Recently I was asked at one of our area hospital’s quarterly employee meeting. The hospital‘s CEO gave a “state of the hospital” briefing, and I followed with my presentation on fire and EMS response in the post-9/11 world.

Obviously there always will be natural and intentionally caused disasters that will produce injury and death and require the services of a hospital. These include an airplane crash, bridge collapse, fires, floods, tornadoes, and hazmat and mass-casualty incidents. A disaster also may involve a pandemic with response currently being preplanned by the Centers for Disease Control and others in public health and the threat from both domestic and foreign terrorism.

My discussion centered on recent events with common threads that could be relevant when discussing what hospitals might expect in the future. I drew on such attacks as the Oklahoma City bombing, the Sept. 11 multi-pronged attacks, bombings in Malaysia and Madrid, the London bus and subway bombings, the failed London car bombs, and the Glasgow Airport attack. The common denominator in these incidents was the terrorists’ desire to cause a maximum number of casualties and disrupt a normally safe environment. In several cases, the attacks included a small detonation designed to draw the crowd into the path of a secondary and much larger explosion.

These incidents produced an overwhelming number of walking wounded who found their way to the nearest hospitals on foot or by public and private transportation, reserving ambulances, medic units and onsite triage for the most critical patients. My discussion with the hospital staff included how to deal with this surge of wounded, including the gross decontamination of potential patients before they could enter a medical facility. If, for example, local fire and EMS resources are dealing with the most critical injuries, rescue and extrications, who is left to set up any decontamination? Alternate means might be needed to treat the masses.

The discussion then turned to the order of any emergency response activation. Unless there is a prestaged event such as an impending hurricane or the Super Bowl, the order would most likely be:

• Local fire/EMS responders and initial mutual aid departments: up to 12 hours




• Regional and intrastate mutual aid: four to 24 hours




• EMAC activation: 24 to 72 hours




• Federal resources: 72 hours to demobilization

The bottom-line discussion determined that the hospital staff needed to be self sufficient for at least 72 hours with food, fuel, decontamination equipment and supplies, as well as manage the schedule of their professional and support staff to avoid burnout. If this sounds familiar, it should; This is what FEMA has begun asking the fire service to do when it is deployed to other locales. The final discussion points included the need to consider revising their plan and practice for future events including those of longer durations caused by both natural disasters and terrorist attacks.

What‘s in the future is anyone‘s guess, but preparing for emergencies of longer durations with more casualties is probably a good guess.

Many U.S. fire and EMS organizations use some form of the 24-hour shift for around-the-clock staffing, but that may soon be changing for both employers and employees. Changes may stem from decreased employee safety and decision-making capabilities while working 24-hour shifts, increased organizational liability for actions by employees working 24-hour shifts, and shifts in worker attitudes about work schedules in general.

In its study entitled Sleep-Wake Cycle: Its Physiology and Impact on Health, the National Sleep Foundation found that sleep deprivation has an adverse affect on:

• Physical health and well-being. In the past few years, investigators have found that sleep loss may have harmful consequences for immune and endocrine systems and can contribute to serious illnesses such as obesity, diabetes and hypertension.




• Cognitive performance and mood. One study showed that people who were awake for up to 19 hours scored substantially worse on performance and alertness tests than those who were legally intoxicated.

Other studies have found that after one night of total sleep deprivation, subjects scored significantly lower on tests of judgment, simple reaction time, explicit recall and inverse word reading. Also daytime alertness and memory are impaired by the loss of eight hours of sleep, especially when sleep loss is sustained over a few nights.

Think about this in terms of rising EMS calls. How functional is an EMT or paramedic in an ambulance at 2 a.m. when he or she has been awake and on duty since 8 a.m.? One of the attractive features of the 24-hour shift is the firefighter’s ability to live a significant distance from the assigned duty station yet still have time for the commute. If that same medic awoke at 5:30 a.m. to arrive in time for ta tour of duty, he or she really has been awake for 20.5 hours when faced with a critical patient-care decision at 2 a.m.

In a Merginet survey of EMS providers, respondents were split almost in half regarding their preference for 24-hour shifts in both the hospital and pre-hospital community, even in light of the research that sleep deprivation has an adverse impact on decision-making.

In light of that same research, can fire and EMS managers continue to support shift schedules that, though desirable to the employee, aren’t in the safety interests of the employee or the public? When more than half of all EMS accidents involve operation the ambulance, can a department afford to have an employee behind the wheel whose cognitive abilities may be akin to those of the motorist taking a field sobriety test at the scene the motor-vehicle crash? We need to be asking ourselves that question and before a plaintiff‘s attorney does it for us.

For more than 30 years, fire departments across America have taught and encouraged individuals to learn traditional cardio-pulmonary resuscitation methods in the event they should witness a sudden cardiac arrest. That‘s about to change.

A few years ago, Sarver Heart Center, Mayo Clinic College of Medicine, Arizona’s Bureau of Emergency Services and the Arizona Fire Chiefs Association formed a cooperative program called Save Hearts in Arizona Registry & Education or SHARE.

Under the program, 38 Arizona fire departments have been instructed in cardio-cerebral resuscitation, a method for use only on adults. Dr. Bentley J. Bobrow presented the statistics based on the switch to CCR this week at the Arizona Fire Chiefs Association’s annual meeting.

