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The Committee, following the usual NFPA format, will ultimately consist of 30 members divided evenly into 10 representatives from manufacturers, 10 from users, and 10 from regulators. The operant words, "open" and "fair" define the NFPA process (http://www.nfpa.org/). What happened at the first meeting? Well, imagine a couple dozen folks from the previously mentioned groups sitting in a room together - any room, anywhere. You could cut the tension with a knife, err - make that a chainsaw. So there were a few presentations: ambulance crash data (or lack thereof), history of federal government ambulance specifications, development process of the NFPA 1901 standard, resources available from NFPA, and the standards development process. Lunchtime.
First problem: define ambulance. Couldn't do it. Created a subcommittee. Next question: what's out there already? Probably the most popular are the federal KKK-A-1822 standard and the National Truck Equipment Association (NTEA) Ambulance Manufacturers Division (AMD) standard (2007 version). Why reinvent the wheel? Another subcommittee. Merge KKK and AMD with the NFPA 1901 format and let's see where the cards lie.
Not a bad start. In fact, the initial nervousness that some cockamamie standard was sure to be concocted that would blow the socks off the EMS world quite obviously was not on any member's radar. Phew! People actually seemed to leave reassured that consensus is within reach, maybe more within reach than it was for writing fire apparatus design standards. There were common goals amongst the players and now a sense of purpose that will lend itself to a deliberate path. The two subcommittees will report by the end of August, probably on a phone conference. Then the real work will begin. Timeline? Anyone's guess. Don't hold your breath. You'll be cyanotic.
Fire Engineering magazine
(and NFPA Ambulance Committee member)
posted by Mike McEvoy
6/17/2009 11:04:00 PM
“In other fighting, one marine was killed in the Al Anbar providence after a humvee he was riding in hit an IED.” That was what I read in the AP news piece. It was one line of several paragraphs that summed up the days casualties in Iraq during another day of the war that has gone on for three years now. These reports are so common, most people do not even read them, or listen to the 30 second blurb that follows, “Another day of violence in Iraq where…” on the evening news. For us, the reality is much different, a horrific drama that is played out in the field, in forward surgery tents, and combat support hospitals every single day.
Today the warning came over the radio, “urgent litter coming in by ground” I immediately respond to the ETR where the buzz is usually in full swing. “IED, Marines” is all the ETR nurse said as I walked in. Damn, I thought. One day left – all I asked God for was no more marines with one-day left on my tour. The hospital staff went into full swing – these people are at the end of a yearlong deployment here, they are experienced, hardened, and cool under pressure. The activity was programmed and efficient. I took my position at the head of bed number one, put my head down and waited.
Within a few minutes the litter team burst into the ETR with the first patient. I could see his arms dangling off the stretcher with bone exposed, and I immediately knew that this was going to be a bad one. When the litter was pulled up aside the bed, I saw the full extent of what I was up against. Driver, I thought to myself. The drivers always seem to get the full force of the IED. There is a pungent smell of gasoline and burned flesh. My first order of business was to remove the IBA before we move him over; to do this we have to sit him up in order to pull the arms through the IBA sleeves. When we did, his arms, broken in several places on each side, flopped around like a puppet. As we moved him over, I tried to ignore the massive tissue destruction of his legs, and focus on potential life threatening chest and abdomen. He was moaning, actually a good sign, the brain was still getting blood flow. Anesthesia moved to intubate him, as the emergency medicine physician started the primary survey. Nurses started lines, lab was there to bring blood, medics held pressure on bleeding wounds, all in a dance that has been repeated so many times before.
The other patients began to file in, eventually filling the ETR. One soldier in a bed next to ours was calling out to my patient, ignoring his own gaping wounds “Your going be okay man, hang in there.” I began to focus on the problem and my plan. Both legs had massive tissue destruction. The left thigh was torn apart and burned with a tourniquet at the groin. The right leg was mangled below the knee with a tourniquet above that. There was a neck wound that wasn’t bleeding and shrapnel to the face. Both arms had multiple levels of open fractures. The pulse was weak and the blood pressure was barely readable. We hung blood immediately. The chest x-ray did not show any thoracic injury. We shot an abdominal film to look for shrapnel that may have gone into the belly – none. As we moved to the OR the hospital commander stopped me to ask if he was going to make it. I told him that I was worried that once we start to resuscitate him, the bleeding would become even worse, and I didn’t know if he would make it. His head dropped as he walked back to the chaos of the ETR.
