Covered Wagon MCI

Over the course of the last few weeks the Ambulance has been preparing to be a part of a local Mass Casualty Incident (MCI) drill.  In fact we were quite excited about this particular drill because we had recently completed MCI training with A. J. Heightman and were ready to practice what we learned.  The focus of the drill was the gas drilling industry that recently has taken our area by storm.  As with all our local drills it included county EMS, Fire, Rescue and the Hospital ER and their hospital based ALS staff.  In addition the Dept of Environmental Resources and regional representatives of gas drilling companies were also expected to assess their abilities during this drill.  The drill was scheduled June 2, 2011, at 1700.

At 1759 on June 2, 2011, dispatchers from the Communications Center began dispatching a rescue call.  During the initial parts of the dispatch everyone assumed that the drill had started late and expected to hear the common “this is a drill” appended to the end of the dispatch.  As we listened to the quiet and calm voice of the dispatcher we began to realize that the things we knew about the drill did not agree with the details in the dispatch.  Station 1 and 10, Medic 1 and 2, four helicopters, in the park for a tree fallen on a covered wagon, multiple injuries, with entrapment.  This is a senior travel group.

Response was nearly instantaneous with the EMS Chief and Assistant Fire Chief  first to contact the communications center.  Further information was relayed to them and they requested two additional BLS ambulances  which had already staged at the scene of the drill only a few miles from us, and BLS ambulances from two other stations the next closest BLS units to the scene.

We responded with our preplanned units for calls in the canyon with two ambulances, a four wheel drive squad, and heavy rescue.  These units were immediately followed up by a rescue engine, ambulance, and another engine to assist with the landing zone for the helicopters.  Station 10  also part of the preplan for rescue responses in the canyon responded simultaneously with equivalent units.

As all the units responded the 11 miles to the access area for the rails to trails hiking and nature area additional information was forwarded by the dispatchers.  Two horse drawn wagons were part of a tour with only one wagon suffering a direct hit by a large falling oak tree.   Callers estimated that more than 20 elderly people were on the covered wagon that was hit and several were severely injured and entrapped under the tree.  At that point helicopters from Western Pennsylvania were put on standby and additional ALS and BLS units were contacted in New York State to determine availability.  BLS units from within the county were also moved up to cover stations closer to the scene.

After gaining access to the trail the Asst. Chief arrived on scene first and set up Command.   The trail consists of an old double track Conrail mainline where the tracks have been removed and the railroad bed upgraded for hiking, biking, and horseback riding.  It is a much visited scenic area with gated access for motorized vehicles.  Another Assistant Chief was identified as staging officer and set up EMS and Rescue staging at the access parking area near the trail entrance.

Medic units proceeded to the wagon and set up initial triage about .75 miles from the access area.  EMS Chief  assumed EMS Branch with paramedics taking roles in both triage and augmenting BLS units with patient treatment.  Needed medical equipment was stripped from the first in ambulances and the SMART triage system was initiated.

Initial triage showed 10 total injuries and 10 other non-injured but stressed fellow riders.  Three of the injuries were triaged as immediate and 7 as delayed.   There were no patients trapped.

One ambulance each from three stations left for the landing zone with one immediate patient accompanied by ALS.  The landing zone was set up at the Airport approximately three miles from the scene.  It afforded the LZ officer the luxury of landing multiple helicopters in a safe easily accessed area with backup radio contact available via airport officials.  The helicopters all flew to the area’s closest trauma facility.

Seven other ambulances each transported one patient to the ER and returned to their respective stations.  After transporting a patient to the airport one ambulance continued on to the ER with the spouse who reported not feeling well.  A total of 11 patients were transported and 9 others sent to secondary triage prior to getting back on their bus.

Transparent to the patients there were a number of things that allowed this brief, less than three hour MCI to dovetail into a smooth effective operation.

