In the absence of gravitas: crapola

[October 27 2009]

The latest in a countless series of grave warnings sent by email with an ever-changing list of signatories, this one was supposedly from a PhD MD RN MSc and opened with this phrase:

"No one should take the swine flu vaccine-it is one of the most dangerous vaccines ever devised"

Tachycardia with a hint of all-out gallop

[October 20 2009]

For whatever reason, the national media haven't quite zero-zeroed in on the realities associated with H1N1, the vax, and high-risk groups. Certainly, the tone of local and regional coverage has shifted from cautionary optimism to creeping negativity.

Whether the media gets it right or wrong at this point is unlikely to make a dent in the public perception of being at the heart of something wicked this way comes.

If you were to take a pulse of America right now, I believe you’d find it in tachycardia with a hint of all-out gallop as intense fear rides on the cusp of all-out panic.

The indicators for me arrive on the hour in the form of email queries from healthcare professionals, community leaders, and emergency management colleagues wanting to compare notes on what personal steps they can take to protect themselves and their loved ones from H1.

To further confuse and confound, there are mixed messages being sent by federal, state and county health officials to the public they serve, e.g. 1020 State officials understand and share frustration associated with H1N1 vax shortages [Massachusetts].

If you ever wonder how rumor generators get primed, read this piece out of North Dakota and imagine the news being transmitted on a national game of broken telephone: 1020 DoH recommends revax of some individuals against H1N1 [North Dakota].

With so many people with functional limitations [the vulnerable at the moment] mixed into the at-risk groups, this ongoing crisis represents a significant challenge for us all. How do we ensure a fully-inclusive response?

Sometimes it feels as if the professionals would rather not disturb the peace with discussions focused on what happens when the victims of emergencies or the emergencies themselves don't act in ways predicted by the plan.

Were it only so easy if disasters had neither victims nor responders but only featured rulemakers who could wear funny hats.

Be well. Practice big medicine.

Hal

Renewing terror and other tricks of mass evacuations

[October 19 2009]

It's been a long while since this happened however it seems the story continues to have a serious impact on those with whom it's shared.

And that's interesting in and of itself in that several colleagues have approached me recently because they've heard this story presented at conferences by folks other than me claiming it as their own.

Except, of course, for the part where the presenters accept responsibility for making fateful decisions because in their telling of my story this happened to 'someone they know' or 'an unnamed colleague' and they proceed to dis' him for his lack of knowledge about their community.

I was actually very familiar with the community I served.

I was the director of Cote Saint-Luc EMS in January of 1998. The City of Cote Saint-Luc was an interesting place to lead a team of emergency medical services providers. There was a very high percentage of the population who were 65 years of age and older and embedded within that considerable slice was a large community of Holocaust survivors.

Our EMS department was innovative in its outreach efforts and in its expanded scope of service that made it more of a psycho-social service than a purely emergency medical services organization.

On January 5 the freezing rain storm began to take a toll on the power grid. At 05h00 on the morning of January 6th, dispatch began to become inundated with calls for assistance. There were reports from Hydro-Quebec that some 700,000 households were without power in a large swath of southern Quebec.

On January 6 we realized evacuations were likely to become a necessity. At 11h35 we received the first of what would be many calls for medical verifications. A 75-year-old man was on a home oxygen system and plans were made for his eventual evacuation.

We were sliding further into crisis. Our calls were multiplying while available resources were shrinking. People were finding it difficult if not impossible to find a hotel room anywhere in Montreal.

From crisis we went directly into the abyss. No need to pass Go. I called for assistance from the provincial government to assist with establishing shelters for the thousands of senior citizens and medically fragile residents we were evacuating from dark, frigid, carbon-monoxide-intensive apartment buildings.

You could not measure the depth of my despair when I realized no help was coming. That feeling of profound isolation was almost immediately replaced by the realization that we would have to take care of ourselves - no cavalry would be riding over the hill to come to our rescue.  

On January 7 at 10h42 our crews began the assessment of a 10-floor seniors residence. At 10h46 the transport of the first 16 evacuees from the building begins. They taken to a shelter established at City Hall. The fire department is called to the scene to ventilate the building after fumes from the emergency generators circulate throughout the hallways.

On January 8, Hydro Quebec reported 950,000 households are without power.

I made mistakes.

We had many senior-centric highrise or multi-building facilities that had to be evacuated. Given the sheer number of evacuations and the limited humans available to carry out the task, we drafted police officers to assist with these mass evacuations.

As police officers, many in tactical or bulked-up gear due to the extreme weather conditions, went door-to-door in the darkened hallways, hundreds of Holocaust survivors flashed back to a time of forced evacuations and transport to the death camps. 

When bubbies and zaidies* scream.

We had, of course, unintentionally made matters worse by providing the police officers with instructions to residents to gather their essentials into a bag as quickly as possible and then make their way to the lobby where they would be loaded into buses for the ride to the shelters.

At the shelters we had the standard line-up check-in procedure. The first round of evacuations resulted in dozens of cases of severe mental trauma and more than a few syncopal episodes. 

When the plans failed, we adjusted.

We adjusted by having our medics accompany the police officers on their evacuation rounds, softened the approach, used as much light as could be hauled around, brought social workers into the mix on the buses and altered the check-in procedure to include large round tables where a social worker and a medic were assigned to each table to help residents acclimate to their new surroundings.

It became more like a last-minute social gathering. Thank goodness. 

On January 10th, Hydro Quebec reported 1.4 million households without power. Water had to be boiled prior to consumption.

On January 11th, the army arrived with more than 11,000 soldiers on the ground. The Abbruzzesse Family had power in their kitchen in Montreal North. Huge trays of wonderful Italian dishes were transported across the city to feed our crews. Smaller army. Just as appreciated.

I remember a satellite phone conversation with someone at an agency considering lending us a hand during the disaster. We were evacuating another 100 or so seniors from a nursing home at the time. The gentleman on the phone said they might be willing to send someone to better assess the gravity of the situation. Right at that moment a large piece of ice dropped off the top of a 20-floor building and hit a parked car on the street behind me. There was a large crash. The man on the phone exclaimed, 'What was that?!'

My reply, 'Hell just froze over, sir.'
 

Be well. Practice big medicine.

Hal

*Bubby and Zaidie are the yiddush words for Grandmother and Grandfather respectively.

