-to-side height created when a school bus it on its side. Note the seats are intact in this view demonstrating additional access limitation. Note also the proximity and size of the roof hatches (now side hatches). Intact seats will make placement of ladders difficult.

Height of side door and intact seats create difficult extrication

Above and below: Hand tools can be used to remove seats and some interior bus components when power/hydraulic tools are not appropriate.

Manage the "MCI in a can" with these five suggestions

Five tips for managing Passenger Transportation Accidents

1. Planning: Situational Awareness is important for all levels of the response community. Knowing your response area and the types of hazards therein is the first step. Pre-incident planning is also a necessity and must involve surrounding agencies. Don't forget to include the non-traditional responders and the health care system in your area in your pre-incident panning and training. Perhaps a best first step is to remember that it CAN happen here.

2. Responding: The actions of the first-in crews will dictate the outcome of the event. I recommend that everyone know where they're going, do something smart with your apparatus, and keep in mind there are events when it is better to not just do something...but stand there. LOCATE (Location, Obstacles, Conditions, Accessories, Treatment, Extra help) works for transpiration accidents as well as single patient response.

3. Managing the scene and incident command: The first suggestion...ask yourself how bad can this get? Then ask; Are we ready for this bus crash? Incident manages, rescue and triage branch leaders need to consider a few immediate actions when working at a passenger transportation accident: the injury/fatality ratio, understand where people (and kids) like to sit while riding buses, and that existing openings (doors and windows) may not be accessible.


4. Emergency Incident Rehabilitation: This may be the most important part of planning, responding and managing any event. Effective rehab helps to keep your personnel safe and working. We should be trying to run a good rehab at every incident. Use my  5 LEVEL Steps to Proper Incident Rehab and use these 4 points to make your Emergency Incident Rehab Functional.

5. Know general bus types and construction: You have to be able to get in and get out of the bus. A general working knowlege of school bus construction features is a tremendous benefit. Don't worry about getting too detailed...just understand the basics of construction and types of school buses.
Doing so will help improve planning, response and management.

EMS considerations for School Bus Rescue

A majority of passengers will be minimally injured after a school bus crash. Utilization of proper access/egress, triage and treatment procedures will improve the EMS response to these high stress events.

School Bus Rescue: Exit at the Rear of the Bus

When existing opening aren't enough...enlarge the opening for efficient extrication of victims.

Above: Firefighters assess access and begin dismantling rear door.

For gaining access and ease of evacuation, remember three simple points: Use existing openings, enlarge existing openings, or make your own opening.

In this installment we consider access and removal of the rear door. We'll focus on enlargement of existing openings and creating your own opening.

As seen in Through the Roof, this full-size school bus has been turned on its passenger side. The side exits and passenger side windows have been rendered inaccessible leaving the front, rear, and roof as access points. In Through the Roof, we looked at operations to enlarge roof hatch openings to improve access and rescue. This post will focus on access, opening, and enlargement of the rear door.  In our next installment, we'll focus on interior operations for disentanglement and access. 

Keep in mind that school bus accidents of this magnitude are rare, but when they do occur there is almost certainly going to be significant injuries, need for disentanglement, and protracted operational periods.  Successful management of incidents such as these require solid performance of the first in units. A significant knowledge of scene size up and vehicle construction are also vital. The 7 basic bus rescue points will aid any responder in the setting of a large vehicle/school bus event.

Below: Most rear doors are hinged to swing open towards the passenger side. In this situation the door does not hamper egress. Most doors lack a hold-open device, meaning if the bus were on the drivers side, the door would need to be supported in the open position or removed to keep it from obstructing operations. In either event, keep in mind there are seats directly forward of the door that do impede the use of this space as an exit. Those seats will need to be removed (as seen in following) in order to maximize extrication space.

Note height of door from road level.

Interior latch assembly can be removed with wrenches or socket set

Above: This view demonstrates the robust latching system and bolt throw (receiver removed). The entire latch assembly can be removed with hand tools (wrench/socket) from the inside; thus freeing the door.

