Learning First Aid in the Mountains

After twenty-five years in career EMS, I'm going to learn firs-aid! Seriously. This weekend I'll be traveling to the High Peaks area of New York State in the Adirondack Mountains to spend some time with instructors from Wilderness Medical Associates.

A weekend in the ADK and putting a new twist on some old skills...learning how to manage situations without a med bag, cardiac monitor, or an ambulance. I can't wait!

Of course, a full review will come in the form of the next "off duty" segment of Mitigation Journal.

Do they get it, or don't they?!

On November 1, MSNBC reported that Gitmo detainees were in line to receive H1N1 vaccine. The article quoted "Army Maj. James Crabtree, a spokesman for the U.S. jail facility in southeast Cuba, said the doses should start arriving this month, with guards and then inmates scheduled for inoculations" and further acknowledged "He acknowledged there may be an "emotional response" from critics who argue that terror suspects should not be allocated swine-flu medications while members of the U.S. public are still waiting due to a vaccine shortage." The full article is shared on the blog, too.

I was outraged at the potential of Gitmo terrorist detainees receiving a vaccine I can't get for my kids! I also posted this on Facebook and got a unanimous response from other "pissed off" people...by the way, I did get one email calling me a "hater" - you figure it out.

Anyway, Reuters News is reporting that "The White House denied on Tuesday that any H1N1 flu vaccine is now going to terrorism suspects held at the Guantanamo Bay Naval Base in Cuba, heading off controversy over swine flu prevention priorities."

Public opinion must have gotten the best of them...so, do they get it, or don't they?

Possible Chemical Assisted Suicide, Ontario County, NY

Possible Chemical Assisted Suicide, Ontario County, NY:
News just being posted on a couple of local media sites (WHAM 1180 and Rochester D and C) indicating that a person has been found dead in a car with five-gallon buckets of chemicals in the back seat and a sign in the window warning of "toxic gas". Residents within a half-mile radius have been evacuated...

We've written about this in the blog and talked quite a bit about it on the podcast...this trend of using over-the-counter chemicals to create what I call "Consumer-Level Hazardous Materials Events" is a grave threat to responders and the public. In cases of chemical assisted suicide, also known as detergent suicide, a mix of several simple household materials combine to create Hydrogen Sulfide...a blood agent similar and potentially more potent than cyanide. I've listed the Podcast and Blog entries related to this topic (We've been following these situations since early 2008 and have quite a collection of information).

If you'd like to see my notes on this topic, click here for my site and scroll to the Training File at the bottom of the page. If you have trouble with any of these files, please email me or call 585-672-7844.

Listen to Mitigation Journal Podcast (free) editions #114 , #104 , #72 , #59
Read the Mitigation Journal Blog postings: More Chemical Suicide (5/31/09), Chemical Suicide in Cars (3/3/09) and Suicide by Blood Agent (4/28/08)

Should we believe it this time?

10 Million more units of H1N1 due by next week. Should we believe it? Or, is it more of what we heard? Remember back in the beginning of September 2009 we were going to have 85 million units of vaccine. I'll believe it when I see it...

Visit msnbc.com for Breaking News, World News, and News about the Economy

Finding Radiation in the Parking Lot

I happened to go out for a cup of coffee with a friend of mine this morning and found something unexpected in the parking lot. In the space next to mine was a pickup truck owned by a construction company with two containers in the back...labeled RADIOACTIVE. Barely secured with an old chain and skimpy padlock, these containers were just sitting in the open bed of the truck with nobody around.

I'm certain they were legitimate. But in today's society, just leaving them out in the open was a bit odd. Certainly, these materials could be used for some untoward event, like a dirty bomb, but more concerning is the number of possibilities that are more likely to happen.

Suppose this truck were to be involved in a collision, a roll-over or rear-end collision for instance. You find the containers after you approach, size-up and being patient care...or worse, you find the compromised containers only after patients have been taken to the hospital.

How about fire? You arrive to find this truck fully involved. Only after extinguishment you find the melted, compromised containers. Do you have radiation detection equipment available? Would you even think about getting it out?

Finally, what will the average citizen think of this? Two containers left out in the open and clearly marked radiation. Perhaps they'll call 9-1-1, how will you respond?

Elmo better than CDC and WHO

Elmo delivers the message in a more concise and understandable manner than CDC or WHO. This says it all! Wash you hands, control your sneezes...that it, the non-pharmaceutical interventions taught to you by a sock.

Here is a link http://www.youtube.com/watch?v=a7u4zUQh1GE

Bio-Event Ready or Die! 3 Thing to do, Today.

