Consumer Level Hazardous Materials Events

Consumer Level Hazardous Materials Events...A New Way of Thinking.

When you hear "hazardous materials" what comes to mind? Toxic materials housed in some giant factory? A tanker truck overturned on a busy highway? Level 'A' protection and special response teams? If so, you're not alone. The scenes mentioned are what most people think of in terms of hazmat or toxic chemicals.

Its time to change the way we think.

I'd like to introduce you to the concept of Consumer Level Hazardous Materials (CLHM )situations. These are situations where there is a creative use or misuse of chemicals that can be found in any grocery store, do-it-yourself center, or your local drug store. CLHM's can be accidental or intentional. Accidental events, as the title implies, is the unintentional use or misuse of chemical products. Examples of unintentional CLHM events can range from simply mixing two different cleaning products; bleach and an acid of some type, to produce chlorine gas. CLHM's can also be used to carry out an intentional act such as Homemade Chemical Bombs or Chemical Assisted Suicide.

To illustrate the CLHM situations, lets look at this case study -

A homeowner is attempting to clear a clogged drain in his kitchen sink. Over the course of three days, he uses several consumer level products from his local grocery store. None of the products work. Indesparation the homeowner now visits the local builders labyrinth (big box do-it-yourself store) for something stronger...still, no results.

Finally, he pours the remainder of all the drain cleaning products into the drain at the same time. In this case, he used Liquid Plumr, Rooto Professional Drain Opener, Comet, liquid bleach, and some sulphuric acid for good measure.  The mixture reacts resulting in a severe inhalation hazard and the homeowner dies. His wife and son are overcome. Responder were called for trouble breathing and entered the structure as anyone might. They are also exposed to the fumes.

This situation actually took place.

Lets take a look at the CLHM involved and get a picture of how bad this is:

• Liquid Plumr = Sodium Hypoclorite and Lye
• Bleach and Acid (from comet) = chlorine gas
• Bleach and Ammonia = Chloramines
• Lye, an oxydizer = caustic burns, defatting/soapification injury
• Take a deep breath
  

All this from products bought in any grocery or department store.  Until next week, just imagine what we could do if we wanted to really hurt somebody...

Survival Basics for Civilians and Responders

Survival basics for your car will keep you going and improve response.

Hundreds of motorists were stranded on the New York State  Thruway this week when a tractor-trailer jackknifed blocking the road during a snowstorm. The storm eventually dumped over 2 feet of snow in the region south of Buffalo, New York. Hundreds of occupants of personal vehicles and commercial vehicles were stranded without any means of escape during the storm. Many were stranded for over 24 hours. Eventually, local fire department and police crews were able to make their way down the miles long lanes of stranded motorists to deliver extra fuel, food, and to assess the situation.

Criticism of the New York State Thruway authority has been building since the event on December 1, 2010. One of the criticisms was that the authority allowed traffic to enter the block area of roadway during the storm even though they were aware of the traffic jam. Another shortcoming has been described as the lack of a plan to deal with such emergencies and allowing the area to go on monitored and not being able to remove the truck blocking the lanes of travel.

This event has important emergency management and preparedness implications for us. First, we have to remember that no response will be successful if the public involved has not done at least some preparedness. In this case, it appears that few if any of the motorists in either private or commercial vehicles had any emergency supplies. Most complained of being cold yet did not have any spare clothing with them… some did not even appear to be dressed appropriately for the environment found in western New York this time of year. Another important thing to consider is the length of time it took traditional responders (police and local fire apartment) to get to those trapped in the snow. Most accounts indicate that it was over 12 hours before rescuers were able to make their way into the traffic jam to deliver supplies and assess the situation. One source was quoted as saying the reason for this delay was because this area of roadway is not routinely monitored by any jurisdiction.

Another frustration expressed by stranded motorists was that the responders were not able to give them any information on the situation. While this may be difficult to do, we should make every attempt to craft a generic statement that will give the civilians some information. That statement could be as simple as which radio station to tune into to get information and updates. A common misconseption is that if we inform the public of the actual situation they will panic. This is clearly a false belief. Information helps keep people calm and promotes compliance with instruction. Disaster research shows that when people are poorly informed, feel trapped, and hopeless that they begin to panic and make poor decisions.