Below: Traditional forcible entry tools and techniques may not be successful on the rear door of a school bus.  

Forcible entry tools and techniques may not be successful on rear doors

Use of a power saw to remove door hinge

Above: A battery powered saw can be used to cut away the door hinge and completely remove the door. The evolution can be completed fairly quickly with a well maintained saw and replacement blades.

Below: Once the door and glass from rear windows are removed, a cutting tool can be used to remove the door/widow frame and create and enlarged opening. Again, this can be accomplished quickly with well maintained equipment and skilled firefighters.

Hydraulic cutters remove frame between rear widows and door

Door/window frame removed. Note edge protection in place.

Above: Door/window frame removed providing greatly improved access. Note seat removal operation taking place adjacent to rear of bus. In combination, these two evolutions provide greater access/egress and facilitate removal of immobilized victims.

Below: Door removed and opening enlarged. Note the added space created by removal of rear seats. This creates an opening that allows for safe, efficient movement of immobilized patients.

Added space created by removal of door and rear seats. Note tape used to protect edges.

Bus Rescue: gaining access through the roof

Bus on the side is rare and challenging. Injuries are almost certain.

For gaining access and ease of evacuation, remember three simple points: Use existing openings, enlarge existing openings, or make your own opening.

Using existing openings will work well if patients can walk or have limited injuries and is the fastest and easiest to accomplish. In the pictured here, the bus is turned on the passenger side, rendering the passenger door, side and window exits unusable. In this scenario your best choice may be to use the rear door exit. Removal of the front windshield may also facilitate movement out via the front of the bus.

When existing opening aren't enough, enlarging existing openings is your next step. Enlarging openings such as roof hatches takes some time, personnel and equipment, but allows for rapid movement of rescuers and gear in and patients out. Once you start to cut on a bus be sure to reevaluate the need for structural stability and any effect on vehicle stabilization.

Firefighters use hand tools to augment power tools in this evolution

Above: Two properly protected firefighters use hand tools to cut the roof outer skin. Its important to rely on hand tools as a back up to hydraulic or battery powered cutting tools. Hand tools can also be affective for arming multiple teams when power tools are in short supply.

Below: The roof hatch opening enlarged (hatch removed) to facilitate movement of a backboard or rescue basket and personnel in and out of the bus. Note the jagged sheet metal. These hazards must be covered. Sharp edges will be present in the interior of the bus as well as a result of cutting the interior skin.

Note the inner and outer skin and the presence of structural hoops

Above: Marked by black arrow - Note the sharp edges on the outer skin (yellow) and the presence of the inner skin (red). Both will need to be removed and edges covered to prevent mechanical injury. FF John Harnischfeger (Ridge Road Fire District) points out a support hoop that has been cut to enlarge the opening. Hoop locations can be determined by the sequential line of rivets. Although these hoops can be cut, caution must be used as the structural integrity of the bus may be compromised. 

Below: A triangle cut made towards the rear of the bus facilitates interior extrication/disentanglement and removal. Caution must be taken to remove any victims from that area prior to beginning cutting operations.  Note the intact roof hatch to the right.

Gaining access no matter what side the roof is on.

Up Next: School Bus - Exit at the Rear of the Bus

School Bus Types

A general review of construction types and features of school buses

A news report posted by MSNBC.com about a "church" bus crash reminds us of the severity and hazards posed by incidents involving school buses. According to MSNBC, there were 29 people involved in this event, 23 were children. According to the report, the crash may have been caused by driver over correction causing the bus to overturn onto its side and resulted in nine injuries.

Lets do a quick overview of buses and some quick tips that you can use today.

Types of buses

Various Type A and B vehicle

Type A and B - described as van-style vehicles, are usually small van conversions with a gross weight around 10,000 pounds. Type A vehicles may carry 8-12 passengers with the main door behind the passenger side front tire. Type B vehicles may carry slightly more with a capacity of 16-24 passengers. The door is in the same configuration as the type A. In the setting of type A/B van-style vehicles, don't be complacent; these vehicles are a measure of quality versus quantity. The van-style buses are often used for transportation of special needs populations adding an entirely different medical, emotional, and evacuation element to the situation. These vehicles may also include special ramps, lifts and restraint devices...you'll need to be familiar with these items to be effective in your rescue efforts.

