Send in the Clowns (Wearing Vests)

July 20, 2009 – 12:12 am

Cross posted to TKT

Well, it looks like the fire service objections to the high visibility vest rules will be sustained by the feds. The Federal Highway Administration (FHWA) rule 634 notice of final rule published in June 2009 apparently will acquiese to fire service cries of foul, allowing exemption from the need to wear hi-vis vests when engaging in fire suppression activities on roadways where the requirement for hi-vis vests would potentially endanger firefighters. The final rule should be published before the end of calendar 2009. We hope. See the feds comments and proceedings here.

Now for my thoughts. Sure, a vest could melt or pyrolize, emitting cyanide and/or other toxic gases. And yes, in the case of a raging inferno, we might be compelled to close the roadway to civilian traffic, essentially eliminating the danger from some errant vehicle mowing down an innocent member. But let’s be real. Real world, that is. I’ve carried my high-vis vest in the pocket of my bunker pants now for three years. When I’m in the road, I put it on. It’s never melted at a vehicle fire yet and if it did, you bet your bipee I’d have my BA on. Maybe you close the roadway - I don’t. Keeping traffic moving, in my mind, lowers risk. Less gawkers, less congestion, more opportunity for the public I serve to see me in action as they pass by, less time I spend restoring normalcy. And heck, read the NIOSH reports - fire apparatus mows down as many firefighters (maybe more) than crazed civilians do.

I’ll wear the vest. And not the $80 special flame proof version some entrepreneur dreamed up to pad their wallet. The $15 one size fits all version works for me. Go figure. If your feet are on the street, the vest should be on your chest. Simple. Let move on.

Mike McEvoy

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A War Surgeon’s Perspective On Memorial Day

May 22, 2009 – 5:35 pm

(Cross Posted to Fire Engineering Editorial Blog and TKT Blog May 22, 2009)

This essay was written by Dr. John P. Pryor. He was a trauma surgeon who refused to be idle when so many wounded Americans and Iraqis could be helped by his skills. He enlisted in the Army reserve and wrote this article after completing his first tour in Iraq. 

   “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.

 

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H1N1 Flu: Get Your Facts Straight

May 3, 2009 – 12:16 pm

(Posted here first, also posted on Fire Engineering Editorial Blog,  Fire Rescue1.com and linked from TKT)

 

 

Egypt ordered a mass slaughtering of pigs as a supposed precaution against swine flu.  Vice President Joe Biden told Today show host Matt Lauer that airplane and subway travel posed high risk for flu virus transmission.   An ED doc in the Dallas area purportedly circulated a panicked email claiming the National Stockpile is virtually depleted, local EDs are overrun with flu cases and the media is engaging in a full blown cover up of actual flu cases.  It seems like swine flu idiots are everywhere.  Never has a time been more opportune for Fire/EMS providers to exercise what they do best: keep people from panicking.

 

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

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Swine Flu: What You Must Do Now

April 27, 2009 – 10:18 am

(originally posted to Fire Engineering Editors Blog and TKT Blog April 27, 2009)

The swine flu buzz is causing information overload. There are three things pertinent to the fire service that must be implemented immediately to protect your members, provide excellent patient care, and be a good public health partner. Here’s the list:

Fire Service Leaders

  1. Immediately notify all members and staff of the emerging problem.
  2. Review your plans using the CDC EMS Pandemic Preparedness checklist.
  3. Set up an email list and web site to provide continual updates and info for your members.
  4. 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

  1. 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?
  2. Relay responses to these questions to EMS units before they arrive on scene.

Firefighters and EMS Providers

  1. Request additional information from dispatch when sent to respiratory, sick person and fever related calls if limited initial dispatch information is provided.
  2. Perform initial interview of all patients from at least 2 meters (6.5 feet) away to determine if personal protective equipment precautions are necessary.
  3. Place a mask on all patients with suspected influenza symptoms before approach. Use a surgical mask or non-rebreather mask (when oxygen is required).
  4. 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.
  5. 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.
  6. 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.
  7. 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

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Swine Flu: A Pandemic on the Way?