...or at least get sick. And there are a few things you can do to prevent even that!

Biological events can be natural or intentional. The intentional kind is what you'll learn about in a weapons of mass destruction (WMD) training class and you read about in the papers. The naturally occurring kind...SARS or pandemic influenza, for example...are the kind that go on almost every year and we don't pay much attention to. One is intentional, one is natural. Both can be deadly, both have lessons to be learned. We've seen both types in the last ten years; SARS and West Nile Virus...naturally occurring, Anthrax, intentional. Again, both situations with lessons to teach. But did we learn anything?

Here we are in 2009 and many documents and memos are urging us to "get ready" for pandemic flu, H1N1 or otherwise. SARS hit the world back in 2003...what did we learn? It is way past time to be getting ready, we have to be ready. Its not as hard as you'd think and you don't need dozens of pages of plans, either.

Despite the intent, there are similarities between intentional and naturally occurring biological events that we can use to our preparedness advantage. Even the traditional WMD training can be translated to natural event readiness. Unfortunately, most of the WMD training has been a waste of time and preparedness dollars spent on big, shinny things and security cameras.

Traditional responders and the health care system is marginally better prepared today than it was on September 10, 2001. After Anthrax, after SARS.

Recently, the Centers for Disease Control and Prevention (CDC) has predicted that 40% of the United States population will become sick with 2009 H1N1 Swine Flu. That's 40% of the average population. Not to mention those in health care, emergency response, and those with risk factors. And considering the disease as it is today...not accounting for any antigenic drift. Keep in mind H5N1 or Avian Flu continues to lurk and there has been a strain of H3N2 found to be undergoing change.

By way of review, the H's and N's stand for proteins on the influenza type A virus. There are several types H's and N's that, in combination add up to tricky business for vaccine procedures. Influenza vaccine has to match the H and N combination. If not, the vaccine is not effective.

My top three things to do to Be Ready for a natural or intentional biological event:

1. Train your people on infection control and personal protective equipment (PPE) more than once a year. This is the time to develop good habits for regular cleaning and disinfection of our vehicles. Also, several studies have pointed to practice with masks...getting proper fit and know how to put them on properly...as being more important than annual fit-testing. By the way, numerous sources have also indicated that the N95 mask may be no better standard surgical masks for protection against viruses.
2. Promote the safety and health of responders and their families. That means getting appropriate vaccine or other medications available for your personnel and at-risk family. Identify those who can't get vaccinated or take medications and take steps to isolate them from infection. Numerous self-report surveys have concluded that one key to keeping your personnel coming to work in a biological event is provide for the safely of the family.
3. Prepare a Can't Go Home Plan. Stock you stations and facilities with food, water, hygiene products and ready additional bunk areas to keep personnel in-house during extended operational periods.
   

As always, I look forward to comment and debate. If you have something you'd like to add to the list...email me at mitigationjournal@gmail.com

It's Only Pepper Spray!

Just a reminder here that those non-lethal or less-than-lethal weapons can cause serious issues. Recently, an REI store had to be evacuated due to bear-spray release. Check out the details of the story here: http://www.mercurynews.com/breakingnews/ci_12939095?nclick_check=1

We've been lulled, perhaps by the name, that non-lethal weapons like pepper spray are not serious concerns.

Wrong.

Even when deployed for legitimate reasons and in proper fashion, pepper spray, mace, and other such products can cause a variety of situations. These materials stress the respiratory and cardiovascular systems and precipitate brochospasm. There is also the potential for multiple people to be exposed and in need of treatment. Saturation and prolonged skin contact can cause burns...especially in those hard to reach, moist areas of the body.

Perhaps most important for the responder; remember the need for decontamination. Victims exposed to mace or pepper spray need to be cleaned prior to being placed in a treatment area or in the back of an ambulance. Appropriate removal of outer clothing and water wash should do the trick in many cases. Understand that failing to do so puts the responder at risk of exposure to the material. And just like any other hazardous material event, no patient should be transported to a hospital without being evaluated for need for decontamination.

Lastly, don't forget the psychological impact of these situations. The "worried-well" can clog a system and deplete response resources at a faster rate than actual victims do!

Vital Signs EMS Conference

The NYS Vital Signs EMS Conference is being hosted in my home town of Rochester, NY this year! I'll be podcasting, blogging, posting to Twitter and Facebook my reports throughout the conference.

Check out the conference page here. Vital Signs is also on Twitter and Facebook.

This conference is always Top Notch. If you can join us in Rochester, October 15-18, you'll be in for a tremendous EMS experience.