Wide range of type C/D buses

Type C and D vehicles are the larger buses that you normal see used as school buses or other transportation uses. Type C vehicles have a capacity of 30-70, also with the front door behind the front wheel. Type A/B/C buses have a rear exit door and may have a side exit as well. Type D buses are those with the flat front and the engine in the rear. They have a capacity of 40-120 passengers. The rear exit is an escape widow above the rear engine.

Use of Exits
Keep in mind that the bottom of rear and side exit doors are about four-feet above the ground. Side escape windows can be six feet off the ground and open upward...with no "hold open" device.

Command and Control
These events will be challenging. Multiple agencies and responders, media, traffic and the environment will all play a role in your bus event. Add to that the fact that many school-aged kids have cellular phones...you'll have frantic family members on scene with, or perhaps a head, of you. Don't ever forget the probability your actions will be recorded, too. 

Bus Rescue points you can use now

 7 take-home recommendations when dealing with any large passenger vehicle collision. 

• Knowing the construction and type of bus or large vehicle involved can be your first clue to the potential severity of the incident. Type A and B buses are the converted van style while Type C and D are the classic school bus types. Size-up must include the type of bus, number of occupants, and the position of the bus. Experience has shown that most collisions involving school buses result in little damage to the bus and the bus remaining upright. 

• Remaining on all four tires is not a guarantee of no injuries inside, while finding a school bus in any other position almost certainly predicts a variety of injury patterns. This is a good time to remind everyone that there may (most likely will) be injuries in any passenger vehicle that has collided with the bus. 

• Your size-up must include factors such as traffic conditions and environmental conditions. These contingencies will impact rescue efforts as well as treatment, triage and transport as well as longevity of responders.

• You should plan for distractions. Anticipate the media will have been contacted and will show up as well as parents. Plan for their arrival. Consider that patients may have walked off the scene prior to your arrival as well. 

• Control the hazards simultaneously with stabilizing the vehicle is a priority. Shutting off the electrical master switch and ignition as soon as possible may be your best bet. If you need to disconnect the battery, remember two things; there may be more than one battery and disconnect the negative cable. It is not uncommon for buses to have multiple batteries in different locations. Removing the negative cable and securing it to prevent contact with other parts of the bus is a good safety tip. 

• Solid stabilization has to be done at either end of the bus or under the center frame rails. Never attempt to crib a school bus under the skirting on the sides. Keep in mind that you'll need more cribbing than usual. Simply choking the wheels may be sufficient if the vehicle is upright; otherwise, the situation will dictate where best to crib and stabilize the bus. 

• For gaining access and creating evacuation , follow three simple steps points: Use existing opening, enlarge existing openings, or make your own opening. First, using existing openings will work well if patients can walk or have limited injuries and is the fastest and easiest to accomplish. Enlarging existing openings such as windows takes some time, personnel and equipment, but allows for rapid movement of rescuers and gear in and patients out. Once you start to cut on a bus be sure to reevaluate the need for structural stabilization and any effect on vehicle stabilization. You can make your own openings, too. I would leave this tactic as a last resort. Cutting into the side or top of a school bus is personnel intensive, time consuming and can add to the hazards. Cutting into the bottom of a bus is doable, but next to impossible.

Reading for Disaster

National Academies Press  introduces Emergency Preparedness/Disaster Management publications

The National Academies Press is offering a series of documents and eBooks focused on various aspects of preparedness. Many of them are free PDF downloads and make a quick read. The ones I'm reading are linked in the sidebar.

Topics include:

Facing Hazards and Disasters: Understanding Human Dimensions

Grand Challenges in Earthquake Engineering Research: A Community Workshop Report 

Preparedness and Response to a Rural Mass Casualty Incident:Workshop Summary

National Earthquake Resilience: Research, Implementation, and Outreach 

Building Community Disaster Resilience through Private-Public Collaboration  

Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response

Shootings, High- Profiles Soft Targets

The threat of intentional attacks on civilian soft targets continues.