April 24, 2009 – 11:24 pm

(originally posted on Fire Engineering Editorial blog April 24, 2009)

Uh oh. By now, you’ve probably read our breaking news reporting a swine flu outbreak in Southern California and Texas. Is this novel virus with confirmed human-to-human transmission the start of a pandemic? Maybe, maybe not. The CDC released a MMWR report with full details of the US cases investigated as of Friday afternoon, April 24th, 2009. The World Health Organization (WHO) is concerned.

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.

Mike McEvoy
Fire Engineering EMS Editor

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HIPAA Horsepucky

April 23, 2009 – 12:04 pm

(originally published on Fire Engineering Editorial Blog, April 23, 2009)

In small town news worthy of national laughter, the City of Albany, New York treasurer refused to release copies of forgiven parking tickets to an investigating committee citing HIPAA privacy rules. The Health Insurance Portability and Accountability Act of 1996, for those with momentary lapse of memory, provided protections against unauthorized and unnecessary disclosure of medical records. Fire/EMS services made numerous business modifications to comply with HIPAA. Some 13 years after implementation, HIPAA remains poorly understood and is often incorrectly cited by folks unwilling or uninterested in sharing information.

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.

Mike McEvoy
EMS Editor
Fire Engineering

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Dead Wrong…Again

April 23, 2009 – 11:13 am

(originally published on TKT April 23, 2009)

The recent news splash about two Las Vegas firefighters who mistakenly declared a patient dead is a painful lesson on the consequences of complacency. The patient, who had shot himself in the head, was found alive by the coroner after responding firefighter/EMTs called off an ALS unit, deciding the patient was deceased. He survived for two days after finally being treated and transported to the ED.

There are multiple opportunities in the Fire service to end up on CNN. Death pronouncements, or mis-pronouncements as happened in this case, provide tremendous opportunity for a couple of folks to make themselves and their entire department look like idiots.

Deciding that death has occured is a big deal. Every time it happens, the folks involved need to consider the consequences of being wrong. In my April 2007 FireRescue1.com article about field pronouncements, I discussed what needs to be done by departments and individual firefighters to prevent this sort of embarassment. The news media is reminding us: it’s time for a review!

Mike McEvoy

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Watch What You Brag About

April 12, 2009 – 5:54 am

(originally posted on the Fire Engineering Board blog, March 10, 2009)

Working to improve your cardiac arrest reversal rate? Keeping an eye on Departments who proudly tout consistently high resuscitation rates? Maybe you shouldn’t. Medicine, particularly cardiovascular medicine, has evolved a hundred fold in the past two decades. We used to focus most of our time and energy trying to lessen damage during an acute MI or attempting to bring the dead back to life. You still do. But the medical community took a long hard look at the causes of cardiovascular disease many moons ago and reinvested their greater energies in preventing these lethal events. And they’ve done a darned good job of it. In some places, that is. With statins, beta blockers, aspirin, ace inhibitors, sophisticated pacemakers, internal cardiodefibrillators, health care practitioners today have made substantial inroads against cardiovascular disease. So much so that acute MI’s are caught early, treated and sent home without significant tissue damage. People prone to sudden cardiac death already have an implanted defibrillator. Heck, if your disease is so horrible, you can even take an artificial heart home with you nowadays. Bottom line: when good medicine is practiced in a community, there are less cardiac arrests. And cardiac arrests do occur, they more often than not represent terminal events - people at the end of their lives: flatline, asystole…

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.

Mike McEvoy
EMS Editor - Fire Engineering

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A New York Oops

April 12, 2009 – 5:45 am

(originally posted to The Kitchen Table blog February 8, 2009)

Go figure. At some point in 2005, the New York Legislature aligned a series of Vehicle and Traffic Laws with federal specifications to assure continuance of federal highway and traffic safety monies. Somehow, somewhere, things went awry. Curiously, the faux paux went pretty much unnoticed by the group most affected: the Fire Service. Until several weeks ago. That was when the New York State Association of Fire Chiefs pointed out that it became illegal in 2006 to drive most fire apparatus under non-emergency conditions without a Commercial Drivers License (CDL). And oooh, the hoopala, the finger pointing, the indignation.