Fat Man On Trek to Conquer Cancer

[September 26 2009]

If you had to pick someone who would be the least likely to become addicted to road cycling more than 30 km each and every day at speed you need not look any further than me.

So, it's a bit surreal to think that come July 2010, I will be joining thousands of other cyclists riding the 250 km [in two days] from Montreal to Quebec City to raise funds to support the fight against cancer.

I'm riding for Abraham, Rose, Mimi, David, Susan, Gil, Mario and many many others who fought cancer right up until their dying breaths.

http://www.bigmedicine.ca/normrooker.htm#Not_as_good_as_I_once_was 

I'm riding because I never ever want to answer the front door again to find a friend so visibly shaken my wife didn't even recognize his face. A firefighter/medic, he had been diagnosed with kidney cancer. He knew something was wrong and even verbalized the probability of cancer before being whisked into a CT scan by a physician who feared the worst.

Of all the private and public hells a firefighter must tackle in the course of his/her career, I cannot imagine the fear and uncertainty that comes with the word, "Cancer." As a firefighter, I was always aware of the risks that come with 'the job' but somehow you never think that one of those risks will come home with you and change your life forever. Certainly, there's the possibility of injury or even death battling blazes or effecting rescues but those are risks we've accepted and worked into our view of life and career.

Cancer wasn't part of the bargain. And yet, here in Canada, thanks to efforts of a few determined firefighters in Winnipeg and Ottawa, several provinces have added “firefighters’ presumptions” to their workers’ compensation laws, deeming certain types of cancers to be related to work as a firefighter unless the contrary is proven. Kidney cancer is high on the list.
 

I'm riding because Mario Peloquin deserved so much better than to have been killed by a particularly aggressive form of cancer. Mario was a paramedic in Sorel-Tracy [about 90 km from Montreal]. He was a lover of jazz and classical music and a musician in his own right. He was a treasured dad. I attended his funeral because I wrote about the efforts of his EMS brothers and sisters who had tried so hard to ease his final passage.     

I’m riding because cancer needs to be beaten back into a corner and then squished like a bad bug - with a big boot.

Please visit my Fat Man On Trek to Conquer Cancer website and consider making a donation. http://www.conquercancer.ca/goto/FMOT

I am committed to raising as much money as I can - with $2500 set as the minimum. I am looking for corporate sponsors willing to match the donations made by individual donors. I am hoping to find others who would like to join me on the ride and in the fight against cancer.

Be well. Practice big medicine.

Hal

You haven't lived till you've been declared dead

[August 31 2009]

I have a strange relationship with the Government of Quebec's Health Insurance Agency. Every couple of years they declare me dead.

They don't actually check to see if I have pulse. No one comes over to verify whether I'm breathing - or not. They don't even send an Sp-3 form over to the house for any physician friends of ours to complete.

They just notify the Director General of Elections for Quebec that I no longer require a Quebec Medicare card because I've ceased to exist. And then the Director General of Elections of Quebec sends a note to tell me that my name has been stricken from the electoral list.

Then I call the Elections folks and assure them I am very much alive, still paying my property, income and corporate taxes, still hold a Canadian passport and have recently renewed all kinds of forms for other Quebec government agencies including my driver's permit and our vehicle registration.

And then we talk about how strange a situation this is.

And I tell them about the last time the Health Insurance folks declared me to be null and void and no longer in need of a Quebec Medicare card. July 7, 2007 was the last time this happened. Actually, it happens every couple of years on randomly selected dates.

The Elections folks have a theory that some bureaucrat is jerking my chain because of the randomness of the dates. They say that if the notification to them that I am pushing up the daisies was at least tied to the date my driver's permit expired, they could write this off as some kind of bizarre one-in-nearly-eight-million IT system error.

The apparent randomness of them receiving notification of my sudden departure from this address and this plane of consciousness leads them to believe that someone is deliberately tampering with my supposed-to-be-sacrosaint-data in their allegedly-secure database.

This does not give me the warm and fuzzies when I consider the future of electronic health records. You have to wonder how it's possible for one citizen's records to be altered on an ongoing basis. And while the deletion from the ranks of the living strikes me as a very serious concern, the Elections folks are aghast that someone could have their right to cast a vote eliminated in this manner.

They weren't going to let this slide. They framed a strategy. They said I needed to reach out to my local elected provincial representative and let he and his staff know what had happened. And if that doesn't work they suggested dropping a line to the Premier's office. No one has the right to mess with your right to vote. Not in this Province. Not on their watch.

The good news is that I have been restored to the electoral list and can vote in the upcoming municipal elections. The bad news is that there is some concern that I'll be having the same conversation with the folks at the Elections office in two years, give or take a month, when news of my death is greatly exaggerated once again.

Be well. Practice big medicine. 

Standing with Serge

[Nov 2 2008 - updated Jul 27 2009]

I’ve been looking at medical surge as a series of ever-larger waves crashing ashore in that they continue picking up more and more debris and carrying that further inland until finally they begin to ebb. 

All the surge plans I’ve seen are based on the notion that the emergency healthcare system will need to handle more and more patients until finally the peak flow is reached.  

There is a fair bit of ‘resurrection medicine’ built into these plans – the need to reach into death’s door and pull the victims back into the land of the living.

Shouldn't we be looking at creating critical care field triage levels that would prevent the surge waves from carrying patients requiring resurrection-medicine from reaching the ERs? Isn't it about time we took a hard look at plans that would include field-based palliative care units?  

Any idea on the total number of mechanical ventilators and respiratory techs there are in any given major jurisdiction in the United States or Canada? Anyone have a breakdown on that number per hospital – just the major centers?

So now that we're seeing a strong run on tickets for a possible Kick Your Ass tour for A/H1N1 in the fall, does anyone have any idea what we can anticipate in terms of both clinical attack and absentee rates when it comes to the respiratory techs themselves? Has anyone got any ideas about who to train and how to train them in Ventilation for the Uninitiated?  

Does anyone have numbers for pediatric vents and resp techs at pediatric centers? It seems that the vast majority of hospitalizations in a more virulent return of H1N1 would be among children below the age of 15. Unless I've missed something, we just do not have the collective pediatric resources to provide care on that scale.   

The estimates I've heard sure don't give me any peace of mind - and the fact that the actual numbers seem to be so closely guarded also gives me pause. Certainly don't get the vibe there are overwhelming numbers of either ventilators or the human beings required to make them effective lifesaving tools.

