Category Archives: Firefighter Safety & Health

Better Lifting for Better Care

Anyone who has been to a national EMS conference in the last few years has probably seen Rick Binder in the exhibit hall. If that name is not familiar, you may be more likely to remember his life-size teddy bear wearing a vinyl vest surrounded with brightly colored handles. While we are friends now, I have absolutely no financial interest to disclaim. In fact, I had initially avoided both him and the product that his dad had developed whenever I saw the booth at trade shows. Personally, I just didnít see the need for it since I was a master with a hospital sheet and had acquired a wide repertoire in the many ways to use it. But there are times that peer pressure can be a good thing. Other teammates from my service had visited with him at EMS Today and appeared to be impressed. Curiosity got the better of me and I wanted to learn what I might have overlooked, so I took Rick up on his free offer to field test the device. It was because of my own experience with the Binder Lift that I was finally sold.

I have learned that there are many lifting situations where this device will be an incredible asset to me as well as my patients. The slogan, ďbecause people donít come with handlesĒ initially led me to think that the use of the Binder Lift was directed primarily at the bariatric patient who requires only a simple lift assist to return them to an upright condition where they can sign my refusal form. While it is certainly useful in such cases, it is definitely not limited only to that situation.

In my first example of these many unique cases, the patient was over six-foot-tall and had been discovered unconscious, but breathing, on his front porch by a third-party caller. I had been to that address before and knew he had a history of stroke that had previously left him unable to drive. We had three responders available and knew we needed to get him to the hospital quickly. After a rapid initial assessment, the patient was rolled to his side so we could apply the Binder Lift. Once secured, one person grabbed his feet while my partner and I were able to grab different handles to balance our height difference and eased his lanky frame down the steps to our stretcher. This movement was much easier on our backs and proved safer for the patient compared to our other options that day.

The simplicity with which we were able to transport this patient made me think back to a previous visit here. I only wish I had had this device when this same patient had been helping his elderly father get to the bathroom toilet. I can only imagine the mishap that led to his naked father falling on top of him – pinning him to the bath tub wall. Then, whether it was due to the fall or just the wait for us to arrive, his dad had defecated quite a lot. The waste had eventually made its way over both of the men. Finding a firm handhold on the slippery gentleman was a challenge made even more difficult by his son being entrapped beneath him. The vinyl construction of the Binder Lift would have made the extrication job much easier to accomplish and also simpler to clean up afterwards. It may have even prevented the need to change my uniform that evening.

In another memorable example, it was about 2AM when the tones dropped for a fall with injury. The husband of a 62-year-old female found his wife on the ground in front of their porch. She had stumbled and fallen forward about a two-foot drop. Unfortunately, she had braced herself for the landing with a stiff arm before reaching the ground. Her primary complaint was pain in the right shoulder which, although closed, did exhibit deformation (a probable dislocation. She denied any other pain along her spine, but as a precaution against a distracting injury, we placed her in a cervical collar per protocol.) Getting the patient to a seated position was accomplished only with significant coaxing and some obvious pain. There was no option of lifting her from beneath her arms and her loose pajamas gave little hope of bearing the weight of her hips to lift her. So after placing her right arm in a sling, we were able to place the Binder Lift around her torso and helped her move her legs into a crouched position without any further aggravation. The patient was then easily lifted upright and the stretcher maneuvered behind her allowing her to simply sit down. The Binder Lift was also helpful in orienting her on the cot. Finally, the slick vinyl material of the vest and straps was easily removed to leave her comfortably in a high Fowler’s position on the stretcher.

In short, the Binder Lift allows for better body mechanics when lifting that not only help to raise the patient safely but can be effective in extending the careers of medics that might otherwise be forced into premature retirement due to back injury. If you donít try a Binder Lift for your patients, at least do it for yourself. I still carry an extra hospital sheet for many situations, but it always lays right on top of my Binder Lift.

Learn more at http://binderlift.com.

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More Reasons to Support Dynamic Deployment

The “Leverage Real-Time Data for Improved Ambulance Response Times” article that Zoll posted on their blog site did a good job of explaining response times and even the benefits of System Status Management (SSM) planning to the patient. But there is still more to the story that we have learned over the years since Jack Stout first introduced it.