Once again we have a local example of Optimism Bias in action. That is, it won't happen to me… if it happens to me, someone will be there to rescue me. We have to take measures to protect ourselves and be able to be self-sufficient (even rudimentary effort would help) in cases where rescue or assistance may be delayed.

Here are my tips for survival when stranded:
 
First, be sure to keep your car's fuel tank greater than half-full. Keeping your vehicles fuel tank  above half full or better will help make sure you can navigate detours if you're route is blocked. Keeping that much fuel in your vehicle will also allow you to run the engine for much longer in order to stay warm. It's important to keep in mind also that you should run the vehicle's motor only intermittently when stranded… just enough to warm up the interior every 30 to 45 minutes. On this point we should also mention the need for good ventilation in your vehicle… keeping a window cracked open to allow for fresh air and periodically checking the exhaust pipe to ensure it has not become blocked with snow or debris. Failing to do either of those could result in exposure to automobile exhaust and carbon monoxide poisoning.

Second keep a survival kit in your car. It does not have to be elaborate put should contain a few simple items. A hat, gloves, extra socks, and a pair of boots would be helpful as well as a warm blanket. It's best also to have some shelf stable snacks available. Candy bars, energy bars, and those little crackers and cheese combinations will work just fine. Along with something to eat you should try to keep something to drink in your vehicle as well.

Third, communications is key. Although we all have cellular phones these days it won't do us much good if the battery runs out. Therefore, keeping your cell phone charger (the car adapter type) in the vehicle will go a long way to letting people know where you are and getting information… especially if you were stranded for a prolonged period of time. Another important part of communications is your communications plan. Although we take traveling for granted it's important to let people know when were leaving and when we plan to arrive at our next destination. This is especially helpful when traveling during inclement weather seasons or in unfamiliar areas.

And finally, don't forget the shovel and salt. Keeping a small shovel in your vehicle may mean the difference between being stranded and effecting a self rescue. Also keeping a small bag of sand, gravel, or rock salt may be able to provide the needed traction to get yourself unstuck.

Although I recommend a shelter in place approach to surviving these situations, there may come a time where you have to decide to attempt self evacuation. The decision to leave safe shelter and walk out into a storm is not one to make lightly. You must consider your level of fitness, your clothing, your hydration and nutrition status, and the environment before attempting self rescue.



Planning and preparedness.
For those of us responsible for responding to such events there are several keys to successful operations. The first, of course, is pre-incident planning. If you have stretches of highway in your area you can find yourself dealing with hundreds, perhaps thousands, of stranded motorists in any season… from any cause. There is no excuse for not pre-planning your response with various size highway incidents involving multiple patients. Your threat assessment is a major part of the pre-planning process and should include natural as well as man-made events.

As a traditional responder you'll need to consider additional points:
First, what personnel and resources will I be able to bring to this situation and how long  will deployment take. In these large-scale events deployment of resources is often best done only after sufficient personnel, supplies, and equipment have been staged to support the effort. Although rapid triage crews may be effective, the main thrust of the response should only take place when all the pieces are together.

Secondly, you must make provisions early on for emergency incident rehabilitation. Your responders will be providing assessment and care in very difficult environmental conditions. Appropriate rehab and rotation of responders will go a long way to maximizing efficiency and extending crew viability.

Third, you'll have to make some difficult decisions as to shelter in place versus attempt evacuation. As noted above there are several conditions that have to be taken into account before people are moved from an area of relative safety into a hazard area.


This post will also appear in Mitigation Journal at www.mitigationjournal.org

What if your department had a Wikileak?

Food for thought...when your internal secrets become public.

 Would you try to stop it? Would you try to prevent your deep, dark, agency secrets from becoming public? We're all familiar with the current wiki leak situation that's causing a stir around the globe. But what if this Internet distribution of sensitive information came home to roost in your emergency service?

 How confident are you that your service is properly collecting Medicaid or Medicare dollars, tax dollars, or is correctly billing for services? How would a wiki week on your billing practices or other revenue-generating activities be seen by your community?

How about your policies and procedures? Would they stand up to public scrutiny if to be suddenly made available to your general public? What about your quality assurance practices? It would be very interesting for the public to find out about some of the well-kept secrets and emergency service surrounding the quality and delivery of that service.

So, while the world is focused on the wiki leak induced hysteria over secret documents, take a few minutes to examine your internal structure… from billing to quality assurance… and ask yourself how would we measure up if all this got out?

Would you shine, or get a shiner?

