Heart Attacks

Heart attacks

Cardiac events are a prime source of injury and death in emergency services. They are attributable to levels of physical fitness and dehydration primarily. Physical fitness is a no-brainer provided you attain it in a responsible manner. A good workout routine will promote flexibility, endurance and strength equally and not push the body to exhaustion or failure. We self-ingest caffeine, energy drinks and protein supplements in our efforts to remain awake and enhance our physical and mental performance; at what cost? Caffeine is a diuretic; it virtually guarantees a state of dehydration. Both caffeine and other substances present in energy drinks override the body’s protective mechanisms and can/do push your cardiovascular system beyond its ability, occasionally causing chest pain, arrhythmia or stroke. Protein supplements require proper hydration to prevent kidney damage, in a firefighting or any high heat, high stress situation you can easily cause yourself permanent damage, or even death when using these supplements while on duty if you are not careful. AP

Hearing loss....what did you say?

Hearing Loss...what did you say?

by Alan Perry

October 1, 2014

Why do fire trucks have headsets? Is it so you can talk to each other? Communicate with the dispatcher? do they just look cool? A federal Q-siren produces 123 decibels of sound pressure, according to most sources this is enough to cause immediate pain and permanent hearing loss within seconds, add a 140 decibel air horn too that mix and you create a dangerous situation for both your crew, and the general public, without substantial hearing protection like that provided by a properly sized and maintained headset. You have hearing protection on the engine. That is good, what about the medic and the other response vehicles? Does the guy in the convertible trapped in traffic in front of you have any protection? Does the small child playing in their yard? 

Warning devices are only one concern, there are many others; chain saws, power tools, PPV fans and pump panels are all dangerous too. Hearing loss occurs from brief exposure to intense sound pressure as well as routine exposure to levels as low as 90 decibels, which is the ambient sound pressure inside an engine or medic just driving down the road normally. Does your Department have a hearing protection policy? Are earplugs available when not in your apparatus? Do all of your response vehicles have headsets like those on the engine and ladder? 

Like respiratory and cardiac injuries we sustain as a result of complacency with the use of other PPE, hearing loss is no different. We injure ourselves in all these ways due to our culture of peer-pressure, not wanting to look weak, and because of lack of enforcement for existing policies and State and Federal regulations. There are two possible explanations for allowing yourself to be injured in these ways; one is ignorance which you can no longer claim at this point, the other is stupidity which I am not equipped to correct for you. 

Don't wait for the hearing loss to occur, if your employer is still able to justify not providing the necessary protection you should provide your own, sustaining a hearing injury or any other injury is never worth making a point. Tradition can be hard to change as can be an organizational culture to presents roadblocks to protecting employee health. New data and studies of the various health effects associated with emergency services are readily available to help organizations and individuals create safer and healthier workplaces, it will be an ever evolving process. We work in a risky profession already, we should remove those risks that we can reasonably control.

Be Safe,
Alan

What's the Future of EMS?

Mobile Integrated Healthcare and the EMS provider

By Alan Perry
9/24/2014

The EMS Agenda for the Future identified the need for Emergency Medical Services (EMS) seeking a broader and more integrated role in the healthcare system. Many variations of that vision have been pursued successfully and are now known as Community Paramedicine or Mobile Integrated Healthcare (MIH).EMS systems are exploring the application of these concepts locally, recognizing that all affected parties; EMT’s, paramedics, firefighters, nurses, doctors, EMS agencies,  healthcare systems & public health, will want to have input in its design. As a provider I have embraced the concept since I first witnessed its practical application some years ago and began to study it intently. I found that the goals of these programs are consistent with the outcomes I want for my patients and provide the tools I need to improve the performance and effectiveness of my EMS system.

Prevention is a key strategy employed by these programs, reducing or avoiding accidental injury, improving recognition and reaction to strokes and chest pain, and linking your patients with the resources they need to remain healthy and reduce both the severity and incidence of hospital admissions. This is the “low hanging fruit” for us; virtually all of these are within our grasp and require no new legislation, regulation, policy or SOP to get them up and running. Those of us that are also in or around the fire service are well aware of the effect of prevention programs on the incidence and severity of fire events over the last 100 years, greatly reducing the incidence and severity of fire events through education, engineering and legislation. The goals of MIH are very similar, if we can achieve even a small fraction of the success of the fire prevention programs it will be a huge success.

