POORLY PLANNED DISASTER DRILLS CRITICIZED AT EMS CONFERENCE
CONFERENCE REPORT
There was much to learn at the fifth annual educational conference of the National Association of Emergency Technicians last May in Boston.
Alexander Butman “What good Is a disaster plan In 11 volumes H other key persons don’t even know of Its existence?”
“Disaster drills and disaster plans are a disaster,” says Alexander Butman, executive director of the Emergency Training Institute in Connecticut.
Too many drills are conducted only once a year, according to Butman, yet they too often show inadequate preparation beforehand and inadequate evaluation afterward. And too many plans show countless hours of preparation but almost no coordination of all the agencies that would be involved in an actual disaster.
Butman also came down hard on those, mostly in rural areas, who make no effort to plan. Their common attitude was described this way: “I live in a small town with only 9700 people. It’s not going to happen here.”
“Bull!” says Butman. Airplanes, for example, can go down anywhere. To demonstrate the possibilities, Butman’s staff charted the flight path of every scheduled airline in the country. Then because a study of crashes showed as much as a 20 percent deviation from the stated route (for a variety of reasons), all flight paths were widened. The result: almost no place where a commercial aircraft cannot crash.
But a too-complex plan may be just as bad as no plan. —
“What good is a disaster plan in 11 volumes,” Butman asked after describing one city’s effort, “if other key persons don’t even know of its existence?”
A plan contained within a single notebook is still too large, he said. Planning for so many possibilities does not indicate foresight to Butman. Instead, it indicates a plan that is too rigid and cumbersome. At least one interconnecting part of a plan always fails, so people on the scene must retain some flexibility.
It’s no good,” added Butman, “if it can t be handwritten on two pieces of paper. And that information must be known and understood by all responders, not just those in charge.”
He then described how drills can in effect teach precisely the wrong things, such as when an unannounced drill is not coupled with a follow-up critique, or has one attended only by officers. Normally, some mistakes are made at a drill, especially when training has not been continuous throughout the the year The effect — in the absence of a critique-is to reinforce the mistakes. The “mistake” is filed away for use next time.
Accounts of actual disasters are suspect, Butman believes, because fire and EMS leadership cannot or will not admit to feing less than perfect. Perhaps they fear lawsuits. The result is not a lot of learning by others.
“What they said and what they did were not always the same,” he said of incidents he knew. One fire chief asserted that a command post was set up within 4.5 minutes at a particular incident. But the fire, police and EMS chiefs did not show up in Butman’s slides of the command post vehicle, which had a too-small banner and only one radio frequency.
That wasn’t a command post, Butman said. It was merely an abandoned station wagon.
Better command post
A better command post would be the first ambulance on the scene. It has numerous radio frequencies, various supplies and can even serve as an on-scene surgical site, explained Butman. Fire and police chiefs would park next to this ambulance to round out communications needs.
As soon as a disaster is confirmed, he advised, radio codes should never be used. Plain English is better for avoiding confusion among various responders.
The purpose of a mass casualty incident (MCI) response, Butman reminded, was to produce the largest possible number of survivors. But an analysis of 22 MCls showed that all too often the first ambulances pic ked up the first victims they saw, even if already dead Setting up a single patient-collecting station where triage takes place, and making ambulance personnel understand the reasons why, was said to be the remedy.
MCI triage is different
Triage is different at a mass casualty incident, which Butman describes as any incident at which you don’t have the time or the number of responders to meet each patient’s immediate needs
In daily EMS experience, responders can lake each seriously injured person and focus on him or her with heroic efforts, even when chances for survival are slim. But an MCI requires that available medical personnel focus on the patients who are most likely to be saved if transported quickly, but without constant care.
David Hon
It a student misses Important Information by daydreaming, or misunderstands the technique, the computer quickly finds out.
Al Weigel
A strongly motivated student can overcome many deficiencies, but a low reading level Is the strongest obstacle of all.
If a patient is not determined to be the highest medical priority for transporting from the scene-but is causing extreme disruption at the collecting area, Butman recommended upgrading his priority, if necessary. The reason: That person can slow your progress in dealing with other patients.
Do you still use canvas stretchers? Butman asked. Well, you should be using rigid wooden boards, he answered.
The use of canvas stretchers with multitrauma victims is totally inappropriate where spinal injuries are likely present, he insisted.
Computer instructor
It takes a trained person to handle an emergency medical incident, but a computer can now teach a class in CPR. Early results of evaluations on the CPR system suggest it can also bring the student along faster with more learning.
The total system includes an Apple computer connected to a videodisc player, two TV sets and a modified CPR mannikin. It was the idea of David Hon, director of the American Heart Association’s division of advanced technology development. And it is a preview of the possibilities for fire service and EMS training.
The system works this way: An instructor on the videodisc introduces CPR technique and leads the student through practice on the mannikin. But that’s only the ordinary part. There’s more.
Sensors and switches in the mannikin determine if the airway has been opened properly. The computer knows if a breath or chest compression is too soft, too hard or just right. Or if the rate is correct.
