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.

Are You Ready for an Active Shooter?

Co-posted on Mitigation Journal

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.

New Protocols and You

MLREMS Publishes 2012 Protocols

The Monroe-Livingston Regioal EMS (MLREMS) Standards of Care have been published by our local Program Agency. There are significant changes being addressed with an equally significant training initiative. The training for this update incorporates on-line video and testing. 

The training materials and protocols can be found at www.mlrems.org.

All providers in the MLREMS system must begin using the 2012 standards by April 30, 2010. They are, however, live now - meaning once the training is completed, they may be used. 

Downloads page for MLREMS documents

Populous Demandous

 ProRepsonder re-launch by popular demand

ProRepsonder was created to deliver content relevant for the traditional response groups. News, commentary, and training information are at the core of this endeavor.

Within just a few postings, ProRresponder built a loyal reader base since November, 2010.  I've been amazed at the number of visits and how they continue to grow. The trickle of emails has turned into a steady flow of requests asking if we could please continue reporting and training through this forum. Until now, I've had to tell these folks that, as much as I'd like to keep ProRepsonder going, our other projects - Mitigation Journal and Occasional Vagabond - reach thousands each month and demand quite a bit of time. We simply don't have the hours in the day. Well, that's all changing.

Many Mitigation Journal followers are active in field work of some type - emergency management, fire service, and prehospital care and have asked that we focus more on EMS. We're listening and I'm happy to say that we are going to continue creating content here on ProRepsonder. Our focus will remain traditional response groups with a special eye toward Emergency Medical Service in Rochester, NY.

In the coming days we'll be posting original content weekly in the form of text content and training material. There will be local news with my commentary added, too. Guest posts will also be welcome.

So bookmark us, sit back, and enjoy the updated content and changes to the site. We look forward to being there with you.

 I invite your participation as we continue to grow this site. Please feel free to email me or call 585-672-7844. You can follow me on Facebook (search rick russotti) and on Twitter @rickrussotti. I also hope you'll continue with the all-hazards approach to response by following Mitigation Journal.