In the operating room we started by getting control of the external bleeding of the legs. There was blood coming from everywhere; bright red arterial blood, dark blue venous blood, and areas where the two swirled together in pools between the flesh. Two orthopedic surgeons and I worked frantically to get control of the bleeding, which as predicted, became worse as we started to resuscitate him. Anesthesia was struggling to keep a blood pressure, infusing unit after unit of packed red blood cells, and plasma. I was having trouble finding the source of some bleeding high on the thigh, and I was going deeper and deeper into the groin to track down the source. Suddenly my hand broke into a space, and a gush of blood came out. I realized that I was in the retroperitoneal space and the bleeding was coming from here. This was the worse case scenario. Bleeding from this location is the toughest area in the body to control. The packing did nothing; blood flowed from the wound in a constant stream. We opened the abdominal cavity and clamped the arteries that feed the pelvis, but it didn’t help. Bleeding from this area is almost always from large veins that cannot be controlled with sutures or arterial control. We packed as tight as we could, and then put a sheet around the pelvis to pull the bones together in an attempt to tamponade the bleeding, but it was not enough. His heart went into a lethal arrhythmia. We shocked him, and pumped epinephrine into his blood stream. After a few minutes, his heart stopped for the last time.
The marine was dead.
There was an immediate silence in the operating room as soon as I announced the time of death. Most of the staff had tears running down their faces; this was a long year for them with so many of these kids dying in this room. I could not physically move for several minutes. I looked at this young kid, a child, and I apologized to him for not being skillful enough to save him. As a trauma surgeon every death I have is painful, every one takes a little out of me. Loosing these kids here in Iraq rips a hole through my soul so large that it hard for me to continue breathing. After a few minutes, I collected myself and began to direct the care for his final journey home. We closed what we could of the wounds, and wrapped the ones we couldn’t get together. We washed all of the dirt and oil off his skin, combed his hair and washed his face. He was transferred to a litter and brought to a private enclosed room where we placed him inside a heavy black body bag. The body was draped with the American flag and a guard was posted. The chaplain gathered some of the providers and we said prayers over the body.
There was, and always is, a palpable grief that comes over the entire staff when we loose an American solider. Everyone is affected, and everyone deals with it in a different way. For me, this is not an objective depressing thing to be a part of; it is very, very personal. I was the surgeon who couldn’t save him. For me the grief is intolerable. I become the focus of the morning for the staff– people come and give me a hug. They ask me if I am okay, they pray for me. I appreciate it and hate it at the same time. Often my misery turns into anger. Sometimes I become angry with God for allowing this to happen. I just want the whole thing to be over, and all of these kids to go home to their families and live long lives. I have seen so many soldiers and marines die here; I just want it all to end.
As I made my way out of the hospital, I saw the marine unit gathered together. Two humvees where parked, and weapons were leaning against the vehicle. I notice this immediately because a marine is never without his weapon, they would never be stacked like that. These were the weapons of all the marines injured in the latest attack. I spoke with the first sergeant, the father figure of a marine unit. I know him well, we have lost several of his marines and had many more injured and treated here. We arrange for his buddies to come in and say goodbye, something that I cannot even bear to watch. After a time of reflection, the unit gathers the equipment and prepares to go out again that night. This is some of the raw courage that I talk about, the ability to loose a friend in battle and go right back into the fight. I love every single one of them.
The body was eventually taken to the LZ and loaded into a helicopter with some of his buddies as escorts. He is taken to BIAP where mortuary affairs prepared the body for transport home. A friend of mine was at BIAP when the body was loaded onto the C-130. All activity on the tarmac stops when the casket is brought onto the airstrip. All personnel in the area stop what they are doing and attend a 45-minute ceremony on the airstrip. They tell me that this happens twice to three times a day, but everyone takes time out to attend the ceremonies. Soldiers manifested in these flights are going home or on R&R, and as anxious they are to leave, they all take the time to honor the marine. An honor guard then brings the flag draped casket onto the aircraft with full military honors. The casket is situated in the center of the aircraft with nothing placed on either side or directly in front or back. Personnel then enter the aircraft and accompany the marine to Kuwait. In Kuwait the casket is removed first, again with a full honor guard. The marine will be brought to Dover Air Force Base in Delaware, and then eventually home and to his final resting place.
If I could say something to this Marine’s parents it would be this: I am so sorry that you have lost your son. We, above everyone else, know that he was a true American hero. I want you to know that the Marines, medics, doctors, nurses and of the 344th CSH did everything possible to save him. I want you to know that I personally did everything that I could, and that I am sorry that it wasn’t enough. I want you to know that although we never knew your son, we loved him. I want you to know that although he lost his life, we preserved his dignity after death. We held his hand when he died and prayed for his soul and for God to give you strength. I want you to know that he had great friends who cared deeply for him and that they were also here when he died. He was never alone for his journey back to you. I also want you to know that I will never forget your son, and that I will pray for him and all of the children lost in this war.