 I had already mentioned that two months prior A. J. Heightman held his MCI class at our station allowing us a real opportunity to practice working an MCI and setting up a true EMS command structure.

·         Our Regional Medical Council provided SMART triage tags for our use on all ambulance calls during National EMS Week in May allowing all BLS staff a recent opportunity to practice with the tags, ALS staff to re-triage patients during that week, and ER staff to become familiar with the use of the tags.

·         The coincidence of having an MCI drill scheduled for virtually the same time and date allowed a quicker response for our units that were already manned and ready to report to the drill.

·         Due to the distance from populated areas our scene was easily secured and police and state park personnel had little or no trouble with on lookers.

What we learned.

·         You cannot overestimate the assistance that your communications center can provide.  They simultaneously dispatched on two frequencies, provided updates while we responded, set up medical channels, contacted medical helicopters, made an unknown number of important phone calls including state and local notifications, and generally used their collective expertise to stay one step ahead of our requests.

·         Stations that regularly respond as a cohesive group from opposite sides of the canyon to provide technical rescue and medical services to park visitors.  Knowing and having confidence in those coming to help you reduces some of the initial stress.

·         Scene control is important, even in the middle of nowhere.

·         It is much better to call for resources early than to need them when they still have an extended ETA.

·         And, that much of the work takes place after the incident is complete as ambulances are restocked, rescue and fire vehicles are again made whole, and the paperwork is completed.

Forward to the Past

If you remember the "Orange Book" you are officially older than dirt.  This year is its 40th anniversary and for the 1970s there was no other source for minting an EMT other than this book and hours of hands on practice.  As I recall those men and women that blazed the first steps for us from ambulance driver to EMS I am indebted to them for what they accomplished without OPQRST.

We came from funeral home based transport, to first aid, through the national introduction of paramedics and EMTs, and landed professionally where we are now.  Not always appreciated but at least an important cog in the emergency medical wheel.  Who cares?  Well, we are heading back to our roots.  OK, not as far back as those nice riding Cadillac ambulances but far enough so it is deja vu all over again.

This year the Brady company purveyor of those things printed for the EMS community has determined, with the help of learned scholars and an update in the National EMT Curriculum, that the thing we we now call the practice of prehospital care needs to have its pathophysiology adjusted.  We came, we saw, we memorized, we neumonic-ized and we prioritized.  Yet we never got to the critical thinking phase of the care we provided.  

This update will take care of that.  Instead of treating signs and symptoms we are instructed to delve deeper into a "body systems approach."  This will create a "reinforcement of the critical thinking and differential diagnosis processes for the EMT while completing a medical assessment and developing a patient care plan." The quotes are from The Transition by J Mistovich.  So in other words gain insight into the patients condition by obtaining a patient history.  Perform a primary and secondary survey and reassess the patient during transportation.  No more initial assessment, focused history and physical exam, and ongoing assessment.

I couldn't have said it better myself, of course the orange book did 40 years ago.  How nice to have been doing it correctly for all of those years.  Thanks for confirming my unscientific 40 year study affectionately named "Shut up and listen to what the guy/lady is telling you."  Yes I do know what I'm doing...and I'm older than dirt.

When It Works It Pays More Than Dividends

Take a look at an excerpt of an E-mail I received from The Secret List
:
 A Cleveland (Ohio) FF had a very close call but his life was saved by his own actions, and those of his crew members. CFD's 44-year-old FF Kevin Brady works in one of the busiest house in the city.

"It was just a pain I never felt before. I just knew there was something not right about it," he said.
Brady was having a heart attack. And it turns out, he was experiencing the leading cause of death among firefighters nationwide. When FF Brady finished operating at a working fire on March 10, he noticed chest pain as he took off his mask. He alerted one of his fellow firefighters who immediately took him into the ambulance and got an EKG on him. The EKG was transferred directly via the internet to the E.D. at the Cleveland Clinic. The cardiology fellow checked the readout on his Blackberry and mobilized the catheter lab.
 Within minutes, Brady was in the cath lab having a stent put in to clear the blockage to his heart. Brady was out of danger by the time his wife Cathy, who is mother of their four young children, got to the hospital. Because Brady was treated very quickly, his has little to no damage to his heart and his doctors have given him clearance to return to work April 12 with no restrictions. Good News.

