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.