Of course, it is best for the patient (and the service) when an ambulance arrives to the scene in a short time. The media often picks up on poor response times with stories like†the GSW patient dying in Clevelandsurrounded only by police and fire personnel. Even the doctors at JAMA can’t resist publishing an article showing response times as an inherent failure of EMS in certain cases. Unfortunately, many will read the solution as medics “speeding” to the scene, yet we have learned that lights and sirens have little impact on times and may even prevent some patients from calling for an ambulance in the first place. However, when the deployment of ambulances is responsive to the dynamic demand patterns throughout the day, ambulances can literally be moved closer to the scene even before they are dispatched. Literally hundreds of High Performance EMS agencies across the US have significantly reduced their 90th percentile response rates through technology. Forecasting the future does not involve magic, at least not for predictable phenomenon like emergency calls for service. Not only can we forecast the quantity and types of calls we will receive (necessary for adequate staffing), we can determine where they are likely to originate from with significant accuracy as well. Shortening the distance that an ambulance must travel is a safer alternative than asking a crew to speed in order to achieve the same result.

Another positive impact of shorter response times is patient satisfaction. There are many reasons that healthcare providers should be†using patient satisfaction surveys, both for the benefit of the patient as well as simplifying the accreditation process for your service.†Beyond safety, satisfaction and simplification; proper SSM can improve finances. Some services have recognized marked reductions in the number of post moves for crews and ultimately reduce the total number of unloaded (read unreimbursed) miles driven which saves on vehicle wear and tear in addition to fuel costs. Other agencies, particularly those who contract their services, can reduce financial penalties for “exceptions,” or late calls beyond the target response time.

Frankly, the public often expects performance measured in minutes. Whether we approve of the measure or not, we are often graded and compared based on response times. Whether the penalties for missing targets are financial, patient satisfaction, or driven by bad press reports, being late simply hurts. Until EMS is designated and funded as a critical service for government, it will be dependent on political funding allocations and insurance reimbursements. As long as performance is measured by how long it takes to be on scene, response times will be critical to the financial well-being of services. The least we can do is perform to the highest safe standards possible.

 

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Analyzing Routes and Response Times

This is a second preview chapter of a new book in the Primer series from Bradshaw Consulting Services to be titled ‚ÄúClosest Vehicle Dispatch: A Primer for Fire‚Ä? to be released in time for the FDIC 2017 at the end of April.

Whether you are held to the standards of NFPA 1710, which addresses predominately career fire department responses in the US, or NFPA 1720, which deals specifically with volunteer departments, the challenge of meeting these response time standards is increasingly difficult for many reasons. Higher demands on limited resources and increasing performance expectations from the public are just a couple of those forces opposing response efficiency. Another elementary factor that critically impacts our response times is the route we choose in order to arrive at an incident. In most cases, there is not always a single route that is consistently the best choice at all times of the day or week. These differences can also include seasonal variations or be complicated by special events which may be planned or unplanned (Demiryurek, 2010). The subjectivity of route selection is further complicated by dynamic characteristics such as traffic or weather in addition to the extent of the mental map we develop of a service area or what that map may be lacking in adjoining or mutual aid areas (Spencer, 2011).

Most of the considerations that we process as we consider a potential path of travel in an emergency vehicle are often made subconsciously through personal experience and knowledge. While there is no legitimate argument against knowing your service territory well, the question becomes do we have sufficient awareness to consistently make the best route choices?

According to U.S. Fire Administration statistics for 2005, responding to alarms accounted for 17 percent of firefighter on-duty fatalities (Response, 2007). Deaths in road vehicle crashes are often the second most frequent cause of on-duty firefighter fatalities. In 2014, this percentage dropped to only 10 percent with a total of just 7 fatalities. Although the change is positive, it is too early to consider this to be a trend since it is only the second lowest number of crash deaths over the past 30 years (Fahy, 2015). While these accidents are not all due to their route choice, it can be argued that there are times where crews were clearly in the wrong place at the wrong time. Furthermore, the shortest path is not always the quickest route, and the fastest one may not have the simplest directions either (Duckham, 2003). Given the technology and data available today, there is little doubt that we can make strong decisions provided that we understand how we make these choices and what information may improve them.