No doubt the “error” will be remedied. Legislatively, most certainly. Put things back the way they were. Whose crazy misinterpretation was this anyway? Obviously moronic. But is it? Some might say no.

What truly is ludicrous is that a state government, arguably one of the most top heavy in the nation, could somehow overlook a detail like consulting with the Fire Service before they changed a law with such significant impact. Even more amazing is that not one fire service organization, union, association, department, or local noticed. Out of touch? Seems like it. But then, Congress wiped out fire and EMS protections in the Ryan White Law a couple years ago without telling anyone. And no one noticed that until that deed was done, either.

Back to the CDL thing. Bad idea? Maybe not. I took a little inventory of my small upstate New York volunteer fire department. Most of our members actually have a CDL. And if you ask any of them if a CDL helps make you a safer chauffeur, they’ll think for a minute and say it probably does. For my part, having learned all about air brakes, truck transmissions, diesel engines, and everything else that came with my CDL some thirty years ago seems to give me better command of any fire apparatus I operate. Now of course, ask any member without a CDL whether having one would make them a better chauffeur, and they’ll typically think not.

In most states, you can drive a 48 foot motor home with nothing more than a regular drivers license. So why not a fire truck? Indeed. That’s the way it’s always been.

Mike McEvoy

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Courage and Pain: Dr. John Pryor

April 12, 2009 – 5:42 am

(originally posted on The Kitchen Table blog January 7, 2009)

It happened on Christmas day. A single mortar fired randomly into the Mosul Air Base killed combat trauma surgeon Major John Paul Pryor, MD, age 42. Dr. Pryor was serving with the Army’s 1st Medical Detachment, based in Fort Totten, New York. He served in 2006 as a trauma surgeon for the 344th Combat Support Hospital in Abu Ghraib. He volunteered to go. He leaves behind a wife, Dr. Carmella V. Calvo, and three children, Danielle, 10, Frank, 8, and John Jr., 4, his parents, Richard C. and Victoria Pryor of Florida, and his brother, Dr. Richard J. Pryor of Albany, New York. John was the trauma program director at the University of Pennsylvania, affectionately known as HUP (Hospital of the University of Pennsylvania) in Philadelphia. His family, colleagues, friends, and neighbors are devastated.

 

I feel somewhat responsible. Around 1991, John Pryor, at the age of 17 joined the Clifton Park-Halfmoon Ambulance Corps in the small upstate New York community where I lived. He worked with myself and a cadre of other medics who shared a lifelong passion for EMS. To say that John developed an interest in medicine would be a gross understatement. Truth be told, the bug bit him and became his lifelong passion. I taught John in his first EMT course, precepted him as a medic, wrote countless medical college references for him, and remained friends with him until he died on December 25th, 2008.

 

I’ve said this countless times over the past weeks: the story of John Pryor is one that needs to be told. Why would a successful trauma surgeon with a lovely wife and three young children volunteer to serve in Iraq? I’ll tell you why in John’s own words. The way John viewed the world changed while in medical school in Grenada. John realized that he was privileged. After September 11th, 2001, he found it very difficult to, “sit around and drink a beer knowing that there were soldiers in Iraq who needed surgeons.” He had a special skill and there was a need. The risks were enormous. Every soldier, surgeon, and medic knows why John Pryor was in Iraq on Christmas day. He needed to be there. “He was there so that we can be here,” said Lt. General Eric Schoonmaker, surgeon general of the Army who spoke to family and friends at John’s burial.

 

John was not only a talented surgeon, he was a loving father, wonderful friend, and very personable human being. All the years I knew him, he was upbeat and happy. John had a knack for being able to put people at ease. He was humorous and playful. He lived life with passion. He missed his family whenever he was away from them. Surgeons who trained under John often described him as a gentleman, a word rarely seen in the same sentence with the word ’surgeon’. He shared his knowledge and expertise with anyone who asked, speaking at EMS conferences, teaching nurses and medics, and mentoring others. His family has established a website to honor John’s memory at www.drjohnpryor.com.

 

The life of John P. Pryor was extraordinary. His loss is felt profoundly. His memory calls upon each of us to examine how we live our own lives.
Mike McEvoy
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