If a compression was too soft, a human instructor would tell the student to press harder. This system does, too.
The videodisc has recorded responses for every possible correct and incorrect action by the student. Each is stored on the disc in bands similar to songs on a phonograph record. The computer “reads” what the student is doing, evaluates it, chooses the correct response, finds it on the videodisc, and plays it for the student . The student feels like he is having a conversation with a real instructor more than he feels like he is just watching TV.
While the video instructor is explaining a needed adjustment in technique, the second TV shows compression and rate in graphic form for immediate feedback.
If a student misses important information by daydreaming, or misunderstands the technique, the computer quickly finds out. Quite simply, the student cannot proceed through the lesson without demonstrating the proper technique.
On the other hand, a good student does not have to wait for the students who slow down a class. Each lesson is, in effect, personalized for each student. Hon says some students are taking the CPR course in half the time.
Hon thinks the tremendous success of video games — Space Invaders, Pac Man, etc. — should be telling trainers and educators something: Students are no longer satisfied with just sitting in front of a TV or an ordinary film. The video games feature challenging interaction, and that personal involvement is the key to maintaining attention.
Competency-based learning
“Training has become a fixed routine in EMS, and the quality of education has dropped. Let’s be honest about that and see what to do,” stated Al Weigel of the National Registry of EMTs in Columbus, Ohio.
Too often, he explained, instruction is built around a set number of classroom hours. Or students compete against others for grades based on the class average. Better than that is competency-based learning, which refers to concentrating on the body of knowledge to be learned. The final test results are then more important than classroom hours, especially in something like EMS.
Preselection of EMT candidates should get more attention, according to Weigel. He is convinced that a candidate’s reading level is one of the biggest determinants of success in a program. A strongly motivated student can overcome many deficiencies, but a low reading level is the strongest obstacle of all, Weigel says. Some spokesmen have said that a minimum 10th or 11th-grade reading level is required for a paramedic candidate.
Relying on that alone, however, can be found discriminatory, he warned. But combined with evaluations of medical and psychological backgrounds, the overall results can be a safer indication of probable results in a program.
Objectives are the key
Steve McDonald joined Weigel to say that the key to competency-based learning is a set of objectives, or what McDonald calls a clarification of expectations.
Nets Sanddal
Hypothermia Is common In urban areas because of drug and alcohol abuse, and because of the presence of Infants and the elderly.
Richard Judd
Sudden Infant death syndrome Is the highest cause of death between the ages of four weeks and seven months.
Objectives are especially important when multiple instructors are used in a class, as is common in EMS because of specialization. Without written objectives, McDonald indicated, each instructor is uninformed about what other instructors might have said. Overlapping may be too little or too much. Without directions, the instructors often fail to cover in sufficient detail what the student will ultimately be tested upon.
Some flexibility must be retained, however. “Too-specific objectives can lead to mechanical behavior,” McDonald said.
“Before you teach, you need to know where your students are,” he suggested, meaning their current knowledge level. This pretest identifies the gap between current and desired knowledge. The gap is the course.
Teaching without a pretest assessment is like treating a patient without an examination assessment, according to McDonald.
From the audience came a question: What about the person who just cannot take a written exam, cannot even put his name in the right place, yet can perform miracles on patients in muddy ditches?
“I think that kind of person is essentially a myth,” McDonald answered. “The person who can’t do the test realistically can’t perform well in the field.”
Hypothermia
Hypothermia is an abnormally reduced body temperature (95 degrees F is often used) resulting from physiological causes. It’s more common than the public thinks.
“Most people think of hypothermia as more of a risk in the remote outdoors,’ explained Nets Sanddal, training coordinator with the Montana EMS Bureau. But sudden immersion in water on 30 to 40degree windy days, even in urban areas, can be a greater risk, he added.
The EMT’s dilemma is that there is much disagreement over treatment. It is a very young field for specialization; the term did not seem to exist before 1967, Sanddal said. Even now, two books present opposite advice on some treatment.
Contributing factors
Hypothermia is common in urban areas because of drug and alcohol use, and because of the presence of infants and the elderly.
Children have a proportionally large head area, where much heat is lost, and an underdeveloped autonomic thermal control in the brain.
Normal body temperature in the elderly may be down to 97 degrees to start with. Sanddal reported that over 50 percent of hospital admissions for this condition were over age 65.
Another study reported 63 percent of victims were known alcoholics. Diabetes was also said to be a contributing factor.
The primary complaint from some patients in the field may not be hypothermia, Sanddal warned, but EMS personnel should evaluate for it.
Symptoms
Early symptoms are easy to note: Shivering and numb skin at internal temperatures between 98 and 95 degrees.
A slow, stumbling pace, mild confusion and apathy, and some muscle incoordination can be noted in the 95 to 93 range, according to Sanddal.
At 93 to 90 degrees, gross muscle incoordination, slow thought and speech. and retrograde amnesia enter the picture. The hands cannot be used.
Below 90 degrees, he indicated, is the real danger point. Shivering stops. The person cannot walk or stand. He is incoherent, irrational.