In selecting a route for any particular apparatus, we may consider the physical or geographic characteristics of the roadway that determine the maximum speed of travel based on the maneuverability and size of our apparatus. Similarly, we must consider the likelihood of traffic congestion and also the safety of our crews as well as the public. As we increasingly rely on algorithms for making driving decisions, it is important to appreciate the mechanics of how the technology components function together. The Global Positioning System (GPS) is often credited with providing guidance to vehicle operators, but this is not exactly true. The satellite constellation that makes up the American-operated GPS (and similarly the European GLONASS) simply sends accurate time signals by radio waves to our portable receivers who detect the length of time each signal has traveled through space and then triangulates a position based on the calculated distance from those man-made stars (Hurn, 1989). The accuracy of the position that your GPS unit determines is based on the quality of those signals received and the precision of the local clock used to compare the time encoded in the signals. These satellites have no concept of transportation networks or traffic congestion on earth. It is Geographic Information Systems (GIS) that model the street networks and also track the vehicles using them. Unlike the limited number of GPS-like constellations in space that help us derive our position, there are a multitude of GIS-based computer services that offer routing recommendations. Some of these services, like the consumer-based routing applications available on your smartphone, are located on ‚Äúcloud servers‚Ä? (although they are quite terrestrial) while others may be hosted privately on local government networks and available only to ‚Äútrusted client‚Ä? applications on your Mobile Data Terminal (MDT).MARVLISiOSinFD

Each of these GIS services has unique embedded algorithms for recommending directions or to estimate arrival times (Keenan, 1998). As users of these systems, we become subject to the specific assumptions inherent within their design leaving them far from being equivalent to one another (Psaraftis, 1995). For instance, network models must account for the elevation differences of overpasses in relation to the roadway below in order to prevent suggesting that a vehicle take a turn off of the side of a bridge. The cost of that ill-fated maneuver would be insurmountable, but other legitimate turns have minor costs associated with them because the apparatus must slow down to navigate the curve safely. A traffic light, or oncoming vehicles, can add further to that turn delay. Accounting for these delays requires logic in the GIS routing algorithm as well as valid time estimates coded into the street network data at each intersection.

The most basic feature of any transportation network model, however, is the cost of movement along a road segment in either direction which is known as its ‚Äúimpedance.‚Ä? Many systems will assume the speed limit over the distance (impedance_time=speed/distance) between intersections to derive a similar “drive time” in both directions. Real world conditions (including traffic, terrain, and weather) will prove that speed limit-based assumption to be overly simplified and can lead to poor routing decisions because of unrealistic impedance values in the model (Elalouf, 2012). Crews will quickly recognize these failures and the lack of trust that these errors engender can compromise the entire routing program. Realistic impedances should be variable based on the time of day or day of the week in addition to the direction of travel.

More complex online routing services now offer near real-time traffic updates. While this traffic feedback can be invaluable to most drivers, its practicality to emergency vehicles appears limited in general. If our task was to deliver pizzas, we would be constrained by normal traffic regulations. Knowing where traffic congestion is at any given moment would allow us an opportunity to seek an alternative to bypass a congested intersection. This is a common type of need for drivers and therefore many consumer routing apps seek to address that specific function (Ruilin, 2016). But when our duty is to respond to the accident at that same intersection that is causing the delay for others, these typical consumer routing applications may fail our unique requirement. This objection is especially valid where emergency vehicles are not strictly constrained by the driving patterns of other vehicles on the roadway. In certain situations, it may be allowable for an apparatus to use the road shoulder for travel or even cross a median to use an on-coming traffic lane or to traverse a one-way street in the wrong direction (Harmes, 2007). The only reasonable exceptions to this generality are those dense urban areas where congestion is excessive and these “open” lanes or roadway shoulders simply do not exist to allow apparatus to circumvent that traffic. In a recent trip to New York City, I visited a fire station in downtown Manhattan. They received a call and exited the station with red lights and sirens blaring, but even the air horn was unable to move traffic. The engine sat at the traffic light behind the rest of the cars until the intersection cleared enough to allow drivers to create a path up to the next intersection.

In general, when we look to leverage technology for our unique demands in public safety, a system would ideally be able to learn our peculiar patterns of travel and record typical impedances based on how our own fleet resources travel. Additionally, these impedances will likely be different during certain hours of the day or on specific days of the week and vary even further seasonally based on whether school is in or out of session. These cyclical patterns will have a huge impact on actual drive times and any route recommendations must account for them accordingly. Current consumer routing applications are continually improving their ability to recognize and address the needs of passenger cars or ordinary delivery trucks, but this still does not necessarily translate to better routing of emergent public safety vehicles in most cases.