IED - improvised explosive device
ETR - emergency treatment room
LZ – landing zone
BIAP – Baghdad international airport
IBA – individual body armor
R&R – rest and relaxation
CSH – combat support hospital
John P. Pryor, MD was a trauma surgeon at the hospital of the University of Pennsylvania and a Major in the United States Army Reserve Medical Corps. He was the general/trauma surgeon for the 344th Combat Support Hospital in Abu Ghraib, Iraq. John was killed on Christmas day 2008 during his second tour in Iraq.
Posted by Mike McEvoy
Fire Engineering magazine
posted by Mike McEvoy
5/22/2009 05:20:00 PM
Investigation of the 2009 influenza A (H1N1) virus, although genetically linked to pigs, has not been found in swine. Pigs do not appear to be involved in the ongoing spread of infections. In an effort to leave the poor pigs alone, the World Health Organization asked that we replace the term “swine flu” with H1N1 influenza A. Hopefully, Egypt got the memo. Joe “shoot from the lips” Biden certainly got a memo from his boss, President Obama, as the White House went into damage control mode. And the Dallas ED doc has no doubt been deluged by calls from his more sensible colleagues. A Harvard School of Public Health study reveals the extent of the panic: full 46% of Americans believe they or someone in their family will get sick from the H1N1 flu within the next 12 months!
Here’s what you need to do to step up to the plate and put the smack down on swine flu idiocy. The public wants answers. Fire/EMS providers want information. Information overload and panicked messages abound. Firstly, you need three sources of information: the Centers for Disease Control (CDC), the World Health Organization (WHO), and your state and local information filtered through your department or service. The CDC set up a nifty minute-to-minute update site at www.cdc.gov/h1n1flu/whatsnew.htm. Scope it out. Everything you need to know is right there; if you want email updates, RSS feeds, or a Twitter follow, that’s there too. The WHO is not so sophisticated, but offers a wealth of information at www.who.int. Local info should be all this and more, but whoa: no need for overload! Your department (pay attention Chiefs) must keep you up to date on your state and local activities and get it to you before the newspaper or CNN. Local info must be filtered – you don’t care how tissue specimens need to be submitted for pathology evaluation nor do you give a hoot about precautions hospitals are taking when caring for suspected flu patients. Your department must give you manageable, filtered, understandable, and timely information needed to do your job and answer questions from your family and the public.
New York State loves paper, memos and advisories. Their Health Department wasn’t too happy with me when I passed their flu advisories on to my Fire/EMS services with commentary that they contained nothing of value to EMS. Guess what? State EMS folks quickly caught on and have themselves started qualifying transmittals with a listing of the salient points specific to EMS. That’s what I need, what you need, and what we all need in a time when our mailboxes are totally overloaded.
Here are some things the public wants to know. Firstly, “how do I know if I have the flu?” Most influenza infections share common characteristics: high fever, chills, myalgias (body aches), headache, non-productive cough, sore throat, and runny nose. The hallmark differentiating flu from other viral illnesses (such as the common cold) is rapid onset. Common cold virus symptoms begin gradually and tend to worsen over time. Influenza symptoms often begin abruptly, causing a perfectly well person to instantly become extremely ill. Fevers typically exceed 101°F; such body temperatures are quite disabling. Influenza A H1N1 infections have included all these typical flu symptoms and, in a small number of patients, vomiting and diarrhea as well.
Secondly, “what is the flu and how do I get it?” All influenza variants are respiratory viruses. They are transmitted through contact with respiratory secretions from an infected person who is coughing or sneezing. The incubation period ranges from 1 to 5 days between exposure and onset of symptoms; most average 2 days. Viral illnesses are communicable for a maximum of 1 to 2 days before symptoms appear and from 4 to 5 days afterwards. The greatest period of communicability correlates with fever. As a public health tool, 7 days is considered the maximum period during which symptoms would appear following an exposure. For reasons not well understood, children can remain communicable for much longer periods of time.
