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?

 

Schools fail at biologic events

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.

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).

WNV: hype or example of emerging infectious disease

Special podcast from Mitigation Journal with the MedicCast and This Week in Virology

Read Mitigation Journal

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 Rick Russotti (Mitigation Journal), 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)
Mitigation Journal
This Week in Virology
MedicCast

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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.

When EMS could make a difference but doesn't.

Prenotification as important as EMS treatment

Early hospital notification from EMS could speed the care of stroke patients, yet in one third of stroke situations, there was no prenotification. Those are the findings from 2 published studies looking at the treatment of acute ischemic stroke patients.

Alerting the hospital of ischemic stroke patients allows for appropriate teams to be assembled and speeds evaluation, imaging and treatment such as tPA.

Early prenotification in these situations is based on recognition of the problem. The EMS provider has to be able to identify even the subtle indications of an ischemic stroke event. Abnormal findings in mental status, cranial nerve exam, and motor function are warnings signs of stroke that should be transmitted to the receiving facility as soon as possible.

Although patient history is vital in these situations, remaining on scene for a prolonged period of time to obtain a history or detailed exam may not benefit the patient. Keep it simple and focus on:

• patient info: when was the patient last seen as normal by family/caregiver?
• obtain vital signs including blood glucose. 
• history points: any history of trauma? Of headache?

Continual assessment is required as symptoms may evolve after the initial exam is conducted. Its estimated that 80% of strokes are ischemic - resulting from an occluded cerebral artery as a result of thromboembolism. Clot formation can come from the heart or another blood vessel.

The goal of any EMS system should be to identify and prioritize patient needs, treating accordingly. Early prenotification to the appropriate receiving facility has to fit into this line of treatment. The question then becomes one of identifying why prenotification is not taking place as often as it should. Are signs and symptoms of stroke not being recognized in one-third of stroke patients? I find that hard to believe. Or, is technology the problem. The modes of communication between ambulance crews and hospital workers varies from location to location. Perhaps one way of correcting this situation is to improve the means of communication and information delivery.

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

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

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. 

Chemcials in Suicide

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: The Next 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.

EMS and Y2K: Planning like its 1999

Considering the Next Y2K
Coposted on Mitigation Journal

"No phone, no lights no motor cars,
Not a single luxury,
Like Robinson Crusoe,
As primitive as can be."
-the ballad of Gilligan's Island, G. Wyle/S. Schwartz. source: http://www.lyricsondemand.com/tvthemes/gilligansislandlyrics.html

Do you remember Y2K?
That "thing" commonly known as the Millennial Bug that was supposed to happen when the calendar changed from 1999 to the New Melania. What would happen when computer systems that were designed around a two digit date encountered the year 2000? Who knew? Computers were going to stop working, banks would loose all your money, and business systems throughout the globe would cease to function.

Amid the hype there was preparedness  
Information Technology exploded into a fury of activity that lasted for years and spent billions of dollars. The Y2K threat was taken seriously even though the impact could only be estimated. Governments and small businesses alike mobilized ahead of the threat to reinforce computer systems and upgrade technology. Fearing some form of cataclysmic event, civilians also took precautions and readied themselves for the December 31 deadline.

And nothing happened. Did nothing happen because nothing was ever going to happen; or, did nothing happen because there was a unified preparedness effort?

Thinking of the Y2K situation made me think about how we would respond to a threat on our technology systems and internet today. We're in a far different world today than we were in 1999. The use of technology has increased exponentially in the last few years and certainly over the last decade. Today, automated systems control everything from finance to water treatment facilities. We're also in a far different world concerning preparedness. How would we do with a Y2K threat today?

It's not just business
We're used to swiping a card rather than paying in cash for everything from fast food to fuel. We've become accustomed to (if not demanding) instant access to our information and entertainment and we're accessing that content on the go via Smartphones, tablets, and other handheld devices. We rely on internet communication for telephone, email, and other communication.

Is there a threat on the horizon? 
Would we embrace preparedness efforts with the same level of enthusiasm today as we did in 1999? Would we endorse the expenditures in terms of time and money to make preemptive changes? If today's climate of complacency is any indication...we'd do nothing until the PlayStation stopped working or the iPhone wouldn't connect...we'd be too late. This Nike spoof of Y2K just might capture the level of awareness. Then what?

"When nothing happens, nothing happens...nobody wants to pay when nothing happens."

Today's Threats
Y2K came with substantial warning time. Time to analyze, harden, prepare. Information technology professionals had about two years foresight to begin working on the issues once the Y2K threat potential was identified.

Would we have any Y2K-style warning today? Would we take the warning seriously?

Magnify the Y2K threat beyond the inconvenience of losing your email and social media for a few days. Computer viruses, cyber attack, infrastructure failure, and the potential of electromagnetic pulse (EMP) top the list of threats. These critical threats will almost certainly come without warning; turning us back to analog for weeks if not months or years. We recently discussed the issue and potentials of a cyber attack and our lack of ability to detect it until long after it has happened. With all things considered, the biggest threat we may face will be our own indifference to the potential. Remember, it can't happen here. Can it?

How far have we come since 1999? View the video Y2K: Tensions in the Last Days of the 1900's and answer that yourself.

Commerce, Communication, Infrastructure
Damage to communications systems and commerce may be immediately felt by government and civilian populations.  Managing life without our cellular communications, chat, text messages, FaceTime, and social media may be difficult...extraordinarily difficult. The real punch of a Y2K/cyber attack will be rendering our critical infrastructure useless. Rather than crippling a water pump in a processing station, lets turn off the United States power grid. No access to your money, no use of credit/debit cards. Lack power for a prolonged period of time would begin a cascade of system failures that would include loss of domestic water and fuel supplies. Civil unrest and potential for violence should be considered. Suddenly, $4.00/gallon gas seems like a bargain. How about water for only $10.00/gallon...cash only.

No Panic, Please
The intent of this post is raise awareness and assess threats. Cyber threat is not a Cassandra Paradox, it is a reality. What to do? Simple. Acknowledge the threat potentials and employ your standard preparedness strategy...and don't, repeat don't, take anything you see on Doomsday Preppers seriously...that's a topic of another post.

EMS a Key to Crisis Standards of Care

Standard to Sufficiency: IOM Framework Paves the Way 
Coposted on Mitigation Journal

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

Chemical Suicide Sickens Paramedics

Latest Chemical Suicide Attempt Prompts HazMat Response
Coposted on Mitigation Journal

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

Bath Salts, PumpIt!

A new "Ivory Wave" of synthetic drugs

Video from Mitigation Journal

PumpIt!, Ivory Wave, and Bath Salts are just a few of the label names of a 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 Salt 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 reported 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

Soft Targets Attract Active Shooter Events

Co-Posted at Mitigation Journal

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.