As my friend Roy says, "It has been nearly five years since the discussion of vent shortages in the United States began with SARS as the stimulus. So, in five years the US has apparently done little to increase the number of ventilators available for pandemic flu surge and train a much-enhanced healthcare cadre to manage ventilator systems in compromised patients."

The problem is, as Roy so aptly quips, "Vents are not particularly sexy or worthy of discussion in a healthcare system barely able to manage a bad season of colds and flu."

My educated guess would be that roughly 85 percent of the available mechanical ventilators in Montreal hospitals are currently in use. Combine that with an average ER occupancy rate in the 90-something percent range and we're not talking surge - we're talking about a damned near bankruptcy of the emergency healthcare system.

Roy's educated guess is that the same percentage of current daily use holds true for the 100,000 or so ventilators available across the United States at any given moment. 

"Disaster preparedness typically includes plans that address the need for surge capacity to manage mass-casualty events. A major concern of disaster preparedness in respiratory therapy focuses on responding to a sudden increase in the volume of patients who require mechanical ventilation." - Mechanical ventilation in mass casualty scenarios. Augmenting staff: project XTREME, Hanley ME, Bogdan GM. 1: Respir Care. 2008 Feb;53(2):176-88; discussion 189

While I recognize the wonderful work done by major trauma centers that kick themselves into overdrive to deal with 20-30 seriously injured patients from a single incident, I believe it's time to take a real-world look at what happens when there are 100 or 200 or 300 or maybe 1,000 people who are sick or injured?

Or when there are tens of thousands of people concerned about their children who are presenting with the signs and symptoms of pandemic flu.

And perhaps it's not a one-time event.

I live in Montreal where the EMS system runs on a Basic Life Support platform and where firefighter-first responders have been limited to a SSU [sticky side down] approach when it comes to providing care for patients prior to an ambulance crew's arrival.

The idea that somehow the combined Fire/EMS system would be able to successfully triage, then transport more than 100 critically ill patients from a single incident without completely outstripping available resources is pretty well pure science fiction.

The EMS system is constantly short of ambulances and crews. There are a finite number of firefighter first responders. And that's when the going is relatively good. Throw in an icy night and a few multi-patient car crashes and maybe simultaneous multi-alarm fires [definitely not unheard of in a major metropolitan area].

And we don't need to be talking pandemics or terrorism. We could be talking about an ethyl-methyl-bad-stuff incident at one of the multiple chemical facilities that are smack dab in the middle of a heavily populated center. All that's required to tip the balance between feasible and outright chaos is a higher percentage of critically ill patients.

If the walking wounded aren't - then we've got a serious problem on our hands. It's not as if we're going to tell the populace to get a pick-up truck and an air mattress and take their neighbors to the ER on their own. One major incident doesn't come with permission to suspend operations for the rest of the population. Just standing with Serge and talking with Roy watching the waves crash on Tundra Beach.

Be well. Practice big medicine.

Hal

A medic who lost his way

[July 18 2009]

Signing thanks

[July 16 2009]

Be well. Practice big medicine.

Hal

Not so private musings

[July 13 2009]

Social media and emergency management 140 characters at a time

[Jul 12 2009]

USA #H1N1 | Statement by NACCHO on RAND study of states' provision of online info concerning H1N1 [Jul 9 Washington DC] http://bit.ly/7jUIe

9.48 pm Jul 9

USA #H1N1 | Health depts get mixed marks for using web to communicate about flu crisis [Jul 9 Alexandria VA] RAND Study http://bit.ly/uW8QZ

9.48 pm Jul 9

USA | CDC launches new environmental public health tracking network [Jul 9 Atlanta GA] http://bit.ly/hOaE2

9.47 pm Jul 9

Check out Laurie Van Leuven's 'Web 2.0 for Emergencies' http://tinyurl.com/6gfmgf 'access to emergency information is critical'

5.24 pm Jul 9

Have you checked out sneak preview of 1st chap of W. David Stephenson's new book on democratizing data? http://tinyurl.com/6x5m63

5.22 pm Jul 9

Saturday musing: http://socialcollider.net/ The Social Collider reveals cross-connections between conversations on Twitter.

6.30 pm Jul 4

So, what would social media look like if apps were designed to include emergency mgmt - can we design an experiential experimental network?

1.11 am Jul 2

#ogma personal reflections: absolutely blown away by DHS willingness to engage w/out political rhetoric. ogma was thoroughly free of dogma!

1.09 am Jul 2

#ogma Network Sci reflections - education - CERT is good starting point.. incorporate W2.0 in all relevant training activities

6.06 pm Jul 1

#ogma Network Sci reflections - infrastructure - craft procurement standards.. inventory asset mgmt.. culture of rapid change

6.05 pm Jul 1

#ogma Network Sci reflections - application - develop a construct for app.. goal directed.. define for public safety use.. functional reqs

6.04 pm Jul 1

#ogma Network Sci reflections - mandate use of W2.0 among your own teams.. use social media to share knowledge.. enhance outreach to W2.0

6.03 pm Jul 1

#ogma Network Sci reflections - sharing - clearinghouse..community of champions.. cross pollination for practitioners.. tech evangelists

6.02 pm Jul 1

#ogma Network Sci reflections - mechanisms to educate people at the top.. better describe needs.. get a sense of value and communicate it

6.01 pm Jul 1

#ogma Network Sci reflections - push, pull, mobilize.. infrastructure needs.. education.. protocols.. trust.. knowledge sharing.. broad spec

6.00 pm Jul 1

#ogma Hybrid people can act as translators among various EM/HS tribes. Easier to pull off in medium term vs systemic changes

5:56 PM Jul 1

#ogma We haven't done a good job in this country in sponsoring research - prove the need to Congress.

5.55 pm Jul 1

#ogma Other research funding streams available - need to make it matter. Tie research to deliverables.

5.54 pm Jul 1

#ogma We need to provide real-world funds for researchers to publish findings, actionable info in EM/HS trade journals

5.52 pm Jul 1

#ogma so how do we move from stream of consciousness and free verse to paragraphs to a narrative.. a real need to continue dialogue!

5.44 pm Jul 1

#ogma My own experience in creating NEMRC-Big Med Gustav/Ike streams is proof positive remote virtual teams can play integral role for EOCs

5.14 pm Jul 1

#ogma New VistaCorps for young people to assist EM/HS?