Thirdly, “how close is too close?” Respiratory secretions are large droplets; they don’t travel very far. The “hot zone” around an infected person is considered to be less than 6 feet. Beyond that, even a forceful cough or sneeze would be highly unlikely to land droplets on another person. Placing a simple surgical mask or oxygen mask over an infected person reduces the “hot zone” to inches. When a patient is masked and health care providers also wear N-95 or better respirator masks, human-to-human spread becomes virtually impossible. There is little evidence that wearing surgical masks in the community will reduce spread of infection but, if it makes the public feel safer, the practice should not be discouraged. At the very least, an asymptomatic infected person (who is potentially communicable) wearing a mask in public significantly reduces their likelihood for infecting others. Airplanes, trains, public transportation, and places of mass assembly are no more dangerous right now that they have been during the past six month flu season. Sure, there is a risk of someone coughing or sneezing on you. The greater risk, however, lie with what or who you touch and whether you remember to wash your hands.
Fourth, “how long can flu virus live on surfaces?” Good question. Respiratory droplets can land virtually anywhere. Doorknobs, telephones, computer keyboards, steering wheels, faucets, dishes…the list is endless. Environmental temperature and humidity strongly affect virus survival; in fact, flu season begins and ends when weather conditions change. As a guideline, influenza viruses will survive on hard non-porous surfaces such as steel and plastic for 24 to 48 hours and cloth, paper, or tissue for 8 to 12 hours. Once picked up on your hands, viruses last for 5 to 15 minutes although within this time period, all it takes is touching your face, mouth, eyes, or nose to transfer the virus into your respiratory tract to produce infection. Two rules are obvious: wash your hands often and keep your hands away from your face.
Fifth, “what should I do if I think I have the flu?” It depends on how sick you are. Despite media accounts, the H1N1 influenza has typically produced only mild illness. If illness is severe, or an infected person has other medical problems, antiviral medications may be helpful to reduce the severity and duration of the illness but only if started within 48 hours of when symptoms began. The best advice is to stay at home so you don’t infect others, call your health care provider, rest, drink plenty of liquids, and use the same cold and fever remedies you ordinarily use. The flu season has not yet ended in the United States; many people worried they had contracted the H1N1 flu have either not had influenza at all or had a seasonal variant of the flu. Many of these illnesses could have been prevented by seasonal flu vaccination. Take the opportunity to remind friends, family, and the public of this. Influenza is a serious illness. Over 200,000 Americans are hospitalized and 36,000 die each year from the flu. WHO estimates there are over 500 million cases worldwide, killing over 250,000 people annually. So who are we testing for the H1N1 flu? People who show signs of febrile respiratory illness and have traveled to or had contact in the past 7 days with people who have either traveled to Mexico, been infected with the H1N1 flu, or live in a community where there have been cases of H1N1 infection. And is the treatment any different for H1N1 flu versus seasonal flu? Nope, not at all.
Sixth, “is there a vaccine?” Not yet. The CDC announced that they had identified the 2009 influenza A (H1N1) virus on May 2nd, 2009 and will begin development of a vaccine. With current technology, this will not be ready for several months, hopefully in time for next year’s flu season. Keep in mind that a variant of H1N1 is included every year in the seasonal flu vaccine and this may possibly provide some immunity to the new virus.
Lastly, “is it safe to eat pork?” Yes; pigs do not carry the H1N1 influenza A, people do. Don’t eat people.
Let’s keep this outbreak in perspective. As all hazard responders to the emergency needs of our communities, we must prepare for the worst. We are not certain what direction the H1N1 flu will take. But the facts are being grossly blown out of proportion. The US city with the largest number of H1N1 cases is New York. Despite 8 million New Yorkers living and working in close quarters, the infection has failed to spread beyond the Queens high school students originally infected in Mexico. New Yorkers ride subways, buses, trains, and crowded elevators every day.
The public looks to firefighters and EMS providers in times of crisis. There are plenty of swine flu idiots out there. Panic serves no one. Let’s help calm the hysteria by offering common sense, practical help to each other and our communities. It’s what we do best.
Fire Engineering Magazine
posted by Mike McEvoy
5/03/2009 12:19:00 PM
Fire Service Leaders
- Immediately notify all members and staff of the emerging problem.
- Review your plans using the CDC EMS Pandemic Preparedness checklist.
- Set up an email list and web site to provide continual updates and info for your members.
- Monitor news reports and government resources. Communicate with your local public health officials. Use the CDC minute-to-minute swine flu update site.
Communications Center/Dispatch Leaders
- Implement severe respiratory infection (SRI) screening for all callers with chest pain, difficulty breathing, headache, or general illness (sick person). If using the Medical Priority Dispatch System (MPDS), activate the SRI drop down on ProQA or add the following questions to paper card numbers 6, 10, 18, and 26 for further interrogation: (a) has the patient recently been in Mexico (or other outbreak location) or exposed to anyone who has (paying particular attention to those who stayed for 7 days or longer)? (b) are they febrile or have a fever and, if so, is it higher than 101 F (38 C) and (c) do they have a cough or other respiratory illness symptoms?