As I think about my daily practice, I would much rather spend a little time at a school or senior living center providing this information, than responding to and transporting someone who is injured, or waited too long to call for help. I’m there to help, that’s why I sought this type of work, my goal should be to educate my customers and provide them with resources that will enable them to avoid injury and poor outcomes. Building a new culture within EMS to make this a reality will require changing the way we think about our service delivery and our role as educators. As these programs mature other changes within the health care system are also likely, our role as an emergency resource will remain and our role as educators will expand, beyond that I do not know exactly what our program will look like, but I have a good idea it will be a win-win for everyone.

Be Safe,

AP

Death by Overhaul

Respiratory and inhalation hazards on fire scenes

By Alan Perry

August 30, 2014

Smoke is a complex and dangerous by-product of combustion presenting multiple dangers to firefighters and building occupants during and after a fire event. The most obvious concern is during the fire; where super-heated gases loaded with toxins and asphyxiants can enter the airway & lungs, causing acute respiratory problems. These threats are well understood, as are the dangers of post-fire exposure to carbon monoxide and cyanide, but this is only the tip of the iceberg. I would like my comrades to consider a fuller disclosure about the dangers of post fire exposure.There are other asphyxiants, irritants, chemicals and particulates that are also present during overhaul, investigation and recovery stages, that we do not routinely monitor, but are injuring and killing us due to our complacency. I believe many are lulled into a false sense of security by the lack of information about the harm caused by, and technology for measuring these harmful agents. Consider the typical fire where the scene is declared safe for removal of SCBA based on a low level of carbon monoxide alone. What other agents may be present that have not been tested for, and what are the compounded effects of multiple agents’ short term and long term? If a firefighter or citizen has detectable levels of CO and/or cyanide in their blood, what other agents have they been exposed to? The by-products of combustion are not always present in a recognizable form such as smoke; they can linger for hours or days in the debris and residue at a fire scene and on tools and turnout gear. Just because you can’t see it does not mean it is not there.

The compounds present in the post-fire environment include asphyxiants, irritants, complex compounds and particulates. Most of these are present in all fires; the exact composition will depend on what is burned and how it burns. The transition in home construction and furnishings materials, as well as items kept in storage areas such as garages and sheds can yield a very wide variety of harmful agents when burned. This makes it virtually impossible to predict exactly what, or how much, is present in any given fire event. As I stated earlier, most every firefighter is aware of the dangers associated with CO and cyanide, we talk about these a lot, and we have tools to measure and treat the effects of these. Now let’s look at the “other stuff” that is injuring and killing us.

Asphyxiants- these compounds interfere with transport of oxygen in the blood stream and use of oxygen by target tissues or displace oxygen, causing hypoxia.

            Substance                                 Source                                       effects begin

·       Carbon Monoxide (CO)                   incomplete oxidation of organic fuels

·       Hydrogen Cyanide (HCN)               organic fuels containing carbon & nitrogen                  <130ppm

·       Carbon Dioxide (CO2)                     organic fuels

·       Oxygen deficient atmospheres

Irritant gases- these compounds irritate and in many cases damage the airways and lung tissues reducing their ability to function and causing pulmonary edema and introducing toxins which affect the nervous system, the heart and other organs.

·       Hydrogen chloride (HCL)                plastics, polymers, PVC                                               35 ppm

·       Hydrogen bromide (HBr)                synthetic polymers, flame retardants                          5   ppm

·       Hydrogen fluoride (HF)                   fluorinated synthetic polymers                                    0.5 ppm

·       Sulfur dioxide (SO₂)                        fossil fuels, rubber, tires                                                  0.4 ppm

·       Nitrogen Oxides (NO_x)                    any combustion in ambient air                                       20  ppm

·       Phosphorous pentoxide (P₂O₅)        electrical components, flame retardants                      n/a

·       Acrolein                                                          wood, cotton, paper                                            0.5 ppm

·       Formaldehyde                                  wood, cotton, polymers, plastics                                    0.1 ppm

·       Ammonia (NH₃)                               wood, coal, paper, household waste                             50 ppm

·       Chlorine                                                          plastics, polymers, synthetic rubber                 1 ppm

·       Phosgene (COCL₂)                           chlorinated compounds, plastics, polymers                3 ppm

Complex molecules- long carbon-chain and carbon ring compounds. These compounds can have acute effects and are known carcinogens & mutagens, in addition to their irritant and toxic effects. Several have delayed onset of symptoms.