5.13 pm Jul 1

#ogma Have you established protocol for monitoring W@.0 and social media in EOC? Beginning to move in that direction...

5.11 pm Jul 1

#ogma California using data pulled from OnStar to analyze real time traffic flow. Push, Pull, Mobilize!

5.08 pm Jul 1

#ogma i have learned there is a real future for Big Med's intelVIEW near-real time streams for situational awareness. Go figure.

5.06 pm Jul 1

#ogma govt procurement cycles are 2 yr process. by the time acquisition is made some tech providers could be bankrupt. not a timely gig.

5.04 pm Jul 1

#ogma reality is not using social media as a disruptor for existing psap

5.03 pm Jul 1

#ogma how do you harness the power of 'virtual' volunteers?

5.02 pm Jul 1

#ogma great california shake-out .. home depot measures sales behavior..still unsure who bought and what was impetus . Messaging, content?

5.01 pm Jul 1

#ogma challenge if tech folks are disconnected from ops - better incorporating tech depts within systems for EM/HS

4.58 pm Jul 1

A River runs through us

[July 3 2009]

I am just back, bare feet tucked under desk, typing away on my keyboard after spending three game-changing days at the Ogma gathering at the Navy Post-Grad School in Monterey, California.

Thoughts in a non-linear somewhat faithful to chronology flow:

Ogma. Celtic god of alphabet.

A River of information runs through us. There is no point in pretending that it is somewhere out there and that we have the option of turning our heads away in order not to see or feel the flow.

The much sought-after ideal of true community resilience depends on our willingness to embrace the notion of the River - W2.0 - social media.

An enormous obstacle comes in the form of ensuring there is an interactive flow of information. We need to create real, not intangible BS, value-add for both providers and consumers of information.

Are we perhaps afraid to acknowledge the River because to do so is a tacit admission that we have somehow lost control of the flow of information? Are we migrating between stages in a grieving cycle linked to the proliferation of social media?

Are we, as emergency management practitioners, confronted with the reality that our position in society is in flux? That's a terrifying concept for many leaders to confront. Organizational change is usually measured in multiples of years. How do we create a framework for a phenomenon evolving at an exponential pace?

What are our known needs? How can we know what we need if we have not yet accepted the mere notion of the possibilities available?

We are excellent at creating networks but how do we measure whether or not we have achieved the key element identified by multiple Ogma players - how do we measure Trust? How can we rebuild a social network on the fly if it is compromised? What are the metrics we are using to measure Trust?

Before I set out for Ogma one of my daughters asked if there was going to be a test at this gathering. I told her the whole thing was a test I couldn't study for.. turns out I was right.  

Where do we go from here? How do we get there? Are there any lines on the horizon or is everything stitched together seamlessly in varying shades of grey?

Be well. Practice big medicine.

Adopt A Medic

[May 31 2009]

The Adopt A Highway program was created to promote community pride and to help carry out or sponsor activities such as mowing, weeding, landscape beautification and litter pick-up. There's even a company you can pay who will provide the cleaning so that you can receive the recognition and 'display your civic pride.'

While adopting a section of the Trans-Canada Highway would certainly give me the opportunity to put Big Medicine's name on a sign that would be seen by thousands of motorists each and every day, I've been thinking that maybe what we really need is an Adopt-A-Medic program.

We could donate a bit of money each month to an organization that would be tasked with ensuring our adopted medic's family can afford more than just the basics. Basics that are hard to come by when our government continues to pay the same base salary of the old days while continually adding to the individual responsibilities of the medics and simultaneously refusing to bolster support for the system itself.

Daniel Garvin is a street medic in Montreal. We've known each other for a couple of decades. He's still working on the ambulances. I'm 49 years old and I cannot even imagine hauling myself into those garages every morning to start a shift. It's a tough job. It tears at your heart and it hammers away at your soul. It follows you home even when you try to leave it in the rig. It has to be a calling because otherwise who the hell would voluntarily take on such an insane role.

"One of the biggest hardships of being an EMT-P here in Montreal is obviously the salary. While many of my friends and neighbors ask why do we continue to work in such conditions, my answer is always the same, we are in this for the people, not the money. I feel that EMS is a calling, more than just a job."

"Most people I know have the regular 9-5 boring obligation and rarely talk about the workplace in social circles. On the other hand, whenever we gather socially, my job always sneaks its way into the conversation. "Busy week Dan?" "Did you work that accident on the 40 the other day?" "Any news about your contract?"

"The paramedics that I work and am associated with in other systems are dedicated to rendering the best possible pre-hospital care they are capable of giving. The salary is secondary.

"Lately though, our employer has been putting more responsibility on our shoulders and not matching that with compensation. When I began in EMS some 24 years ago, we were officially trained to perform CPR and administer oxygen to patients in need. That was almost the extent of our services in the medical sense and the salary reflected that.

"Today, we administer front line medication, intubate patients to establish airways, deliver shocks to patients whose hearts have stopped beating, monitor patients' vital signs and intervene when necessary while en route to hospital, deliver babies in diverse situations, deal with psychiatric emergencies - sometimes while putting ourselves in great peril.

"These and many other interventions are what make up our day on a regular basis and we are still being paid the base salary of the old days. When will we be recognized for what we do?

"Our families do without because of this injustice. Paramedics in Ontario are being paid properly and doing the exact same job we do here in Montreal, paramedics across Canada are being treated much better than Quebec."

Danny would likely punch me, hard, if I told him my idea about the Adopt-A-Medic program. He's not the kind of guy who has ever sought a hand-out in his life. He is a feet-on-the-ground family man who is the kind of paramedic I'd entrust the lives of myself and my family with. He is a hard core street medic. You need to be pretty damned hard core to continue working in an EMS system that has been Circling The Drain pretty much since the day it was established.  

The more I think about the Adopt-A-Medic program the more I like the concept. We could become sponsors for Quebec's paramedics. They could wear a patch on their uniforms with our names on it so the people they encounter each day will know that our paramedics are a source of civic pride - at least for some of us.

Of course, I realize that it's the role of our government to adopt and embrace our paramedics and treat them with respect and appreciation. I have never understood the government's unwillingness to recognize the importance of the people who provide our emergency medical services.