Finally, the last critical piece of route selection is a review after the call. Comparing the actual route traveled with the recommended path is an important feedback mechanism to both ensure that the system is operating as intended and to build confidence within your crews that encourage them to trust the system. This is not to suggest a blind obedience to technology, but constructing a learning process for everyone in developing tools that function to improve overall performance. No technology is perfect in the real world, just as no person has ultimate knowledge at all times. But cooperatively, we can learn to make improvements in either the computer or human systems as needed to enhance awareness in the other. The most successful implementations of routing assistance create cooperative relationships between responders and the GIS staff responsible for maintaining the data. Failures discovered in any system should not be used to condemn an otherwise useful technology, but seen as opportunities for improvements in either the algorithms behind it or the data that fuels it.

One of the critical outcomes of route selection, aside from arriving safely, is the total time of travel. No matter when the clock starts for measuring your response time, it is the minutes and seconds that the wheels are rolling that often consume the majority of it. The longer that time or distance, the higher the cost. A cost that can be measured both in actual vehicle operating expenses as well as the risks associated with its operation; not to mention the losses adding up on scene prior to your arrival. In general, the shorter the time (and distance) between dispatch and your safe arrival on scene, the better it is for everybody.

 

References:

Demiryurek, U., Banaei-Kashani, F., Shahabi, C. “A case for time-dependent shortest path computation in spatial networks.” GIS ’10 Proceedings of the 18th SIGSPATIAL International Conference on Advances in Geographic Information Systems. ACM, November, 2010; 474-477.

Duckworth, M., Kulik, L. ‚Äú’Simplest’ Paths: Automated Route Selection for Navigation in Spatial Information Theory.” Foundations of Geographic Information Science. (2003) 169-185. Berlin: Springer-Verlag.

Elalouf, Amir. “Efficient Routing of Emergency Vehicles under Uncertain Urban Traffic Conditions.” Journal of Service Science and Management, (2012) 5, 241-248

Fahy, R. F., LeBlanc, P., Molis, J. Firefighter Fatalities in the United States-2014. NFPA No. FFD10, 2015. National Fire Protection Association, Quincy, MA.

Harmes, J. Guide to IAFC Model Policies and procedures for Emergency Vehicle Safety. 2007. IAFC: Fairfax, VA.

Hurn, Jeff. GPS: A Guide to the Next Utility. (1989) Sunnyvale: Trimble Navigation.

Keenan, Peter B. ‚ÄúSpatial Decision Support Systems for Vehicle Routing‚Ä?. Decision Support Systems. (1998);22(1):65-71. Elsevier, Salt Lake City.

Psaraftis, H.N. “Dynamic vehicle routing: Status and prospects.” Annals of Operations Research (1995) 61: 143.

‚ÄúResponse-Time Considerations.‚Ä? Fire Chiefs Online. ISO Properties, 2007. Web. 20 May 2016.

Ruilin, L., Hongzhang, L., Daehan, K. “Balanced traffic routing: Design, implementation, and evaluation.” Ad Hoc Networks. (2016);37(1):14-28. Elsevier, Salt Lake City.

Spencer, Laura. ‚ÄúWhy the Shortest Route Isn‚Äôt Always the Best One.‚Ä? Freelance Folder, November 2011. Web. 7 December 2016.

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The Fallacy of the "First Due" Area

The following is a preview of a book coming soon from Bradshaw Consulting Services to be titled "Closest Vehicle Dispatch: A Primer for Fire" which is a follow-up to "Dynamic Deployment: A Primer for EMS".
Watch for the new release in time for the FDIC 2017 conference at the end of April.