Wow!  How does your service stack up to this nearly miraculous turn of events?  If I can't provide this level of service, why not?  EKG, Internet, Cell phone.  We have those things.  We do not have to reinvent the wheel to take advantage of these opportunities.

How about taking a look at  http://510medic.com/2010/09/07/why-ems-2-0/  Maybe not such a bad idea either.

Patience Not Patients

It occurs to me that my patience is inversely proportional to the opportunities that I need to use it.

OK Sisyphus, let's roll it up again

Occasionally you must return to a once difficult battle and re-wage that part of your campaign which you thought was won and complete.  Hence the Sisyphus reference.  Quite possibly it is not as futile a battle as that of Sisyphus but spending a department's time and funds twice is opportunity cost at its worst.

OK, so we do things a little different here than anywhere else.  We're a little different too.  What the heck it all works out in the end right?  Apparently not.

Every new guy, every guy that comes here from another station, tells us we're wrong and their way works better.  Why don't you do it this way?  This thing works better.  Why doesn't anyone answer my questions?  Well we were one upped this time.  The big cheese got a four page letter indicating everything that was being done is generally suspect and we are nothing but a bunch of lazy, uncaring, louts.  OK, so they got the uncaring part right.  We don't care about complainers.

We are a show piece for the county.  We know that, our fearless leader knows that, and the rest of the stations begrudgingly understand that too.  We get stuff because we make calls.  When a unit has to be replaced do you replace the ten year old one with 20K miles and hours or the five year old one with 90K miles and hours?  One that makes 300 calls or 1400?

We suck up on every call.  We are presentable.  We greet everyone we see.  We invite them all in to walk around.  We make a point to talk to the guys with the purse strings and mini sales pitch at every opportunity.

Station of the year, Firefighter of the year, EMS provider of the year, highest % billable, best PM program, least complaints?  Yeah, all here last year.

"The morale is low.  No one knows what is going on.  No one cares.  You better do something about this."  Or what?  You're going to cry?  You've been here a grand total of two seconds on the overall scale of things.  The service has been here 140 years.  Some of us over 25 years.  You know what's dragging down morale?  Your candy ass whining all the time.  SHUT UP!  Pay attention to what we do.  We've been doing it well since before any of us were here.  And I expect that it will be done equally as well even after we are all gone.

Become part of the structure here.  You are the new guy, possibly for years.  Get used to it.  Absorb what we have to offer.  What you take for granted other stations or departments would kill for.  Learn the nuances of the job before you try and change something that truly works, and no we don't do stuff here just because we have always done it that way.  Hell, a large minority of us are actually sought after instructors.  We see the good bad and ugly everywhere.  We learn, we adjust, we adapt.  Do the same.

Brothers, and then there are Brothers

A few days ago one of the truly great bloggers of the universe http://www.motorcopblog.com/ asked a question of his readers:  If a house is on fire and someone inside yells help, what do you do?  The follow up question was if you hear a gun shot in a house and then help what do you do.  I answered his question with a twist.  See what you think of our combined answer:

Now on to my family...staring me as the fire dweeb and my brother as the grizzled veteran cop.

Me:  Fire?  Help?  It's a two story ordinary construction single family dwelling with smoke showing from side D.   Life safety issues are paramount.  Engine and Truck are not on scene.  Seek ingress and perform primary search for victims.  Save damsel in distress.  Make attempt to put out fire while calling for help.  Receive, aw shucks medals and awards.  Remain loved by community.