After all, no matter who you are, when the shit hits the fan and you're critically ill or injured, your life will be in the hands of Daniel Garvin or one of his colleagues. I already know they'll do their best in those extraordinarily difficult moments.

What I'd like to be assured of is that the government is doing its best to support them and their families with a real-world living wage, with a generous pension plan, and with resilient support systems that will stand the test of time and changes of administrations.

Be well. Practice big medicine.

Hal  

Gone fishing

[May 25 2009]

Last evening I exchanged notes with a well-regarded television journalist who seemed to be actively refusing to acknowledge the importance of news-on-the-net via social media as a real-world alternative to the nightly newscast.

The discussion was surreal at best. She truly believes 'we' need her and her colleagues to be our filter because we can't understand the facts on our own. 'We' need journalists to decipher the code for us.

When I mentioned that near-real-time situational awareness already exists via the net her reaction was almost comical were it not so damned tragic: She warned me about the dangers of too many fragmented views.

My friend Andrew Fielden [follow him on Twitter @AndrewTF] reminds me on a regular basis that no one service provider can have a monopoly on the sources of the data.

He attended last week's Media140 gathering in London and among the many comments he made afterwards was that "Twitter itself is seen as the latest threat to the media in that it appears to allow people to go direct to the source in real time and create an instant news thread which require only the presence of the microblogs and linking through to blogs and other supporting digital elements."

So what happens when the 'great unwashed' are unleashed and able to generate news of their own making? Are there any guarantees that what they produce will be any less important than that which is professionally produced in a multi-million dollar studio?

I think not. Often, I am struck by the incredibly poor job the 'professionals' do at communicating a story. Last week, I read an op-ed in the Washington Examiner wherein the name of a man who was sent to Syria and tortured because he was mistakenly suspected of being a terrorist was replaced by the name of a man awaiting trial for allegedly killing an American medic in Afghanistan. Do not disturb with the facts. Professionals at work.     

In emergency management, we talk about situational awareness as if it were the holy grail and in many ways it is. That ability to sift through multiple streams to pull the essential nuggets out on an ongoing basis is at least as important as the ability to craft a compelling narrative to ensure the information can be shared effectively.

However, the key to gaining that type of perspective is knowing what kind of nuggets you need to be fishing for at that moment in time - or more importantly, for the next several moments in the future.

Retired Canadian Forces Col. Richard Moreau [now a VP with Ottawa-based Prolity] teaches a serious 'leadership in crisis program' that emphasizes the need for intelligent awareness. According to Richard, if you don't provide guidance on what you're looking for, don't be surprised when your intel crews come back excitedly proclaiming, "We've got cod! We've got cod!"

At some point, you're going to have to explain to them that you were looking for swordfish.

Which brings me back to my exchange with the television journalist. I'm not sure what she's fishing for, because of course, there's no way for the collective 'us' to provide her with guidance on what we believe is important. It was clear in the course of our brief conversation that she thinks she knows what we need to learn and that we would be lost without these self-anointed guides. She mentioned words like 'trust' and 'credibility' however left out key terms like 'depth of understanding' and 'real-world expertise.'

So, I go fishing on my own, looking for a spectacular mix of views, opinions and facts from which I will draw down my own intelligent situational awareness.

I don't need a nanny journalist to 'sort it all out' for me every evening.    

What we have here is a complete and total failure to communicate

[May 2 2009] - Updated May 6 2009

This morning I received the following press release from a colleague in the United States. I've highlighted the passage of greatest interest to me.

Release No. 0142.09

Contact:
 

Statement By Canadian Minister of Agriculture and Agri-Food Gerry Ritz, U.S. Secretary of Agriculture Tom Vilsack, and Mexican Secretary of Agriculture, Livestock, Rural Development, Fisheries and Food Alberto Cardenas
 

May 02, 2009
 

"We would like to express our deepest sympathies for the victims of the current outbreak of H1N1 influenza and emphasize that our governments are doing everything they can to bring the outbreak under control.

"We strongly urge the international community not to use the outbreak of the H1N1 influenza as a reason to create unnecessary trade restrictions and that decisions be made based on sound scientific evidence. H1N1 influenza viruses are not spread by food. International organizations, including the World Health Organization (WHO), Food and Agricultural Organization (FAO) and the World Organization for Animal Health (OIE) all reiterate that the consumption of pork meat and related products do not present a health risk of contracting H1N1 influenza. Canadian, American and Mexican authorities have emphasized that they have not found a case of influenza in swine herds. All three of our countries are committed to ongoing monitoring and vigilance in both public and animal health.

"The current outbreak of H1N1 influenza, which is being spread from person to person, is being addressed by the health and sanitary authorities of our three countries, emphasizing the need for cooperation and a common front against this new virus. In addition, we fully support OIE efforts to alert and disseminate relevant information published by its members' laboratories in real time about the disease."

This afternoon I received word from a trusted source in Canada that two pig farms in Alberta [Clearwater County] were under quarantine after the first probable human-to-swine transmission of the A/H1N1 flu virus. A farm worker returned from Mexico after contracting the disease. The virus found in the Alberta pigs is the same strain of A/H1N1 found in human cases. [The carpenter, the producer, and the producer's family had been ill with flu like symptoms between 14-29 Apr]

The story is now being reported in the mainstream media. 

The question I would like to ask is, "How long has the Canadian government known about the situation in Alberta?"

Just curious because, according to CTV News, "when a lab cannot identify the subtype, it has to be sent to the National Microbiology Lab in Winnipeg which is the only lab in the country that can confirm this new strain of H1N1."

The testing process takes more than just a few hours so you'd begin to wonder what the chain-of-discovery would look like on the political level. Who would make the decision to go out with a statement reassuring people the swine herds are safe? Would they be in the same information loop as those working to confirm the genetic makeup of the virus affecting the pig herds in Alberta?

[Updated May 6 2009] - And the answer to this question "How long has the Canadian government known about the situation in Alberta?" is - since April 21st as a possibility, April 28th as a probability and since May 1st as a certainty. 

"A Canadian Food Inspection Agency (CFIA) team attended the premises on 28 Apr [2009] and collected samples from swine for influenza virus testing. Swabs and serum samples were received at the CFIA National Centre for Foreign Animal Diseases (NCFAD) in Winnipeg on 29 Apr 2009. The samples were run in conventional RT-PCR for the Matrix and the H1 gene (primers kindly provided by the PHAC [Public Health Agency of Canada] National Microbiology Laboratory, Winnipeg). These results showed that 19/24 samples were positive for the M gene and 15/24 samples positive for the H1 gene."