Homeland Security Threat System to Retire

Color Code Homeland Security Advisory System to Retire...Well, maybe. 

The Department of Homeland Security is considering a retirement of that ridiculous color-coded threat assessment system. According to a number of mainstream media reports, this system which has been in place since 2002, is now out dated. You may recall that this threat level color code system was instituted by a Homeland Security Presidential Directive 3 (HSPD three) and has come under scrutiny and criticism ever since. So with this system gone, we have to ask; what will replace it.

My opinion is that we should take the entire color code style assessment system and replace it with the old “test pattern” that used to see when a TV station went off the air… for those of you that remember the days when television stations actually stopped broadcasting at night.

Why do I say that? Simply because no one paid attention to the color code system since its inception. Worse than that, often times the system was misleading and failed to provide any type of useful information to the public. But while we are bashing the terrorism threat color code system lets not forget that there are other systems that are equally ignored by the public like fire alarms and public alerting sirens. These other systems have a few things in common with the color code threat level system… that common thread is: irrelevance.

 And here is why I think the Homeland security advisory system is irrelevant: it does not do what it was designed to do… it never did. And worse, those other types of alerting systems suffer the same level of "ignore it and it will go away" attitude from the public.

 While we don't know what type of system (if any) will replace this color code terrorism threat thing, I do have an opinion as to what the next generation of threat alerting system should do:

First, any warning system should engage the public with meaningful intelligence and data.  The information the system provides has to make sense to the public and provide some type of concrete information.

Second, a warning system has to define an action. It has to underscore the level of preparedness that should be taken for each level of warning… it has to call us to action. Think about the last time you were in a public place in the fire alarm went off. Perhaps you've been in a restaurant when the fire alarm system activated. When in public, how often do you see people actually leave the location when the fire alarm goes off? Often times you'll see people continue about their business while the fire alarm rings. To be effective a warning system has to change behavior.

Third, an alerting system or warning system has to inform the public when to de-escalate or stand down from a threat. Unsubstantiated and prolonged periods of increased vigilance lead to sensory burn out and decrease the efficiency and effectiveness of future warnings. A warning system has to have a defined end point–just the opposite of telling people what to do when the threat level increases or the alarm goes off, we have to tell them what we want them to do when the threat has been relieved.

In Our Boots

This PSA comes from FireRescue1.com.
It's worth a minute to watch...trouble is, were not the ones that need to see it...



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Ultrasound in Pre Hosptial Care

EMS uses of Ultrasound...an introduction. This is a quick video created with the help of my friend Peter Bonadonna. Pete is the Paramedic Program Director at Monroe Community College and leader in EMS education. In this clip, we look at uses, training, and other issues surrounding the use of Ultrasound in the pre hospital environment. We recorded the ultrasound images live (Peter was scanning himself) via internet.  This video will also appear on our "Videos" page (see top row of tabs) and on Mitigation Journal.  Join me, Matt and Peter as we discuss EMS and Ultrasound on Mitigation Journal podcast edition #198...available 11/29/2010...click the Podcast Player in the right sidebar to listen.

Trauma Assessment Tips

Five assessment tips to better trauma assessments

Tip #1: It’s okay to be distracted by traumatic injuries. It’s not okay to be fooled by them.
Traumatic injuries to the face, to the head, or open injuries to the chest, abdomen and to the extremities can certainly be distracting to your assessment. Being distracted by The devastating injury or injury pattern is a natural, human response. The paramedic cannot be fooled, no matter how devastating these injuries may appear, that they are the only injuries or the most serious injuries the patient has. The point is that no matter what is ripped open sticking out or impaled into the patient, the paramedic must fully assess the patient, mechanism of injury, and the surroundings. Bottom Line - You can be distracted...just don’t be fooled: as long as momentary distraction does not lead to being fooled by a nasty looking, less serious injury

Tip #2: What lies beneath? Anatomy!
Understanding of anatomy in relation to injuries, injury patterns and mechanism of injury. It’s not enough to simply observe and injury from the surface. The paramedic must understand the implication of that injury on the tissues, structures and, organs that lay beneath. What appears to be a superficial soft tissue injury on the outside can have substantial structural/organ injury underneath. Only by possessing a solid foundational understanding of anatomy will the paramedic be able to relate exterior body damage to where the true injury is… that is to the structure, organ, or system that’s impacted by the trauma. Bottom Line: Think about what lies beneath...Anatomy lies beneath and your understanding of anatomy will lead to better treatment.