The dropping body temperature may take a while to go from 98 to 90 degrees, but the drop is more rapid when shivering stops.
As body temperature approaches 80 degrees, muscular rigidity becomes severe. The heartbeat and respiration slows. Death usually occurs around 80 degrees body temperature.
Treatment
The first treatment suggested by Sanddal was to stop the cooling. But putting a victim in a thick blanket or sleeping bag is dangerous. The victim’s body is unable to adequately warm itself. In that case, a sleeping bag acts as an insulator, not a heater. It keeps warmth from reaching the victim, and the victim’s body still cannot do the job.
While refraining from recommending detailed treatment. Sanddal described some options, reminding the audience about the controversy over treatment.
William Jaillet
“Don’t lose your temper. If you
do, you’ve lost more than you
know.”
Passive external warming is one option. That means a heated room. Active external warming includes immersion in 105-degree bathtub water, or placing hot water bottles at armpits, groin and other areas.
Active core warming means raising the critical internal core temperature with heated oxygen. There was some indication that this was the best way, but Sanddal explained how warm oxygen is not readily available Most ambulances, he said, carry oxygen in a convenient — but outside — compartment where it gets cooled.
“If a victim is less than one hour from a hospital, don’t rewarm,” suggested Sanddal.
Death and dying
EMS personnel see a lot of death and dying. Richard ludd, a professor of emergency medical sciences at Central Connecticut State College, called that the most burdensome responsibility in medical care. As a result, some EMS personnel withdraw from the psychological aftereffects
“But we must come to grips with it,” ludd said, “in order to be most effective with the living.
Anxiety over death can come from frustration at not being able to control the incident, he explained, even when the EMT or paramedic was not at fault.
Or the difficulty may be seen in the families, especially spouses, of the deceased. Understanding is necessary here, too, and intervention may be indicated in cases of severe depression, paranoid states, suicide proneness and posttraumatic stress syndrome.
A paranoid state could lead to unreasonable accusations against EMS personnel or excessive belligerence. Read the body language, ludd said. Great tension in a person warns to stay a way. He reminded that the EMT cannot do everything for everybody.
Total apathy and depression could lead to suicide, ludd urged EMTs to listen for subtle hints of the consideration of suicide.
It s OK, he said, to ask gently if a person is feeling so bad they want to die.
Most experts agree, he reported, that it is important for family members to be able to see the body of a deceased person if they ask, except in cases of mutilation and burns. It helps in their acceptance of the reality of the death.
Sudden infant death syndrome (SIDS), the sudden and unexplained death of infants, is the single highest cause of death between the ages of four weeks and seven months. Parents typically feel guilty, and EMTs could be very helpful, ludd said, if they explain the phenomenon and remind parents that they are not responsible. Those parents might appreciate being referred to the National SIDS Foundation at 310 S. Michigan Ave„ Chicago, III. 60604, telephone (312) 663-0650.
Judd concluded, however, with a caution to discretely watch out for possible child abuse.
Personnel
Personnel matters grow more complicated in view of increasing legal challenges of discrimination, according to William Jaillet, a supervisory personnel management specialist at the federal General Services Administration in Boston. The difficulties apply to all supervisors, Jaillet said.
He asked a hypothetical questions: “Considering that fire and EMS personnel must work on Sunday, is it reasonable (and legal) to ask a candidate for employment.
‘Does your religion prohibit working on Sunday?'”
Jaillet said it was neither reasonable nor legal because it could be a basis for discriminating unfairly. For example, the idea may be against someone’s religion but not actually observed by the candidate.
Instead, he suggested how critical information can be exchanged without opening up charges of discrimination. Rather than ask the question, make a statement: “This position requires work on Sundays. Can you fit into this schedule and requirement?
Instead of asking about physical or mental disabilities, a city or company physician can screen applicants with discrimination. Or all candidates could be required to have their personal physicians to certify they can perform the indicated duties, Jaillet said.
Discipline
Discipline is another area where the supervisor can challenge legally. Equal punishment for equal offense is the rule. But at Christmas, for example, an offense may be excused in the spirit of the season … at your peril. If another employee breaks the same rule in January, and you’re so fed up with that offense that you then discipline the second employee, you are set up for a discrimination charge.
Especially when dealing with union contracts, a “past practice” precedent may be set up by overlooking an earlier rule violation.
Common mistakes of new supervisors include dictatorial practices. “We’re gonna do it my way” they say on the first day. But Jaillet suggested keeping things the old way until you evaluate the existing system, and then make changes slowly.
“Don’t promise more than you are sure you can deliver,” he suggested. Saying “I’ll take care of your problem” could lose the respect of your subordinates if you cannot deliver. Better to say, “I’ll see what I can do “
A supervisor’s public comments carry heavy weight, reminded Jaillet, “So don’t criticize an employee to other employees.” On the other hand, he cautioned against giving extra attention to extra performers. It appears to be playing favorites.
A strong Jaillet warning was, “Don’t lose your temper. If you do, you’ve lost more than you know.