It's interesting because when I searched on Google for "Release No. 0142.09" I found myself on the Newsroom of the United States Dept of Agriculture website with the following notation:

Release No. 0142.09
Contact:
USDA Office of Communications (202) 720-4623

Printable version
Email this page Email this page
 

This Content Is No Longer Available

___

This is yet another example of the communications disconnect that has plagued [sorry] the A/H1N1 outbreak from the start. One mouth has no idea what the other mouth is saying. All speak and no listening.

One scientist says we have nothing to fear. The other says it's only a matter of time before things get worse.

Be well. Practice big medicine.

PS. Received the following at 18:30 this evening.

CANADIAN FOOD INSPECTION AGENCY

May 02, 2009 18:20 ET

CFIA: An Alberta Swine Herd Investigated for H1N1 Flu Virus

OTTAWA, ONTARIO--(Marketwire - May 2, 2009) - The Canadian Food Inspection Agency (CFIA) indicates that it has found H1N1 flu virus in a swine herd in Alberta. The safety of the food supply is not affected and Canadian pork continues to be safe to eat.

It is highly probable that the pigs were exposed to the virus from a Canadian who had recently returned from Mexico and had been exhibiting flu-like symptoms. Signs of illness were subsequently observed in the pigs. The individual has recovered and all of the pigs are recovering or have recovered.

While further testing is needed to more fully characterize the virus, the CFIA is taking a precautionary approach. The herd has been placed under quarantine, and the Agency is working with public health colleagues to determine the most appropriate next steps to ensure that public and animal health remain protected. The chance that these pigs could transfer virus to a person is remote.

Influenza viruses do not affect the safety of pork, according to the World Health Organization (WHO) and the Food and Agriculture Organization of the United Nations (FAO). As with any raw meat, pork should always be properly handled and cooked to eliminate a range of food safety concerns.

Pigs in Canada are tested for influenza viruses on an ongoing basis across the country during routine investigations into respiratory illnesses. The CFIA is working with provinces, territories, the swine industry, and private sector veterinarians since April 24th to enhance monitoring of swine herds for signs of illness and to maintain enhanced biosecurity measures on farms across the country.

Which begs the questions:  How would it be possible for a farm worker "exhibiting flu-like symptoms" to be in contact with the herd on a swine farm? Were there no bio-security protocols in place?

A minifesto for the Quebec pre-hospital care system

[Mar 27 2009]

Quebec's prehospital care system and the tragedy on the ski hill

[Mar 19 2009]

Natasha Richardson died yesterday. She succumbed to injuries suffered on a beginner's trail at the Mont tremblant ski resort. She was 45-years-old.

Some folks have suggested that a neurosurgeon and an MRI within two hours of injury might have made a difference.

Sacre Coeur Hospital is a long haul [about 80 km - 36 miles] from the Ste-Agathe Hospital where Ms. Richardson was initially transported - that’s a very long ride in an ambulance.

I cannot help but wonder if the outcome might have been different if the accident had occurred in a jurisdiction with advanced care paramedics and an integrated helicopter medevac system that would have ensured rapid transfer to a tertiary care facility.

And that lingering doubt shows no sign of fading, especially in light of the news this morning that the first ambulance crew called to the scene left without ever even seeing Ms. Richardson.

Interestingly, when there are NASCAR or Formula One races in Montreal, there are medevac helicopters on standby to transport injured drivers from the track to one of the two major trauma centers that serve Montreal.

Sadly, that’s not the case for the rest of the year and for the rest of the people.

So, while there are Advanced Life Support paramedics based on ambulances, firetrucks, and helicopters everywhere else in the G8 - here in Quebec, the powers-that-be have decided ALS paramedics are just not necessary for the chain of survival.  

That’s your chain of survival, folks. To quote Jim Duff, “It’s the system that begins with a 911 call and ends when the hospital moves you out of intensive care — or to the morgue.” 

In Quebec, we don’t have Advanced Life Support paramedics because, despite the embrace of all things secular, when it comes to our provincial Emergency Medical Services [EMS] system we have placed our faith in God – and the skills of the resurrection specialists working in our hospitals' ERs.

If God is smiling down upon you, you just might survive the ride in the ambulance that delivers you into the hands of his emissaries in the ER.   

With one of your feet already firmly planted in death’s door, the nurses and physicians of the ER will do their darndest to successfully pull you back towards the light. And once you’re confirmed to be back among the ranks of the living, there will be high-fives all around in the crash room as yet another soul has been saved.               

And if you die, well, you died because you were destined to do so despite the best efforts of the team waiting in the Emergency Department.  

You just cannot have an effective Advanced Life Support Emergency Medical Services [EMS] system in a society that has bought a lifetime prescription to the notion of supporting a monopoly on who should save lives. 

In Quebec, physicians save lives. Ambulance technicians [primary care paramedics] deliver patients to the physicians.

Perhaps one day soon we will begin placing our faith in the people who have the wisdom, experience and courage to work the frontlines of emergency medical services instead of having them continue to serve as the pick-up and delivery service for the ERs.

In the meantime, you can try praying for a miracle. 

There should never be a monopoly on saving lives or helping people in an extraordinarily difficult moment of their lives.

Because heroes are human

[Mar 14 2009]

"It may sound absurd but don't be naive

Even heroes have the right to bleed"

- lyrics to Superman [Five For Fighting]

"Yesterday I received news that a young firefighter/medic had taken his own life. Another gatekeeper of the cracks who somehow managed to slip into the abyss that exists in the shadows between the ranks of fellow EMS providers. 'He was a gentle soul who was genuinely caring and a real pleasure to work with'... and he was practiced in the art of self-isolation enough to drift in ethereal misery until he finally capped his own existence" - October 2007 Big Med"

"The first people to arrive on the scene, emergency services personnel witness traumatic events with every shift. Yet they continue to perform their essential duty of saving lives -- often in the face of unspeakable tragedy. So unspeakable, in fact, that many of these heroic individuals struggle quietly with the physical, psychological and emotional effects of their jobs." - the Tema Conter Memorial Trust www.tema.ca

Vince Savoia is one of my heroes. Not for the work he did as a paramedic although I am certain there were heroic moments in those days.