Tip #3: Assess all critical areas...even if they're not injured.

No matter what the injury, injury pattern or MOI is, always assess the head, neck, chest, abdomen, pelvis, and long bones. These areas often go unchecked one-way focus on a single area of the body. The point here is, that no matter where the injury is all of these areas have to be assessed… even if they appear on injured. Note on the neck...we spend a lot of time worrying about c-spine injuries and trauma to the posterior neck...thats good thing. But, we cant ignore the injuries to the lateral and anterior neck...vessels and airway. Bottom Line: Always assess the critical areas...head, neck, chest, abdomen, pelvis, and long bones...even if they’re seemingly uninjured.

Tip #4: Change you view...you'll get a better look!
We too often assess trauma patients while they’re supine starring straight down on them. After all, that's how you were doing it in practice in EMT class...To be effective, change your point of view. Get down on the patients level and examine from the side, survey the patient from a short distance, observe a few breaths while kneeling at the patients feet or head. Bottom Line: Change your view...move around and look at the patient from various views and from a distance...get as much of the picture as you can before you leave...you're the only one who is going to be able to do this!

Tip #5: Assess any trauma patient for hypothermia and any hypothermic patient for trauma. Think: Trauma=hypothermia, hypothermia=trauma. Trauma patients may loose the ability to thermoregulate and have a difficult time keeping warm...especially if there is uncontrolled internal or external hemorrhage. Hypothermic patients may not be able to feel the pain of an injury or have the mental ability to comprehend the injury and report it. Bottom Line: Trauma and hypothermia...they go hand in hand. Any trauma patient should be assessed for hypothermia and any hypothermia patient should be assessed for trauma.

Cooking Safety from the USFA

Cooking Safety...Don't let fire or injury put your holiday to a bad end.

We could all use a good reminder about fire safety in the kitchen. Especially us responders. The United States Fire Administration has a few good tips for use to keep in mind...at home and away.

According to the U.S. Fire Administration:

Watch What You Heat

• The leading cause of fires in the kitchen is unattended cooking.

• Stay in the kitchen when you are frying, grilling, or broiling food. If you leave the kitchen for even a short period of time, turn off the stove.

• If you are simmering, baking, roasting, or boiling food, check it regularly, remain in the home while food is cooking, and use a timer to remind you that you're cooking.

• Stay alert! To prevent cooking fires, you have to be alert. You won't be if you are sleepy, have been drinking alcohol, or have taken medicine that makes you drowsy.

• Plug microwave ovens and other cooking appliances directly into an outlet. Never use an extension cord for a cooking appliance, as it can overload the circuit and cause a fire.

Keep Things That Can Catch Fire and Heat Sources Apart

• Keep anything that can catch fire - potholders, oven mitts, wooden utensils, paper or plastic bags, food packaging, towels, or curtains - away from your stovetop.

• Keep the stovetop, burners, and oven clean.

• Keep pets off cooking surfaces and nearby countertops to prevent them from knocking things onto the burner.

• Wear short, close-fitting or tightly rolled sleeves when cooking. Loose clothing can dangle onto stove burners and catch fire if it comes into contact with a gas flame or electric burner.

Short Steps to Better Planning

 Steps to better Pre-Incident Planning

Pre-incident planning is known by many terms: emergency, contingency, disaster, crisis management planning all say the same thing. Regardless of the type of term you apply to the situation Pre-incident planning is essential for successfully minimizing the effects of crisis and disaster situations in any community. We've all heard the old adage “failing to plan is, planning to fail” . But how many of us put enough time into our pre-incident planning to do all we can to prevent “failing”? Here are some simple steps… a few things to think about… when doing your pre-incident planning:

What are you planning for? 

Pre-incident plans are valuable for any crisis situation or emergency. That is, anything that happens suddenly–disrupts daily activities, jeopardizes citizens and the economy, and of course, demands your immediate attention. The pre-incident phase is exactly as it sounds; planning before the situation happens. In order to do this effectively you have to know or at least be able to predict the possibilities that your community may face. You make these predictions based on your hazard assessment and risk assessment. Your pre-incident plans also become an important tool for successful training activities later on.