·       Polycyclic aromatic hydrocarbons (PAHs)  organic materials                                            n/a

·       Dioxins/Dibenzofurans                    PVC, PCB, plastics                                                       n/a

·       Isocyanates                                       polyurethane foam & plastics                                      1 ppm

·       Perfluoroisobutylene (PFIB)           PTFE, fluorine containing polymers                           n/a

·       Particulate matter                           

None of the sources of these materials are unusual, therefore nearly all of these agents can be found in varying concentrations during and after any fire event. The interactions and effects on the human body are still largely unexplored but clearly are likely to affect the health of those exposed. The effects may be delayed for hours, weeks or years and the cumulative effects will be even harder to predict. With this information we can no longer be passive and complacent with respiratory protection. We know the environment during and after a fire is dangerous, we have been given the best possible equipment to protect ourselves, now we must be accountable for our part in preserving our health for our own sake as well as those we love and work with. It's not just the PPE, we have to acknowledge that how we use it, clean it, store it, inspect and maintain it is not someone else's problem, it will surely be ours if we fail to recognize and address the risk.

Something to think about before you pull your face piece off next time.

References:

Wakefield, J.C., A Toxicological Review of the Products of Combustion, Health Protection Agency, 2010

Demling, Robert H., Smoke Inhalation Lung Injury: An Update, Harvard Medical School, Burn Trauma Center, 2008

Thriving on Change

Thriving on Change

By Alan Perry

August 3, 2014

I think that many public safety administrators, and their organizations, struggle with attitudes and traditional beliefs supporting the notion that they are somehow insulated from change by the slow moving wheels of government. The recent history of public safety organization survival challenges can be easily related to the organization’s ability to manage change. Redirecting this traditionalist mindset that believes rapidly changing best practices, regulations, and political pressure do not affect them, is truly challenging. There are several constructive pathways out of this situation, if the leadership, and each of its members, are truly committed to improving the organization. There is no silver bullet, every organization is different and must work within certain parameters defined by local government, a budget, human resource limitations or a myriad of other possible roadblocks. The obstacles to improving your organization’s agility, effectiveness, and value, can be stubborn and will persistently test your resolve.

Our Duty

Our duty, as public resources who exist because of public need and financial support, is to provide the highest quality and most cost-effective service we can with the resources we are provided. We do not have the power or authority to go beyond that; or do we?* we can analyze the attitude of our organization toward change and look in the mirror ourselves asking the questions that need to be asked. Change is a two edged sword, it is rarely a clearly defined or single item that is involved. If not carefully made, changes get bad reputations, leading to skepticism and push-back when implemented. If not made in a timely manner, other less desirable organic solutions may take root or we may miss the opportunity altogether, appearing inept and unable to catch up. We cannot prevent change from occurring, it is desirable to recognize and implement timely, appropriate and responsible change in an efficient and predictable way.

Promotion

The attitude of the organization will mirror the collective attitudes of the members of the organization, with those placed in leadership roles exerting greater influence in most cases, than the front line professionals. We have, after all, given those we promote the ideological nod, reaffirming their personal characteristics and management style. These ranking members are frequently the source of information, and direction for the organization even though they may not be functioning on the front line and may not have done so for a considerable length of time. An organization can easily fall into the trap of hiring and promoting those who do not challenge the status quo and fit a narrow ideological and personality profile. The survival and vitality of the organization will depend on creating diversity in this process, providing a more balanced resource for managing change and avoiding group-think. We should look for those who respectfully challenge the status quo and explore new and better ways of delivering service in the promotional process, and abandon the search for dinosaur eggs.

Hiring

Those entering public safety are frequently termed “type A” personalities which loosely describes people who are self-motivated, enjoy challenges and are assertive; all desirable qualities in public safety. Those we hire tend to fall into even more narrow categories depending on the evaluation criteria. The lack of diversity in public safety is widely known. Any selection process can allow personal and organizational bias to affect an objective outcome. Much like a promotional process, the individuals selected to review the applications, do background checks, and conduct interviews are selected by the administration because of some characteristic that is valued. These individuals in turn will seek out individuals that have characteristics they prefer, likely similar to their own, perpetuating the organizational culture. Does your process intentionally exclude those who challenge authority?, are too analytical, or confrontational? The body is made up of many different tissues, each one essential to our existence, an effective and responsive organization must have variety in its membership, each working cooperatively to help it meet its mission and survive.