"Locations of critical infrastructure such as hospitals, will need to be protected from attack as will other civilian locations. Hotels, coffee shops, and shopping centers lack the deterrents necessary to prevent attacks. The psychological impact of an attack on any of these soft targets will nearly as devastating as the loss of life."

I wrote that in a post quite some time ago and unfortunately, its proven accurate again.

In response to the recent shootings at a movie theater in Colorado -

Consider the following:

1. Soft target - lacking any deterrent or protection from an attack
2. Lone Wolf - individual acting alone with considerable planning, action intelligence,  resources, and motivation
3. Multiple threats - secondary devices, chemical hazards
4. Prior events show commonalities for preparedness (Olympic Park, Columbine H.S.) - lessons from case study improve response efficiency 

Lessons:

1. It can happen here
2. If you haven't conducted joint training, response will suffer
3. Include case study in your training program

Recommendations:

1. Plan for the realistic threats you face - maybe you should skip the airport/crash drill this year and replace it with an active shooter event at a soft target
2. Evaluate your plans
3. Evaluate your exercise design program and consider including tabletop exercises

How ready are you for an active shooter?

Co-posted on ProResponder
Ready or not, soft targets are at risk

Active shooter situation may be the most difficult to domestic terrorism situation to deal with. Many of the active shooter situations take place in a work environment and may have no warning. Firearms of all varieties have been noted in active shooter case studies from the United States. According to the Department of Homeland Security

"An Active Shooter is an individual actively engaged in killing or attempting to kill people in a confined and populated area; in most cases, active shooters use firearms(s) and there is no pattern or method to their selection of victims..."

These events are unpredictable in nature and timing, but the outcomes and be generically predicted.  If we follow the basic principles of Life Safety, Incident Stabilization, and Property Conservation, we'll be able to keep personnel safety and response priorities in balance.We'l focus on Life Safety and Incident Stabilization in this post.

Life Safety. In active shooter situations life safety means protection of responders, elimination of freelancing, and accountability. While the first step in life safety is pre-incident planning, the root of successful is understanding the response priorities of each responder discipline. In active shooter situations the rapid deployment of law enforcement is paramount to life safety and incident stabilization. The response priorities of law enforcement in active shooter situations is going to be different from those of fire and EMS responders. While fire and EMS responders may be focused on evacuation of live persons or treatment of wounded, law enforcement may have to delay action on the part of other responders to secure the scene and progress toward the actual suspect. The urge to rapidly gain access to wounded persons must be suppressed until law enforcement has deemed the situation safe. To help understand law enforcement perspectives on these situations, I recommend this article from PoliceOne.com

Incident stabilization. First arriving units may encounter persons leaving the scene or may be inundated with wounded. A slow approach with good positioning well away from building egress points will be the best first-in location. EMS should use the delay in patient contact to establish patient collection points and staging areas within the geographical confines of the situation. Keep in mind that wounded persons may have left the scene prior to your arrival and gone into nearby buildings or neighborhoods...you may receive calls to your dispatch center from multiple locations outside the shooter area. Deployment of resources on the perimeter will help speed response to these areas.

The Department of Homeland security has issued a list of good practices for persons in an active shooter situation:

• Be aware of your environment and any possible dangers
• Take note of the two nearest exits in any facility you visit
• If you are in an office, stay there and secure the door
• If you are in a hallway, get into a room and secure the door
• As a last resort, attempt to take the active shooter down. When the shooter is at close range and you cannot flee, your chance of survival is much greater if you try to incapacitate him/her.

Also, according to DHS, there are thee main steps people should take;
Evacuate if there is a clear path of egress
Hide Out if evacuation is not possible
Take action against the shooter only as a last resort when your life is directly in danger.