“We cannot do what we cannot measure, and the first step in addressing a problem is to document it,” said Bobrow. “A bystander doing CCR triples your chance of survival, and Arizona is the only state that has been able to publish its statewide cardiac survival rate.” This fall, the results of the SHARE research will be presented to the American Heart Association.

CPR calls for two mouth-to-mouth breaths after 30 chest compressions. CCR is 200 chest compressions immediately followed with shock and the sequence is repeated. “We have a tremendous tendency to over ventilate people,” Bobrow said. “It‘s the kiss of death. Focus on chest compressions … 200 chest compressions, uninterrupted by pulse checks.”

Bystanders who witness a sudden cardiac arrest tend to not do CPR because of the mouth-to-mouth resuscitation, but might be willing to do CCR because it doesn‘t involve ventilation. Glendale Fire Chief Mark Burdick has set a goal to teach CCR to 25,000 people in his city annually. Also all volunteers for Super Bowl XLII will be taught CCR. “The goal is to train as many people as possible,” said Burdick.

Each year, more than 400,000 Americans die from sudden cardiac arrest and “only a fraction survive,” Bobrow said. “Out-of-hospital cardiac-arrest survival rate is usually very low.” In fact, one fire department’s survival rate with CPR was 2.6%. After being trained and switching to CCR, the fire department’s survival rate increased to 9.1%. Another department’s survival rate just from 3.7% pre-CCR to 33.9% after CCR was implemented. Eleven of 38 departments are now using the new CCR protocol.

“It‘s more than just saying a fire department is doing it,” said Bobrow. “It‘s about if you are actually doing it. It comes down to compliance.” He compared the response of an emergency medical crew to a NASCAR pit crew. Each member of the emergency medical crew has a specific part to play, and timing is critical. “Even a 10 second interruption is enough to decrease survival,” he said.

So far this year, more 270 lives have been saved in Arizona using CCR. “In 25 years, nothing has shown improvement in survival rates,” said Bobrow. “The whole country is watching what we‘re doing here in Arizona.”

Other areas of the country also are switching to CCR. In Wisconsin, Rock and Walworth Counties have introduced Call and Pump, a “simplified CPR. It is a rural implementation of an urban effort that was initiated … in Tucson, AZ by Drs. Ewy and Kern of the Sarver Heart Center.”

Earlier this year, Chesterfield Fire & EMS responded to an early morning blaze in the Village of Ettrick, an unincorporated area southern end of Chesterfield County, Va. The 1.5-story single-family dwelling on Totty Street was practically outside the backdoor of Fire Station #12, home to Engine and Truck 12. Though those units were on scene within minutes, the 6:30 a.m. fire already had an advantageous head start. Intense smoke and heat from the fire claimed the lives of two young children, and a third child suffered burns and smoke inhalation. It’s been a long time since we’ve had a multiple-fatality fire in Chesterfield County; in the early 1980s four children lost their lives in another early morning fire in a single-family dwelling. This fire prompted me to think about the stuff that firefighters do every day to help make Chesterfield County a safer place to live.

Working smoke detectors in family dwellings are the real deal. One big factor in my not being able to readily recall the last multiple-fatality fire is the great work that we’ve done in pushing the installation of smoke detectors and ensuring that they work. We put them up for free, we hand out batteries for free, and we check them for free while on other calls for service. Many firefighters can recall stories that either begin or end with, “if not for the smoke detector going off.” Unfortunately, there were no smoke detectors in the dwelling on Totty Street.

The challenge today is to ensure that immigrant populations get the smoke-detector message. We must work to ensure that there are working smoke detectors in every family dwelling that we go into. This is going to require a different strategy because of the language barriers. We‘re working to establish working relationships with existing community groups like churches and social service agencies that already have connection with these new populations to get our message out. Many of these folks are on the lower end of the socioeconomic scale, their housing is in poor condition, and that housing is more densely populated.

Fire company in-service training scenarios aren‘t make-believe. Green Bay Packers coaching legend Vince Lombardi once said, “perfect practice, makes perfect.” Every officer that I’ve ever known who has had responsibility for developing in-service training has tried to provide realistic scenarios that challenge firefighters to “practice well so we can play well.” Each of the fire companies in our combination system — we have three platoons of 22 engine companies and five truck companies, approximately 600 career and volunteer personnel — receives a full day of in-service training three times per year. Many of our in-service scenarios over the past couple years have featured a burned-out stairwell or a fire-threatened stairwell as a critical factor. The house on Totty Street had stairwell that was completely burnt out, denying access to second floor via the stairwell.

We are a fire & EMS department. Like many of our colleagues across the country, about 70% of our calls for service involve EMS. Of the remaining 30%, many are calls for a wide range of services having little connection to structural firefighting. In the words of Gordon Graham, noted speaker and subject matter expert in the area of organizational risk reduction, fighting fire has become a low-frequency, high-risk activity for our department and many like us. Therefore, we must continually be prepared, regardless of where we are stationed, to engage in the physically and emotionally charged atmosphere of firefighting where lives are on the line. Our “first name” is still Fire.