The modern legal definition of response zones can be found in the Code of Federal Regulations, which states that the ‚Äúfirst-due response area is a geographical area in proximity to a fire or rescue facility and normally served by the personnel and apparatus from that facility in the event of a fire or other emergency.‚Ä? (44 CFR 152.2) This banal definition glosses over some very interesting history in the development of modern professional fire departments. In the mid-nineteenth century, there were frequent, and often bitter, disagreements over territories that sometimes resulted in physical confrontations. In fact, the politically powerful New York City volunteer fire companies of that era were known to send out runners ahead of the engine in order to claim the right to fight a particular fire and thereby receive the insurance money that would be paid to the company who fought it. While the monetary incentives are not nearly so direct today, there is still a great deal of pride invested in being the “first responders” to an incident. It would not be a difficult argument to make that we haven‚Äôt changed as much as we would like to think in regards to response.
A retired fire chief recently relayed a story to me about an engine crew that raced through a residential neighborhood¬†in order to beat another engine that had been dispatched for mutual aid since the ‚Äúfirst due‚Ä? engine was out of quarters returning from another call. The need was so great to be the first responding company in ‚Äútheir own area‚Ä? that they willingly disregarded the safety of the public that they had sworn to serve simply to avoid the embarrassment of being second to a call that was ‚Äúrightfully theirs.‚Ä?
The concept of the “first due” area is a strategy to automate a century-old manual concept of pre-assigning the closest resources to specific structure addresses within a fixed response area. The thought that a central station will have the closest apparatus to any potential fire in their district is simple, but with the increasing complexity of urban transportation networks, it is also an increasingly simplistic idea. The reality is that traffic patterns, and increasing traffic congestion, can dramatically change response times, particularly in high density population areas.
Public safety vehicles, even those running emergency traffic, can sometimes struggle to reach the posted speed limits at certain times during a shift. Alternatively, a lack of traffic at other times will permit the discretion of rates above the normal traffic speed. These periods of diverse congestion levels exist not only for intermittent periods of time but can vary dramatically by the direction of travel as well. Additionally, these temporal and directional impacts are confounded by the fact that station locations are often inherited positions that were designated many years earlier when housing, demographic and development patterns were very different from today. In most areas, fire station placements have grown through ‘incrementalism’, often tainted with political influence. In some jurisdictions this inheritance may go back over a century or more. Not all current station locations are the result of some forward-thinking intelligent design. The result of fixing address assignments to these past growth patterns may, or may not, represent who will be able to arrive first on the scene with the right resources. Furthermore, the common overlap of nearly a third between each of multiple urban engine companies means that when they are each dispatched from quarters, the next few arriving fire units, under normal conditions, will likely have a similar response time to that of the ‚Äúfirst due‚Ä? apparatus.

 

The ‚Äúeffective service area‚Ä? of any station will vary during different times of the day based on traffic congestion. On a typical morning, as most traffic is heading toward a downtown business district, an urban station located at the city center will be able to travel outward toward the suburbs with relative ease. At the end of a normal business day, that same station will find that it can no longer travel as far in the same direction in the same length of time. Any sort of break in the normal business routine will further alter that pattern. These exceptions can include weekends, holidays, or special events. Most areas will also experience seasonal changes to traffic as a result of adding school buses or tourists to the roadways. The result of traffic is the evolution a unique ‚Äúfirst due‚Ä? area for different hours of the day and days of the week during different months of the year. A ‚Äúfixed‚Ä?, or ‚Äúaverage‚Ä?, first due area must either ignore, or at the very least, generalize the pressures of these growing realities.

 

Generalizations of Effective Service Areas as Impacted by Primary Traffic Patterns
Morning                                                                     Afternoon

Rzones1      Rzones2

During a typical morning ‚Äúrush hour‚Ä? period, the heaviest traffic may be to the north and west as in the left example making response in that direction relatively more difficult than moving to the south and east. Consequently, the effective response zone represented in gray around two example stations will compress moving with the traffic and elongate against that traffic. In the afternoon, this pattern will reverse since the heaviest traffic would now be moving away from the downtown area making response to the south and east slower as compared to the morning pattern and therefore reforming the effective service area in the opposite direction.

The dispatch of a theoretical ‚Äúpersistently closest resource‚Ä? is made even more difficult when we consider that an increase in call volume makes it increasingly common for an apparatus to be dispatched when it is already out of its assigned station, either on or returning from another alarm. With an increase in call volume, the chances of another call leading to a dispatch before a unit has returned to its station are only increasing. These moving vehicles will have a significantly different effective service area and a different proximity to an incoming alarm when compared to an apparatus that is currently parked in a given ‚Äúfirst due‚Ä? station. Additionally, the ‚Äúchute time‚Ä? in preparing the crew to respond is completely eliminated when the dispatched vehicle is already moving. In this case, the effective response area is larger when considering response time than an apparatus that is parked at its station. However, this dynamic nature of the responding vehicles can also work against the efficiency of a traditional ‚Äúfirst due‚Ä? response. Consider that an apparatus may be available after clearing an alarm at some extreme point within its district when a call is received from an opposite extreme location. The mere fact that the responding vehicle is moving may still not overcome the greater distance that places it significantly further from that next alarm than an apparatus that is parked elsewhere. In this case, the closest unit may well be one outside of the assigned primary response area.