Tune into Mitigation Journal Podcast for pre-conference highlights! We may even award our Mitigation Journal "Product of the Year" at this conference.

By the way, I'll be celebrating my retirement there, too.

Two Chemical Events...Many Lessons!

Once again proving the point that you don't have to wait for a terrorist attack...

The articles linked below highlight the need for all of us to be familiar with chemical event potential. As I've been saying for years, we don't have to wait for a terrorist attack with a chemical agent to utilize the knowledge/training that we have. When I say "we"...I mean traditional and non-traditional responders...EMS, fire, police, and hospital personnel.

Note to the American Fire Service...I don't buy into the idea the fire department will be too busy to support hospital decontamination/protection efforts in large-scale events. Fire departments must be involved in planning, training, and implementing protective measures at hospitals...even if only one fire officer, to help direct mutual aid companies. Hospitals are critical infrastructure.

The first two links below relate to a chemical event at refuge company. I'm getting the impression that something got mixed in the trash and reacted, releasing an unknown chemical vapor resulting in three critical patients, numerous contaminated, many transported...119 total. The underlying situation is that one hospital was ready with decon...they had drilled for such an event with the fire department. Also, EMS didn't send contaminated patients to the hospital and on-scene decon worked. These articles are preliminary, but I'm thinking this will be an interesting case to follow.

The last link is to an article that is much more disturbing; a situation using a chemical dispersal device, chlorine and an incendiary device were deployed...with intent...with strategy...to a specific target. The mainstream media is calling this a hate crime. I'm looking at it as an act of domestic terrorism.

Tune into Mitigation Journal Podcast for more details...look for edition 118 (expected release 8/5/09)

Unknown gas injuries in MA
http://www.projo.com/news/content/NEW_BEDFORD_INCIDENT_08-04-09_TQF9B2N_v17.3b42d27.html

Emergency Decon Drills Paid Off
http://www.southcoasttoday.com/apps/pbcs.dll/article?AID=/20090804/NEWS/908040324/-1/NEWSMAP

Chemical Attack Hate Crime
http://www.kold.com/Global/story.asp?S=10835087&nav=menu86_2

Putting Vaccine on Trail

Here is a great Q&A on the topic of flu vaccine from Nature News. Many of the people I talk with believe we'll have a vaccine in sufficient quantity and all we'll have to do...for H1N1 or anything else...is to go get a shot.
It's not that simple.
As this article points out, there is little if any data on how multiple flu shots will effect the immune system or how an H1N1 vaccine will interact with a seasonal flu vaccine. I still stand by my assertion that non-pharmacological interventions will be key in any biological event.

Read the full article here: http://www.nature.com/news/2009/090729/full/460562a.html

Eyes Wide Open

Individual vigilance is vital to keeping our communities safe...I'm sure there is a line, that line between paranoia and actual concern, that we should not cross. Below is a quote that I think makes sense along with a list of recommended actions from the Terror Alert Center (and it comes with a snappy anachronism, too). I also recommend that you go to your local movie rental place is rent "Arlington Road"...one of the scariest movies I've seen yet. It deals with domestic terrorism, neighbor suspicion, and several other issues we currently face. Here is a link to the wikipedia entry: http://en.wikipedia.org/wiki/Arlington_Road

“With respect to individuals and the private sector, we’re taking a much closer look at how we can support and inform our greatest asset, individual citizens, and with them the private sector. You are the ones who know if something is not right in your communities, such as a suspicious package or unusual activity,” Napolitano said.

What To Do If You Spot Suspicious Terrorist Activity

If you see suspicious behavior, do not confront the individuals involved.

Take note of the details:

S – Size (Jot down the number of people, gender, ages, and physical descriptions)

A – Activity (Describe exactly what they are doing)

L – Location (Provide exact location)

U – Uniform (Describe what they are wearing, including shoes)

T – Time (Provide date, time, and duration of activity)

E - Equipment (Describe vehicle, make, color etc., license plate, camera, guns, etc)

How to spot suspicious activity, from the National Terror Alert http://www.nationalterroralert.com/suspicious-activity/

Get toys and magazines out of the ED

A recent article in the Gazette of Ottawa, Canada and Canada.Com suggests getting objects out of emergency department waiting rooms may slow the spread of Swine Flu or H1N1. The article also notes the need for divided and separated waiting rooms in clinics and emergency departments.