Planning Overview

Pre incident planning has a single yet complicated goal; that is to minimize effects of any given situation. again, we have to assess the threat, the vulnerability, and the potential risk of emergency or crisis. Keep in mind that there is no one single plan or pre-incident plan for every community. Also, your pre-incident plan is only as good is the data you build the plant on that is, you only get out what you put in.
Remember, most pre-incident plans don't deal with normal or everyday situations… and routine policies, procedures, standard operating guidelines may not apply in certain crisis situations. Therefore it becomes important to develop policies procedures and standard operating guidelines for disaster situations that go along (hand-in-hand) with your pre-incident disaster plans.

Planning expected outcomes

your pre-incident planning process will help you ensure that appropriate levels of personnel supplies and equipment are available at times of disaster or crisis. Your planning process will also add your organizational structure and make sure the structure is in place and updated. Another major benefit of the pre-incident planning process is the ability to make recommendations in through the audit process; ensure that these recommendations are implemented. Pre-incident plans can also validate your risk assessment and hazard analysis by bringing all the data into one place.

Pitfalls in planning

 Above all else you must avoid Optimism Bias in your planning process. As said earlier, your plans are only as good as the data you used to build them. Along with that you have to evaluate your ability to implement the plan. Again, you have to be realistic and don't assume you have all the capabilities or resources you'd like. Emergency and disaster case studies throughout history underscore the need for pre-incident planning that emphasizes delivery of a sufficient operation over a standard operation.

Carbon Monoxide Background

Carbon monoxide exposure is one of the most common poisonings in the United States.  Although we often think of CO is a “winter time” problem, carbon monoxide exposure and poisonings can take place at any time of the year. Carbon monoxide exposure incidents tend to increase during the winter months we can also see an increase in these events at any time when a population uses auxiliary heating or power generating equipment; such as seen during major power failures or other natural events.

Carbon monoxide is known as the “Great Imitator” and can mimic a variety of other medical problems such as cold and flu. In fact a study done in 2006 indicated that one in four patients presenting to a hospital with cold and flu symptoms actually had carbon monoxide exposure. Carbon monoxide has also been linked to cardiac events after chronic exposure. Failure to recognize the potential of carbon monoxide exposure can lead to a deadly missed diagnosis. In some cases, carbon monoxide exposure and poisoning has been mistaken for substance abuse.

Common signs and symptoms of carbon monoxide exposure include headache, drowsiness, confusion, tachycardia. Continued exposure to carbon monoxide also lead to impaired thinking and sensory perception.  These effects of carbon monoxide reduce the ability of a person to recognize a hazard or self rescue from an environment.

Symptoms of carbon monoxide differ from person to person and level of exposure. Mild exposures (15 to 20% COHb) symptoms may include headache, nausea, vomiting, dizziness, and blurred vision. Moderate exposure is defined as 21 to 40% COHb and may present as confusion, syncope, chest pain, dyspnea, and general weakness. The severe exposure (41 to 59% COHb) may result in myocardial ischemia, rhythm disturbances seizures, and respiratory as well as cardiac arrest. Exposures to levels of carbon monoxide greater than 60% are usually considered fatal. It's important to note that CO exposure and COHb  levels do not have the same symptoms with all patients.

 Carbon monoxide alarm technology is reliable and found in many residential and commercial structures. In general, there are two types of carbon monoxide detection equipment. The first type is known is a biomimetic style detector. This type of detector uses a synthetic hemoglobin that reacts to acute and chronic carbon monoxide. Biomimetic style detectors are very common and usually resemble smoke alarms or are manufactured in combination with a smoke alarm.  These units typically have a module sensor built-in the battery compartment. Some of the most common manufacturers estimate a module life of two years and a total unit life of 10 years. This type of carbon monoxide detector can be influenced greatly by exposure to cooking products.
Another style of carbon monoxide alarm is the semiconductor style. this style of alarm uses an electronic sensor to measure carbon monoxide  and is typically plugged into a power outlet or other power supply. The general recommendation is that the unit be replaced every 5 to 10 years. Most carbon monoxide alarms activate at an estimated 10% of carboxylhemoglobin or 100 ppm of carbon monoxide.

A few notes on Type A flu

In this post will explore several areas of seasonal influenza. We'll take a look at what influenza is and is not, what causes it, and the various types. We'll also discuss the normal impact of influenza and the potential extraordinary impact of influenza.