Impact of Increasing Call Volume on Effective Service Areas

Rzones3

When an¬†apparatus¬†clears a call, it becomes available in a different location than the station and although it is capable of responding with a “zero chute time”, its distance from the station will impact its effective service area possibly putting it further away from the “next call” than a neighboring station “in quarters”. As call volume increases, the likelihood of being dispatched while returning from another call only increases.

These changing logistical dynamics significantly alter the performance realities for modern fire stations from simple planned service delivery to a complex system of matching dynamic resources to increasing demand. Meeting the expectations of your community requires more than the historical paradigm of ‚Äúfirst due‚Ä? scenarios assisted by mutual aid to that of a cooperative system approach designating primary and secondary response functions on-demand and independent of an arbitrary enforcement of outdated patterns of convenience. Fire departments must literally become dynamic fire services requiring an intelligent coordination of these mobile resources.

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Does 'Narcan' Deserve Any Debate?

While¬†naloxone (marketed under various trademarks including¬†Narcan) is not a new drug, it has enjoyed some incredible news coverage recently as the “safe antidote” for opioid abuse¬†that can bring an¬†overdose¬†victim back ‚Äúfrom the dead”¬†simply and safely with “no side effects.”¬†The surge in its popularity is undoubtedly fueled by a¬†growing problem of¬†opioid drug abuse, especially in the New England states¬†coinciding with the recent development of an intranasal administration option of naloxone. However, stories like, “A drug to stop heroin?” from the Georgetown Record that reads at least in part,

“It works like magic. Spray half-a-dose up one nostril,¬†half up the other and you‚Äôve saved a life”

tend to over-simply the issues involved. Sometimes it works that way, but that doesn’t mean it will every time.

During an overdose caused by opiates, (such as heroin, morphine, oxycodone, methadone, hydrocodone, codeine, Fentanyl and other prescription pain medications) the drug is released into the brain where it binds to opioid receptors. When too many of these opioids attach to receptors on the brain stem, it causes depression of the central nervous system, respiratory system, and leads to hypotension.  These conditions result in poor perfusion and can eventually lead to death. The action of naloxone is not completely understood in detail, but basically seems to displace the opioids on these receptors to reverse the depression of critical life functions. It is important to note that naloxone is only effective at displacing opioids and is therefore not effective against respiratory depression due to non-opioid drugs or illnesses affecting the CNS.  Consequently, recognition of the direct cause of respiratory distress is important in determining appropriate treatment.

Still, even when naloxone is effective at reversing CNS depression, there are conditions that the responder must be prepared to encounter as a result of this intervention. Abrupt reversal of opioid depression may result in vomiting, hypo/hypertension, seizures, VTach/VFib, cardiac arrest, pulmonary edema, severe headaches, severe anxiety, and confusion, not to mention the¬†severe agitation brought about when the patient loses the euphoric feeling often sought from the opioid. There is a safety concern for the “rescuer” in addition to a concern whether non-medically trained personnel can¬†adequately perform the physical assessment of the patient required to ensure the condition hasn’t been misdiagnosed. It appears true that naloxone will not directly hurt patients who are not suffering opioid overdose, but the time delay in proper treatment could be detrimental.

There is frustration on the part of families and even communities afflicted by chronic drug abuse because¬†action is not being taken “fast enough” when the “miracle drug” is known and available. Articles such as, “Massachusetts Police can carry Narcan, but not use it“, where it is¬†reported that even though the state has authorized its use there are still local policy restrictions that prevent officers from administering it, seem like petty politics, or possibly¬†even conspiratorial. I do not advocate undue or burdensome restrictions, but rather welcome a healthy dialog to help all would-be rescuers to understand the ramifications of taking certain actions. I want more equipped professionals to have access to the treatment along with tools such as suction devices, BVM, and an AED to handle possible outcomes rather than simply trading death by one route for death by another. My position on Narcan is actually similar to that of administering CPR. While I want everyone to be prepared to do it, everyone should know something about what results from taking that action. Saving a life is an incredible feeling, but it never comes without some personal cost.