I think this is a good idea and another example of non-pharmacological intervention that may reduce person to person infection. The idea is to keep people with flu symptoms greater than six feet from others...that would be two meters in Canada. Some indicate there should be fully separate waiting rooms for patients with cold/flu symptoms. The problem I see is that once symptom segregation is accomplished - and recognized by the patients - people may not report, or falsely report symptoms in order to "not sit with the flu people". It may be equally beneficial to have someone at the door handout masks and hand sanitizer to everyone.

Considering that the flu virus can survive on inanimate objects for some time, it is reasonable to remove items like magazines and toys - that would otherwise take you mind off the hours you have to wait - to prevent infection. Replacing those items with TV may be a good idea, too. Some level of decontamination for the hospital or clinic waiting room is a good idea. That is, decontamination that goes beyond mopping up the fluid releases from time to time.

I'd also recommend that health care employees not enter the waiting room when reporting to work and that patients in the waiting room are not allowed to wander other parts of the hospital (cafeteria) until they've been seen.

CDC H1N1 Vaccine Priorities

The following is quoted from the CDC update on H1N1 vaccine recommendations.

Recommended Target Groups

• Pregnant women,

• household contacts of children who are younger than 6 months of age,
• healthcare workers and emergency medical services personnel,
• children and young people between the ages of 6 months and 24 years of age, and
• nonelderly adults with underlying risk conditions or medical conditions that increase their risk for complications from influenza.

The committee also addressed the issue of what to do in the event of a vaccine shortage and how to prioritize those groups who should receive the vaccine.

"In general, under most circumstances, we really ought to promote vaccine in all of these 5 focus groups, and...picking them or prioritizing some before others would not benefit the public," Dr. Schuchat said. The CDC's estimate of the target groups totals 159 million individuals, but "there's a lot of overlap in some of the groups...[it is] probably a lower number than that," she said.

"Just in Case" Prioritization Group

However, the Advisory Committee of Immunization Practices also proposed a priority group consisting of a much smaller group, about 41 million individuals, that should be vaccinated in the event of a shortage. These include

• Pregnant women,
• household contacts of children who are younger than 6 months of age,
• healthcare workers and emergency services personnel who have direct patient contact or direct contact with infectious substances,
• children between the ages of 6 months and 4 years of age, and
• children 5 to18 years of age who have underlying risk factors that put them at greater risk for complications of influenza.

Ambulance Abuse Differs from Health Care Abuse

Here is a story out of Buffalo, NY http://www.wgrz.com/news/local/story.aspx?storyid=69029&catid=37 that was sent in Russ Hogue, a paramedic student and podcast listener. It would be easy to get caught up in the health care reform buzz, but I think you have to look a little more shallow to see the real problem. Be sure to view the video, too.

At issue here is one persons use of the 9-1-1 system for access to health care. The example might seem extreme to the EMS uninitiated citizen and may even be shocking to some. But if you've been in emergency response for more than five-minutes, you'll recognize this situation as a common one. You see, there is this guy in Buffalo who has Sickle Cell Anemia. And being legitimately ill with the disease calls 9-1-1 once, sometimes twice a day. The article and video would have you believe this is a health care reform issue...it's not. It's an access to service issue.

The fact is this this guy (and the thousands like him) have actual disease and are either not getting or not following the medical care they need. Without access to care they are left with the only solution they know will get them service on demand...call 9-1-1 and go to the emergency department. I am not going to open debate as to the legitimacy of this guys (or anyone's) needs in this forum. Well just take it at face value that he needs care.

Enter the problem: In NYS ambulances have to transport to an emergency department. Not to a clinic, not to a doctors office...to an E.D. The most expensive and inefficient model of care for non-life threatening cases. The point is made in the story; "you call, we haul", and it is in that phrase that the change needs to be made. Could this persons needs be met at a clinic? Perhaps. Could the EMTs or paramedics use communications and medical control to appropriately triage his needs? I think so. Why not let EMS stop by once a day to help this guy take his medication and verify he did so, and conduct an assessment? Could the more than $300,000 spent on one person be better spent on meeting the needs of the chronically ill, the addicted, or the mentally ill...outside the hospital? Again, I think so.

Its not abuse of health care...Sickle Cell is a painful and debilitating disease...its about abuse of a precious resource because there are no options. That is what we have to fix. And we can fix it on a local level.

This is a story that is repeated hundreds of times a day in the city and suburbs. Although the focus of this story is an African American living in an urban setting, there are plenty of examples of misuse of EMS in the suburbs that go unseen.

Special thanks to Russ Hogue for sending this in.

I await comment and debate. I'll talk about this on the next Mitigation Journal Podcast (#118 to be released 8/5/09)