- Relay responses to these questions to EMS units before they arrive on scene.
Firefighters and EMS Providers
- Request additional information from dispatch when sent to respiratory, sick person and fever related calls if limited initial dispatch information is provided.
- Perform initial interview of all patients from at least 2 meters (6.5 feet) away to determine if personal protective equipment precautions are necessary.
- Place a mask on all patients with suspected influenza symptoms before approach. Use a surgical mask or non-rebreather mask (when oxygen is required).
- Avoid droplet producing procedures whenever possible including nebulizers, bag-valve-mask, suctioning or intubation. If bag-valve-masks are needed, use BVMs with HEPA filters whenever possible.
- Recommended PPE for taking care of ill/potentially infected patients includes: gloves and N95 or better respirators. PPE should be donned and doffed according to published guidelines to prevent cross contamination, including faceshield/eye and gown protection when splash or airborne contamination is possible.
- Alert receiving hospital personnel of the possibility of an infectious patient as soon as possible and hold suspected infectious patients in the ambulance until their destination in the hospital is known, rather than immediately moving them into the emergency department.
- Perform a thorough cleaning of the stretcher and all equipment that has come in contact with or been within 2 meters (6.5 feet) with an approved disinfectant, upon completion of the call following CDC interim guidelines for cleaning EMS transport vehicles.
Remember that this is a continually evolving situation. The most severe flu cases so far have been mostly adults from ages 25 to 45, but patients of all ages have been infected, so the same precautions should be used for all patients. We need to stay on heightened alert until this threat has been controlled. As with all infectious diseases, always remember that hand washing is the number one way to decrease transmission!
Mike McEvoy - EMS Editor - Fire Engineering
posted by Mike McEvoy
4/27/2009 09:32:00 AM
The formula for a pandemic requires 3 things: a novel virus to which all or most people are susceptible, transmissability from person to person, and wide geographic spread. So far, we have a novel virus that appears most people are susceptible to. There has been person-to-person transmission. Wide geographic spread has yet to happen. Essentially, we are (overnight, no less) one step closer to a pandemic than the bird flu. Preliminary CDC incubation period estimates are 1 to 7 days. This is expected to be narrowed to 2 to 5 days with further data. That means we will likely see a pandemic or not within a very short time.
What to do? First, don't panic. Second, wash your hands. Often. Third, take an inventory of where you and your department stand. The CDC Pandemic Influenza EMS Planning Checklist has been available for over 3 years. Review the checklist and make sure you have adequate stockpiles of PPE including N-95 masks and hand hygiene gels. You will not be able to purchase or order them during a pandemic. Check availability of antivirals for your members. Review your sick leave and staffing contingency plans. Assure you have current contacts with public health, government, and hospital officials. Be certain your 911 center can handle calls when no EMS services or hospital beds are available. By now, all these matters should be in place. Make certain they are.
Watch the CDC (www.cdc.gov) and the WHO (www.who.int) for updates and notices. Hopefully, this outbreak remains simply an outbreak.
Fire Engineering EMS Editor
posted by Mike McEvoy
4/24/2009 10:17:00 PM
I've heard nurses not want to update family members about a loved one's condition, hospitals refuse to provide patient information to an EMS crew who had treated and transported the patient, firefighters refuse to tell a family member or friend where a patient had been transported - all wrongly in the name of HIPAA.
HIPAA was designed to prevent medical information from falling into the wrong hands. Parking tickets are not medical information. Anyone a patient wants to know about their medical condition is entitled to have that information. Any health care provider who treats a patient is entitled to medical information about that patient. EMS services are required to post HIPAA information on their web sites and provide education on HIPAA to their members and employees. This parking ticket fiasco serves as an outright silly example of how convoluted HIPAA misinterpretations have become. It's probably time to check the HIPAA knowledge in your department.
posted by Mike McEvoy
4/23/2009 11:32:00 AM
If you're seeing a volume of primary v-fib cardiac arrests enough to ponder over improving your resuscitation rates, maybe you should take a closer look at the quality of primary and cardiovascular care being provided in your community. Cardiac arrests should be on the decline. Cardiac arrest resuscitation rates should be dropping as well. That might be a better measure for bragging rights. Medicine has evolved; EMS needs to evolve with it.
EMS Editor - Fire Engineering
posted by Mike McEvoy
3/10/2009 09:43:00 PM