It is the work he has done since responding to Tema Conter's murder in 1988 that strikes me as filled with sacrifice, dedication, passion and a real sense of purpose. After coping with post-traumatic stress as a result of responding to the call, Vince established the Tema Conter Memorial Trust to honour the memory of Tema and to call attention to the acute trauma encountered by emergency services workers.

Tema Lisa Conter was born and raised in Halifax, Nova Scotia. She was the daughter of the late Dr. Ralph Conter and Deborah Conter, and a sister to Howard and Arlene. Tema was full of life and happiness, and lived life to the fullest. Throughout her school years, university and career she was known to her many friends for her humour, wit and charm and always as the life of the party. Her special personality connected her with people of all ages; once that connection was made they were forever her “buddy”.

Tema was especially loyal and devoted to her family, coming home for visits at every opportunity, also making her grandmother, the late Ruby Hamburg, her top priority. She was generous and caring to her friends, never begrudging the happiness of others but always finding joy in their good fortune. After graduating with a B.A from McMaster University, she then furthered her education at the School of Retailing at Chamberlain College in Boston, majoring in fashion merchandising. She moved to Toronto in 1985 and began a career in fashion management. She worked as a buyer and manager for an established ladies wear retail chain.

On January 27, 1988 at the age of 25, Tema was murdered by a convicted serial killer who had spent most of his adolescent and adult life in jail. In a fatal error of the justice system, this man, who had been placed in a half way house , in a mid-town Toronto neighborhood, entered her apartment building early that morning and attacked Tema while on her way to work. Her brutal and senseless murder, a nightmare beyond belief, was reported in detail in all of the papers.

A virtual sprint towards a Big Med Community

[Feb 28 2009]

Big Med is proud to announce the launch of our tick-it - a powerful communications tool designed to link the Big Med Community via a ticker that resides right on your desktop, laptop or mobile phone. The tick-it is persistent and does not require a browser. Nothing is stored on your computer. And it's free.

tick-it allows members of the Big Med Community to share messages and information while helping organize updates and alerts. tick-it gives each of us the ability to create our own groups - to invite others to share the experience - and to transfer essential info across a busy, fragmented world.

You'll need to play with the tick-it a bit for you to get the hang of it - however it's a quick, easy and fun learning experience. Like CNN and other news tickers, there's a stream of headlines [click on each one to see more of the story and any links].. The remarkable difference with tick-it is that each of us can add news and information to the stream.

Right now, you're invited to join the Big Med Alerts & Info tick-it stream. As soon as you're signed-up for that tick-it group, we'll invite you to join other groups designed to deepen the stream of information being shared. You'll be able to monitor multiple groups or channels simultaneously, or you can switch between them like TV channels. 

Remember, the Big Med tick-it is designed to empower our community. You'll be able to interact with content, post your own news, and share stories with your friends and families - seamlessly and securely. Enjoy!

To join the Big Med tick-it please visit http://tick-it.balaya.com/groups/subscribe/373  to accept the invitation. The group will be added to your tick-it automatically.

You can find out more about this group at http://tick-it.balaya.com/groups/view/373

If you are new to the tick-it, please visit http://tick-it.balaya.com/ to sign up and download the tick-it.

Be well. Practice big medicine.

Hal

PS. Less than 24 hours after the launch of the Big Med tick-it, I was just invited to join a new tick-it group created by a member of our community. That is so cool! 
 

Run away from rescue

[Feb 4 2009]

When confronted with unfamiliar territory and a survival situation, many people follow a line of cascading decisions that lead to the unthinkable - they run away from rescue.

I understand how the average Jack/Jill can end up rejecting the omnipresent dangers inherent in a survival situation and do everything in their power to hold on to the familiar instead of embracing their new environment. I understand how those decisions can lead to someone sticking to what they believe is the trail and walking over the edge of a cliff.

What I don't understand is how a supposedly seasoned emergency manager can make the same type of conscious decisions on behalf of his/her constituents and do everything in their power to prevent new ideas from circulating in their fiefdoms in the midst of a disaster. By refusing to embrace the new environment, they are, in effect, leading the move to run away from rescue.

Yesterday, I found myself having to explain that someone reaching out for assistance in the midst of a disaster probably wasn't looking for a political leg-up. It was a surreal conversation due in part to the fact that the folks doing the reaching out were just trying to help the citizens who rely on them for help in a crisis. You might have guessed that wasn't the surreal part.

You're right. The surreal part was trying to convince a senior emergency management advisor that maybe it was just help these people were seeking and not a threat to the political status quo.

I went with the following line:

"So, what would be the ulterior motive of someone calling from a church in the midst of a disaster zone to my office in Montreal asking for help getting extra supplies to his congregants. All the while, he knows he's reaching out to someone in a different country - except he doesn't see it that way - he just knows maybe there's a chance he can get find some hope from another network of caring people. Maybe he's worked out that going outside the normal system will mean getting lifesaving help quicker. What's the political motive there?"

There was a long pause at the other end of the line. I thought maybe I'd made the point.

Not so lucky.

Clearly calling from the bottom of a hermetically-sealed box, the voice on the phone said, "Maybe he's just trying to embarrass us politically by taking his request to another country."

Or maybe he's just trying to find a source for crates of Ensure to feed the elderly residents who decided to weather the storm in their home, or maybe he's trying to arrange for a couple of hundred of extra blankets to be sent his way because the power might not get fixed for two more cold weeks, or maybe it's the family with a special needs child who need extra medical supplies...

Maybe he has embraced his new environment and determined he needs to take bold decisive action to survive. Perhaps he has decided to run towards the rescuers.

___

Newsflash: Your constituents will, no doubt, take notice when you make a big deal of attempting to halt the flow of help, new ideas, the exchange of lessons learned, or the swapping of stories. It has been my experience that there is no more powerful endorsement of someone offering to help than trying to prevent them from doing so.

Be well. Practice big medicine.

The culture of preparedness

[Dec 30 2008]

Everyone talks about ‘creating a culture of emergency preparedness’ but no one talks about what the key elements are when creating any culture. How do we design a culture of preparedness to be used as a safety anchor for people to grasp onto when threatened?   

If we’re trying to get people to understand that the ‘cavalry’ is not going to come riding over the crest of the hill to save them from most disasters – what are the visible attributes of culture – do we use artifacts [a rooftop with SOS spelled out on it perhaps], stories [Katrina, Ike, Greensburg KS, 9/11], rituals [the annual packing and unpacking of the ‘Go Bag’], symbols, beliefs, attitudes, rules and heroes?  