Rule of Outcomes thinking: Active Shooter events

The value of preparing generically

Subscribe

We've posted several pieces discussing the active shooter situation in Ohio. This weeks Mitigation Journal podcast summarizes many of the issues discussed and introduces Rule of Outcomes thinking as applied to armed gunman/active shooter events.

Click the player below to listen

Soft Targets Attractive to Active Shooter Events

Co-Posted on ProResponder
Active shooters pose active threats

The topic of an active shooter event has tragically made headlines once again. Active shooter situations in a soft target location - a mall, school, hospital/health care environment, or sporting event would be disastrous. We have to acknowledge the fact that these locations are indeed soft targets - they lack the infrastructure to deter an attack and, as current events and case study reminds us, are attractive targets. Further, with all the attention and money spent on chem/bio/rad preparedness, I belive that the active shooter situation has been left behind.

Given this, I've decided to re-post Mitigation Journal podcast #187 (an interview with Net Talon) on active shooter situations, as well as excerpts from prior blog posts on the topic.

Click on the player below to listen to the Net Talon interview!


We're all about situational awareness. Numerous articles and sources have talked about the use of civilians as forward observers...that is, those who are engaged in a situation being part of the solution be providing first-hand data to responders. The best example of this is the cell phone videos that make it to mainstream media; those videos taken by civilians who are actually there and perhaps in harms way. Even more recently we've discussed how many 9-1-1 dispatch centers were now accepting emergency calls via text messaging. Suffice to say, those in the midst of a situation have technology available to get important data out to responders.

I had an opportunity to have Donald Jones, Director of Corporate Development, and Ronald DuBois, Director of Administration and Finance at Net Talon join me on Mitigation Journal Podcast edition 187 for an in-depth look at Net Talon and the Virtual Command technology. What you'll hear on Mitigation Journal Podcast this week is perhaps the most invigorating news on the topic of threat mitigation I've heard in a long time.

Please visit Net Talon on at www.nettalon.com. While you're there, be sure to watch their active shooter demonstration.

7 Surefire Tips for Emergency Plan Failure

Following these simple tips will bring your planning to a bitter end!

Tip #1. Use a template that you found on the internet to write your plan. Just Google for a plan template then use the Find/Replace feature in your word processing application to place your community or organizations name in the appropriate spot. The results will be stunning! You'll have your plan(s) written in no time and they'll be completely dysfunctional. Beware! You might run into a problem when someone else reads the plan or you actually have to put it into action. Don't worry, the following tips are designed to prevent that from happening.

Tip #2. Put the completed plan in a three-ring binder. The next action is to take your generic template from another organization, print it, and place it in a three-ring binder. Slap a label on the binder spine and place it on a shelf! This tip is almost guaranteed to keep anyone from reading your pirated plan! Even better, you'll never have to worry about updates or answering questions on the plan. What a time saver!

Tip #3. Don't have the plan reviewed. Don't even tell anyone about it. The last thing you want is someone reading your plan once its finished, especially someone from outside your agency. To best ensure failure, keep the plan to yourself and quote from it only when absolutely necessary.

Tip #4. Write your plan based on the last crisis you encountered. Remember the last "big one"? Think about what you did during that crisis and build your plan from there. After all, you've always done it that way. Heck, the last "big one" is as bad as it will ever get. Above all, keep in mind that it can't happen here.

Tip #5. Spend fifteen minutes with your Hazard Vulnerability Analysis. Or ignore it completely. You Hazard Vulnerability Analysis will only add work to your plate by making you focus on realistic threats in your community. Why waste the time? If you follow tips 1-4, there is no need to spend time with the HVA.

Tip #6. Write the plan specifically for your organization. Remember, nothing outside of your boundaries needs to be planned for. And any crisis in a neighboring jurisdiction will in no way bother you.

Tip #7. Do not, under any circumstances, test your plan. Save time and build morale with this tip! Skip the realistic training scenario. Table the tabletop exercise. Instead, gather the troops and order pizza! Talk about the good 'ole days and slap each other on the back over what a good job we did at the last drill. Your meaningless template of a plan can remain safe in its binder. No muss, no fuss.