Brother: Fire? Help? Shit! Where's my idiot brother?  Probably sleeping in his Lazy Boy chair.  Mame, can you come out here so I can talk to you?  Keep your hands where I can see them.

Brother: Bang! Help!  Unusual weapon discharge? That was the sound of a Sig Sauer 1911-45-SSS with an eight round magazine.  Probably hasn't been cleaned in a while. Young female inside a home at 1313 Mockingbird Lane sounding distressed while speaking in a loud voice "help?"    All while simultaneously reaching for his concealed weapon, making sure others are safe, getting in his low run stance, moving toward the house, and using his senses to obtain intell on the location of the shooter and the vic.  Ends stand off immediately and brings woman out to EMS for care.

Me: Bang! Help! Shit!  Where's my idiot brother?  I'll bet no one is taking pot shots at the donut shop.  Run toward house and hide in bushes.  See person with gun leaving.  Save damsel in distress.  Make attempt to call for help.  Receive, aw shucks medals and awards.  Remain loved by community.

Epilogue:  Brother receives a "paper" in his personnel file indicating that even though he used his concealed weapon in self defense he had not re-certified on it within 365 days and was therefore not authorized to carry it.  If it happens again he will get three days.  The call happened in a neighborhood watch area and the citizens are asking the mayor to convene a hearing on off duty police officers indiscriminately entering homes without reason.  Woman is now suing the city because she did not want to be saved.  However Brother's Sargent mentions that the shooter is wanted on ten different warrants in six states and has previously shot a cop.  Brother and entire shift go out after work for "stress reduction."

Well at least we both still have jobs.  We hope you do too, and any problems with the police side of the story chalk up to me because I tried to think like him!

Stay Safe.

Sometimes I crack myself up!

Plan B

I have noticed that many of my stories, and those of others have a happy ending because of a "Plan B."  What if Plan B doesn't work?  Has anyone done any planning for those low percentage and high visibility calls when all the stars align just right and you are presented with a major fiasco?

Case in point the December 26-27, 2010 snow storm that hit New York City.  Twenty plus inches of snow blanketed the city with amounts exceeding thirty reported in Northern New Jersey.  This is a Plan B occurrence. But when did it change to a C,D, or E?  When buses unable to move clogged the streets?  When there were ambulances and fire trucks stuck in the street?  When firefighters had to walk a block into a scene because of all the abandoned vehicles stuck in the street?  When priority streets called arteries were not even continuously plowed?  When 1300 EMS calls and an unknown number of other emergency calls were backlogged waiting for any unit to become available to take them (NY Post, NY Times, Phila. Inquirer)?

How do you plan, and what do you do when it's your town of city?  I don't want this to become a Seven Step Process or selecting the best choice technique review.  I just want to get the ball rolling for a discussion of what if based on current events.  A simple way to include all levels of the group and have everyone learn something about abilities and capabilities.

I have long ago forgotten the terminology for sitting around and blurting out the first thing that comes to your mind when a problem or "opportunity" is discussed.  "No answer is wrong, just shoot from the hip."  Then someone writes down the answers and later they are sorted.  At the firehouse it is called the kitchen table.

Here's the way our discussion went.  What if we got 20 plus inches of snow?  I'd ski to work!  I'd find my snow shoes.  I'd probably end up here for a few days.

What about as far as the department?  Well. we have two four wheel drive ambulances.  The medics have a Suburban.  What if there are more than two calls?  We could take the squad it has four wheel drive.  We have those John Deere Gators we use for brush fires.  Yeah, and don't forget the snowmobiles.  Where are they stored?  What if we have a fire too?

You get the idea.  It's not a scripted show.  Talk, remember, relate.  We can see what didn't work on the TV and in the newspapers.  You can literally go as far as you want with this incorporating outside equipment and setting up unified command etc.  Just like the table top exercises that the training and planning guys do just on a different level.

Don't just sit there and say I'm glad it's them and not us.  Maybe you'll even get to Plan F.