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Second Thoughts on 'Scene Safety'

In addition to my regular job, I continue to proudly serve as a medical first responder in my home community. But, now, in the wake of a¬†Christmas ambush of firefighters¬†last year and yesterday’s¬†hostage situation during a fake medical call, I am thinking back on the doors I have rushed through attempting to offer my help to someone in need. When I respond to that late night page, I review in my head the details given to me by the dispatcher and construct my index of suspicion regarding the medical condition I will likely encounter and never suspect I am entering any sort of trap. Just like you, I was taught to say “scene safe” during my drills and exams, but that was in a classroom setting which is far different than I have ever experienced in the field. Now matter how good your imagination, that fluorescent lit room full of desks and chairs never becomes the cramped, dimly lighted bedroom down a narrow hallway. So, how do we relate the real-world idea of safety concerns into practice in the field? Back in school, we have simulators for patients that can respond to treatments providing feedback on my care and mock-ups of ambulances that even make noise to disrupt the use of my stethoscope, but where is the effort to really teach recruits caution before entering a home? Or even how to deal with the dangerously irate family member once we reach our patient? Maybe we need to go down the hall of the community college and ask the theater students to join our tidy little scenarios as grieving relatives.

And it doesn’t always have to be the setup of a deranged psychopath to present a danger, there are times I have simply gone to the wrong address. And in my state, a homeowner is justified in using “deadly force” on anyone who “was in the process of unlawfully and forcefully entering a home.” Hopefully by announcing myself and asking who called 9-1-1, I can argue the ‚Äúunlawful‚Ä? part if logical debates were possible in those late night situations. Fortunately, I have never found myself in a situation where my life¬†was truly in danger. But I suspect other responders have felt that same casual assurance before things went sideways for them. Arming medics is also not the answer. My “concealed carry” training was very good, but it doesn’t begin to help me understand how to react in a hostage taking situation even assuming my hands weren’t already full of equipment when entering the room.

I read of states like Iowa and New Jersey that are having trouble recruiting volunteers and in some cases offering incentives for service. I have always felt that EMS is a calling however. We don‚Äôt just need more bodies in uniform, we need the right people to care enough about helping patients. We also need to do a better job of protecting the professionals (including volunteers) who give of themselves already. We must use the¬†CLIR E.V.E.N.T. database¬†to share experiences of how to make EMS safer and better for responders as well as patients. Take the recent events that have happened and let them make you more aware, not more afraid. Work with others to help them understand the real-world of “scene safety” and practice it in every call. Let your “index of suspicion” always include your own safety, because we need you back doing this job again tomorrow!

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MCIs and "The Downwind Walk"

I never really considered doing book reviews on this blog or writing about specific horrific incidents either, but I finished reading ‚ÄúThe Downwind Walk: A USAR Paramedic‚Äôs Experience after the Terrorist Attacks on September 11, 2001‚Ä? by Steve Kanarian just hours before the shots rang out at a movie theater in Aurora, Colorado. Let me say upfront that this will also probably not be the sort of book review you might expect, but I doubt the book will be what you expect it to be either. The book at least, is much more than it appears. Steve is a Paramedic, a retired FDNY EMS Lieutenant, and now I am happy to call him my friend as well. He has given me a gift through his pain and I hope you will take it as well.

From the title I was expecting a journal of the messy details written by a ‚ÄúForrest Gump‚Ä?-type character who was always in the right place at the right time and would take me into the depths of the response that day. What I discovered was an even more real experience than I imagined. It was his exact experience including the hours and days of simply waiting to be of use. Most surprising was that the greatest interest of the book for me became the continuation of his story long after the actual event and even after his final day working at ground zero. It was the story of every first responder who is called to action at¬†any Mass Casualty Incident (MCI) anywhere.

During my own initial training as an EMT, my instructor dutifully covered the section on stress management from the AAOS guide including Critical Incident Stress Management (CISM) and without hardly a breath broke out of instructor mode and told us flatly that he was required to say all that, but that in reality it simply never happens. I don’t know how it is in very many different services on this topic, but I suspect my instructor was not an anomaly. As both a professional and as a human, my heart goes out to all of the responders in Aurora and elsewhere who have had to clean up the messes left by mass murderers. I believe so strongly that they need to hear his story that I would be happy to send my own copy of the book to anyone who responded to the theater shootings if you cannot get a copy yourself. I think it is genuinely that important.

Sure, it was clear that this was his first book and the publisher made some mistakes in the printing, but for me, the story was well beyond the words. It was the call to action ‚Äď not to help others, but to know your limits, understand yourself, and be willing to seek help when you need it. Your value as a Paramedic, an EMT, a firefighter, or a police officer is not your strength but in recognizing your limits. Thanks, Steve!

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Filed under Command & Leadership, EMS Topics, Firefighter Safety & Health, Mass Casualty Incident