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).

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.

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...

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.

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.