1. Terminology.
The first thing in the need to know about influenza is the terminology… and we've come to recognize quite a bit of terminology surrounding the flu. Seasonal flu (sometimes called the common flu) is exactly what it sounds like; that strain of flu that circulates a given area every year. Avian flu (highly pathologic avian influenza) is the name given to a strain of flu that mainly circulates in Asia impacting various bird species with limited transmission to humans. Swine flu on the other hand, is the name given to a strain of influenza that emerged from South America–Mexico–in late 2008. This strain of influenza was particularly troublesome because it seemed to impact otherwise healthy people in a very dramatic way. And lastly, the term pandemic. A pandemic has been seen by the media as a term that indicates large numbers of deaths from disease. Although throughout history this is often the case, a pandemic is not an automatic term for mass fatalities. The term pandemic simply means the disease has spread around the globe and impacted many areas of population.

2. Types of Influenza.

There are several types of influenza viruses… so more concerned about, others, not so much. Influenza virus belongs to the category of diseases known as Orthomyxoviruses.   The three types of flu are Type  A, Type B,  and Type C. Type A influenza is known as a multi-host pathogen infecting both humans, swine, and birds. This is the most virulent  group and is classified by its surface antigens into subtypes. It is these subtypes that make up the H and N that we hear so much about on the news. H stands for hemagglutinin and N indicates neurominidase.  Both of these are surface proteins on the virus that allow the virus to get into a host cell, reproduce, and then escape. Remember, viruses are parasites and need to have a host to survive. There are 15 different types of H's and nine types of N's giving us a total of 135 potential combinations of type A influenza. Type B influenza is seen mostly in humans and although it's very common it is much less severe than Type A influenza. Epidemics involving type B influenza occur much less often than those involving Type A. It's important to note here that human seasonal flu vaccine includes two strains of Type a and one strain of Type B protection. Given that there are 135 potential type a influenza combinations and only two are included in the seasonal flu vaccine, indicates why we have years when the seasonal flu vaccine is less effective than others… that is, scientists have to guess which two strains of influenza should be included in the vaccine. Type C influenza infects humans and swine and has a completely different pattern of surface proteins. Normally Type C presents with rare occurrences and has mild or no symptoms. In fact, by age 15 most people have antibodies against Type C influenza.

3. Impact.

During an average flu season in the United States there are 35,000 to 45,000 deaths attributed to seasonal flu. The hardest hit by seasonal flu include those with severe medical conditions,  impaired immune systems, or extremes of age… young or old. Epidemics tend to occur in the winter months with peaks of hospitalization and death related influenza during this time.



Further Consideration.
Prevention of transmission of flu sometimes takes on a life of its own. We need to remember that the flu virus is one of the most infectious pathogens we know of and that type a influenza is prone to subtle changes in its structure that make it a challenge to our immune systems year after year. It's also important to remember that droplets aerosols and direct contact can spread influenza.  The flu virus can remain active on a contaminated surface or item for up to 48 hours.

We'll discuss prevention strategies, P. P. E., and pharmacology versus non-pharmacology strategies in our Medical/Biological posting next week.

Re-Introducing LOCATE.
(Originally posted December 28, 2005 in Mitigation Journal)


LOCATE is a system to guide the EMS provider on assessing the patient, the scene, and as a decision making aid.  

It seems simple enough; before you can provide treatment and transportation you have to find the person in need of your service. Actually finding the patient is only part of the job. Providers of emergency medical service (EMS) at all levels must prepare themselves prior to reaching the scene or patient for a variety of potential actions and outcomes. Waiting to arrive on-scene to develop a care plan or mental review of the potential scenarios places both provider and patient at a disadvantage. The fire services use the process of pre-incident planning and size-up to prepare firefighters for potential needs or dangers of any given situation. Pre-incident planning can be used to anticipate additional resources and special needs of a situation. Emergency medical services can and should do the same.

EMS and fire service text are filled with acronyms that have become part of daily conversation. Acronyms are memory aids that range from the simple ABCDE’s that remind us of the basics of patient assessment to SLUDGE as a memory jog for organo-phosphate exposure symptoms. In this installment we will introduce the acronym LOCATE as a means of assessing not only the patient, but the scene and patient needs as a whole.

Location. In the real estate business location is everything and so it is for EMS. What do we as EMS providers need to know about the location we are responding to in order to accomplish our goals and objectives? What can we tell about a situation before we enter the environment? Let’s consider the following questions:
What type of occupancy are we at?
How well do you know your response district?
What geographical special needs or special hazards have to be considered?