Communication

The dissemination of information throughout an organizations structure is essential to effective management, including managing change. Clear communication of new ideas, better ways of doing things, discovery of new challenges, and solicitation for feedback, must occur unimpeded by artificial barriers and tradition. Every organ system in the human body works together to assure the survival of the body, every member of your organization should be given the opportunity to do the same for your organization. An open communication system that permits sharing of ideas and providing bi-directional feedback laterally and vertically within the organization will remove obstacles and improve the speed of communication of ideas and needs. When you burn your finger two things happen; a message goes to your brain informing you that it’s hot, and a message goes directly to the muscle resulting it the reflex removing your finger at nearly the same time your brain feels it. Wouldn’t it be great if your organization could perform that efficiently? How do you think a homogeneous workforce reacts to detecting and managing change?

Justifying Change

Not all change is good, or necessary, and change occurs for many reasons.  Legitimate change improves performance, efficiency and effectiveness, positively affecting the value of the services provided by the organization. Other changes occur due to regulatory or legislative mandates, budget priorities, politics, special interest, personal preferences, changes in administration, because everyone else is, and because it is the path of least resistance. In these cases there is frequently an unsubstantiated need for the change with no tangible benefit. Meaningful change will have a defined goal, represent an evolution rather than change alone, and have a purpose with measurable results. In public safety change should have the added objective of improving the value to the public.

*Or do we?

(Insert can of worms here) We affect the attitudes and perception of the public on a daily basis. We engage in public safety education and are routinely in the public eye. Our organizations are held in the public trust and administered by Federal, State & Local Government bodies that control the environment we must operate in, including our administrations and budgets. Many of us are prohibited from inducing the public to intervene in governmental affairs affecting the organization we are affiliated with, others are not-but the activity is still frowned upon. If public policy or legislation is affecting your ability to make a meaningful change, then confronting that limitation, and compelling its justification, or requesting that it be modified, should not be construed as a hostile act. Any public safety worker, or administrator working for the public good could, and should, seek to educate the public of the particulars and seek their support, if not their active participation, in removing the obstacles.

Get out of the office

As soon as a public safety worker comes off the front line, their perception of the organization (and reality) changes, yet they are now tasked with guiding the path for the organization. The only way to overcome this is to get up and get out on the street with some frequency and understand how your staff are interacting with, and serving the public today. It is a very dynamic environment we work in today, things change almost daily, a sabbatical from the street of 3 months may as well be 3 years. It will be impossible to relate with the needs of the public and your personnel from a desk, an open communication policy will help, but it is no substitute for the raw nuances of the personal interactions and the spontaneity of the feedback you can appreciate in those encounters. You can more genuinely understand you organization and its needs through close personal interaction and more effectively recognize the state of your organization.

Thriving is preferable

Change is required for survival in public safety management. If you put this article down thinking you are safe with surviving and managing change, you have missed my message. Change is inevitable, learn to master it, embrace and love it. Loose the negative attributed to change, it’s not a negative, the changes you make and instill in your organization will be grounded in need and produce value for the public and your people. You and your whole organization can come out of the bunkers and silos, skip through the fields of success, and bask in the sunshine of positive public perception. You and your organization will become agents of change, showing others the way to high performance in public safety.

Be Adaptable,

Danger Everywhere

Danger  Everywhere

By Alan Perry

I came across an article on the NFPA website titled "Firefighter Injuries in the United States", the article summarized some dry data, but I was able to pull a few interesting take way points from it for you to consider.

54% of injuries occur in places other than the fire ground. While fire ground injuries still account for the largest single venue for injury, the majority are occurring elsewhere in training, non-fire events and responding to and from calls.

Since 1981, total fire ground injuries have fallen, but the number of injuries per 1000 fire calls has remained nearly the same.  This demonstrates little improvement in fire ground safety.

The total of non-fire injuries have increased during the same period, with the number of injuries per 1000 non-fire calls declining; an improvement it would seem.

The data does not differentiate EMS calls within the non-fire emergencies even though these account for upwards of 80% of the call volume in most municipal fire departments these days. That may explain the increase in the total non-fire injuries but further study is needed.