Response to group homes, rehabilitation centers, and senior living centers demand special attention by the responder. The structure itself can yield important clues as to the special needs of those inside and impact your options. Calls to medical facilities and clinics add yet another dimension to your response such as dealing with medical professionals and therapy-in-progress. The key to situational assessment is to anticipate, not stereotype.

Obstacles such as ramps, lifts and the presence of customized vehicles should prepare you for the special needs of the person inside the location and warn you about special hazards of getting in and out with all your equipment (including your lumbar spine) safe and intact. Commercial buildings and public places offer some challenges that are not as obvious. Small elevators may prevent your crew from arriving or returning together. Who will stay with the patient and what vital equipment will you keep with you? In public places on-lookers can become an obstacle. Patient dignity and privacy in the public venue must be addressed differently than in a private residence in effort to preserve the comfort and cooperation of the patient during treatment. The responder must also consider the presence of security video surveillance, camera phones, and other digital recorders. Responders must anticipate that a majority of the public owns some type of digital recording device and consider the impact these devices may have on privacy and care.

Conditions such as post medical conditions are a routine part of EMS assessment. Now consider the living conditions you find the patient in. By being observant to living conditions; EMS providers have a unique opportunity not available to others in the health care system. Situational awareness can yield important clues that must be relayed and addressed by the health care system. The GEMS diamond used in Geriatric Education for Emergency Medical Services is a good example. The EMS provider must again ask themselves a number of questions:
Are the patient, the family, and the care givers able to carry our daily activities?
Has there been a change in how the patient cares for themselves? If so, is the cause of the change medical in nature, such as in the setting of CVA/TIA, or social a aspect such as the loss of a spouse or other supporting person?
Family support or lack thereof plays an important role in every situation. The EMS provider must not only find medications but assess if the patient is physically and mentally able to take them.

The presence or absence of Accessories is closely related to conditions and considers physical items.
Is the patient using the cane or walker? If not, is lack of use or lack of the device a cause of falls and injuries?
Has the patients’ ability to use such a device changed and are they no longer able to use their accessories?
Other accessories that should be assessed include home oxygen units, air-powered nebulizers, ventilators, hospital beds and lifts, commodes, and orthopedic devices. The presence of basic medical supplies can also indicate the level of care a person should receive on a daily basis. The presence of many other medical accessories may also indicate the need for another and arguably more important need; and educated caregiver in the home. There is no substitute for the love and compassion provided by a family in the home-care situation. EMS providers must harness the educated family or caregiver as a precious piece of the assessment puzzle. Failure to do so can result in the loss of valuable information, inaccurate diagnosis and treatment, and poor public relations.

Treatment is what you do for the patient. Your assessment should lead to a working diagnosis list and guide your treatment. Treatment provided by previous EMS responses and discharge paperwork from previous emergency department visits is also important. We all have a list of frequent users of our services but, do we communicate what we’ve done to help these people? We shouldn’t have to reinvent treatment each time we see a previously treated patient. Multiple requests for “lift assists” for example, may indicate subtle changes in patient condition or change in social status indicating the need for augmented services. The key is to anticipate, not stereotype.

Evaluate the need for Education and Extra help. The EMS provider has the ability to see the patient in their surroundings as they are every day. EMS should also be knowledgeable of patient education topics pertaining to safety and well-being, social programs, and signs of abuse. Consider the following questions:
Are you aware of the signs of elder, child, or domestic abuse? If so, what are your reporting requirements?
Are you aware of the community programs that may be of benefit to those in crisis?
Being able to provide information on social programs and domestic support are vital for the EMS provider.
Evaluation must begin prior to response. Weather conditions and time of day must also play a role here. Other events; natural disasters and intentional events locally, nationally, and internationally must also be taken into account. It is here that you have the opportunity to help any member of the public prepare for crisis…even those that are not medically related.

Summary
The ability to assess the scene and the patient before you arrive is a skill learned with experience. The acronym LOCATE is:
Location
Obstacles
Conditions
Accessories
Treatment
Evaluate, Educate, Extra help
Use LOCATE to guide your patient care plans on-route, on-scene, and after care to build your assessment of the patient as whole. Pre-planning and size-up are important aspects of patient care; if you LOCATE each patient you will be better able to keep these points and patient care in focus.