My point, if there was one, would be that while Improving safety on the fire ground is still a priority - we need to consider safety and injury prevention in all our actions. On a purely curious note; why does the fire service continue to frame every study in terms of fire ground vs. non-fire if over 80% of our activity is EMS. Why not just add EMS call related injuries? Perhaps it would skew the intended message.

Be Safe,

Alan

Reference:

Firefighter Injuries in the U.S., M. Karter Jr. & J. Molis, October 2013, NFPA

Brotherhood Lost

Brotherhood Lost

By Alan Perry

February 9, 2014

The Fire Service like many other organizations claims a brotherhood among its members, this brotherhood is not elective; it is an expectation. Brotherhood is defined[i] as “the state or relationship of being brothers” and “An association of men united for a single purpose”. In the Fire Service this relationship is (or should be) extended to all members male, female, full-time, part-time and volunteer. Like any familiar relationship there will always be times of disagreement and strife amongst us, if we follow this code we will remain faithful to our brothers and sisters and support them unconditionally regardless of our disagreements. At the core of this belief system are respect, duty, sacrifice and honor. We are good people, how do we avoid human nature and make our brotherhood more than just a word?

I am fortunate enough to have a biological brother, like any set of siblings we have had our disagreements, feuds and physical confrontations, our relationship is stronger because of it, as is our respect and admiration for the path the other has chosen. We would each provide whatever we can to help the other succeed or get through a tough situation without ever the thought of doing anything to harm or diminish the other. This is the standard or lens that I view the Fire Service Brotherhood through. In my career I have had the opportunity to observe the Fire Service Brotherhood from outside and within. I have seen it shine brightly and its name invoked in very dark ways. Like any organization formal or informal our brotherhood will be what we make it, and simply calling it a brotherhood does not make it so.

Unfortunately my first experiences with the “brotherhood” were not positive and made little sense to me. As a volunteer EMS provider I was frequently spoken down to and dismissed by professional firefighters who seemed to view me as somehow less professional in my qualifications and abilities as themselves. I was doing a job they did not want to do, but somehow I was considered a threat to them and deserved little if any respect. In my own department I have found myself on the wrong side of issues supported by this brotherhood and found myself ostracized. While representing my department voluntarily during a national incident I witnessed this brotherhood conducting itself outside its assigned area of responsibility in questionable ways and threatening its members with retribution if they reported it. These were not proud moments, and certainly not what I think our family should be.

These acts persist today; we still treat volunteers and part-time staff like second class members. There is no justification for it. We are all here for the same reason; we cannot assert that a member who volunteers or works part-time is somehow less committed than a full-time person. They frequently do the work we don’t want to do for less or no money and no benefits. We thank them by treating them with disrespect and outright contempt. How can we assert that we have an honorable brotherhood when we treat our co-workers with such blatant malevolence? This may be the exception rather than the rule, but I think that if it occurs even once it is too often and must be corrected swiftly and severely if we are to hold to our true values. Doing otherwise is passively condoning the practice and will undermine the legitimacy and influence of our brotherhood.

So who are our brothers and sisters? Do we limit inclusion to our crew, professional firefighters, our fire department, part-time staff, volunteers, administrative staff, those we like, those that share our faith & beliefs, our race, our church, our lifestyle or all public safety workers? It has been my experience sadly that we tend to find ways to exclude more often than we seek inclusion. This is human nature; we seek and associate more comfortably with those like ourselves. Our challenge is to get away from these narrow definitions and begin thinking more broadly as a “family” instead of a “brotherhood”, including brothers & sisters as well as all others that help us achieve our mission. Treating anyone in our department as something less than a full and equal member is a divisive and reprehensible act. It does nothing but diminish and denigrate the organization and profession as a whole.

Brothers, Sisters, and all of our public safety family, I challenge you to look at your organization. Do you see everyone being treated fairly and equitably without regard for employment status, tenure, rank, who they know, their religion, their lifestyle and skin color? Does everyone have the same opportunity to grow personally and professionally within the organization without regard for these insignificant variations? Does everyone have a mechanism and opportunity to become involved in the discussion and decision making process so their voice and concerns are heard? Does everyone in your family have the support of the organization when things get tough personally and professionally? You must speak for those who are not being treated fairly, disrespected or excluded. By doing so you are representing what is good and honorable about brotherhood and family and can restore faith in it.  

Love, Honor & Respect

Alan

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[i] The American Heritage Dictionary, 2nd College Edition, Houghton Mifflin Co., Boston, MA.