In an age of fragmented views and diametrically opposed priorities – even among professional associations, advocacy groups, and govt agencies in the same space - who is setting the agenda for creating this culture of emergency preparedness?

Please don’t diss the query with a reply of ‘That’s the million dollar question, isn’t it?’ or something along those lines. How do we take this concept forward – without playing the blame game and talking about past failures.  

So what’s your ‘wish list’ – your priorities, your plan, your roadmap? What are you reaching for – is there a list of tangible ‘things’ that will make this work? What are the things – the three things that I can do – that will really make a difference? 

What was it that RFK said about the danger of expediency – “of those who say that hopes and beliefs must bend before immediate necessities. Of course if we must act effectively we must deal with the world as it is. We must get things done.”

The following videos are in French - they are from news coverage of the 1999 Ice Storm Disaster that affected a huge swath of Ontario, Quebec, New York, Vermont, New Hampshire and Maine. You don't need to understand French to realize that events like this are re-shaping our personal views of preparedness.

A wish list

[Sep 18 2008]

Shelter strategy - the cascading effects of Hurricane Ike

[Sep 15 2008]

This is my understanding of what has occurred:

FEMA/Harris County/City of Houston evacuated all special needs residents in those zip codes that were part of the mandatory evacuation zones. They thought that’s where Ike would hit hardest. So they didn’t plan on any other special needs evacuees.

Unfortunately, Ike hit the rest of Houston and surrounding area and took out the electrical grid, the phone grid, the water system, the cell towers, etc.

An instant and cascading special needs ‘vulnerable population’ layer has evolved – which I believe may number in the thousands. Do the math – there are 4.1M people who live in Houston. From my experience, I’d estimate more than 250,000 with special needs, vulnerable, medically fragile [and that’s a very conservative number].

That ‘layer’ will continue to grow because of the cascading effects of rationed access to healthcare resources, i.e., I have received reports through the network of people running low on essential supplies. I suggest you might want to read Tyson Macaulay's new book on 'Critical Infrastructure' - it's an excellent study on the interdependencies of much of what we take for granted.

 
There are now nine shelters in Harris County – and three of those are faith-based which have been stood-up in recent hours. Total capacity for all those shelters is 3450. Unfortunately, the faith-based churches are ‘off the grid’ when it comes to getting a population count. [We had a similar experience with Katrina]. The good news is that three hours ago, there were only two ‘official’ shelters in Houston.

Of the nine shelters in Harris County, five of them are in Houston – and three of those are in churches. The two official shelters are running at near capacity. Total capacity of the additional three church shelters is 400.

Additionally there are church shelters in Baytown [Harris County], and one each in La Porte and Pasadena.

We have been able to reach out to Clear Channel Radio Network to get the word out about the additional shelters. Thanks to Ben S. for that piece of networking. Of course, this has been an early ad-hoc effort. We’ll need to get some high-end buy-in to make this that more effective. 

Thanks for your consideration.

Be well. Practice big medicine.

Hal

Hal Newman

Executive Director, National Emergency Management Resource Center [NEMRC]

W: www.nemrc.net

Changing weather patterns and perspectives

[July 27 08]

How do you change perspectives - the collective mindset - of people who have not been raised with the expectation they will one day encounter a tornado or waterspout?

Let me explain. Up until this week, the usual number of funnel clouds, tornadoes, and waterspouts spotted in Quebec [a massive territory - roughly seven times the size of the UK] during the course of a summer could be counted on one hand.
 
In the past several days, there have been funnel clouds, waterspouts and tornadoes spawned from a series of severe thunderstorms - some of which rapidly evolve over urban and suburban areas. Fortunately, there have been no injuries and very little damage reported.
 
Earlier this week, while discussing the latest event - a rare waterspout - this one came very close to striking structures and ships in the Port of Montreal - the meteorologists on Meteo Media [the local weather channel] were encouraging their viewers to get their cameras ready in case they encountered severe weather and then send their pictures to the TV station. Any dangers posed by the tornadoes
and waterspouts were downplayed entirely.

It's an interesting problem. I read and listen, in fascination, as my colleagues in the United States debate about how to best warn people about incoming wicked weather. And that's in areas that have a longstanding tradition of dealing with tornadoes. How do you get people to prepare, to pay attention to the dangers - how do you even warn them of the danger - in a region where the weather is clearly changing?

Pondering network equity

[June 19 08]

I've been working on the concept of 'network equity'. To further fuel my fire of fascination, I sent the following questions out to friends, colleagues, and complete strangers.

- What are your thoughts on the concept of 'network equity' ?
- Can an individual/organization continue to 'draw down' on a peer/professional/social network without making regular 'deposits' or 'connections'?
- What are the likely consequences of being overdrawn on your network equity account?

Many of the replies I have received thus far suggest a healthy network should be built upon a platform of something for something - quid pro quo - "one of the 'implicit' expectations of engaging in networking is some meaningful form of 'reciprocity.'"

I reject that notion and embrace the opinion of old friend and one-time fellow paramedic, Allan Katz, who wrote that the best kind of networking was exemplified by the late great Time Russert. 'As executive producer Betsy Fischer said, "He always said the best exercise for the human heart was to bend down and pick someone else up." 

I believe that the best networks are the ones built on the premise that dots shouldn’t be connected just for the sake of creating a connection. However, when there's an idea, concept, organization or corporation that just needs to be connected and you are the person who can facilitate or choreograph that relationship – well that's certainly the magic that keeps the karma radio on the right frequency.

I smile as I write this with the realization that there can be no standard for what is meaningful in terms of creating a connection. No easy convenience of 'create a connection to gain 5 credits' or 'this connection will cost you 5 points.' No guarantee of success because often, at the point of making the connection, the end state is nebulous.

Paul Penn, of Enmagine Inc. wrote 'Not all contributions are of equal merit. Many speak volumes but with little content or substance. (Das bloviators...). Others are meager with their contributions, but their minimalism, if substantive and timely, may have a greater effect.'

And sometimes, pretty infrequently - okay maybe once in a lifetime, quid pro quo involves the forceful removal of a meatball from someone's airway.

Thirty years ago, only weeks after being introduced into our social/professional network of paramedics, a young man named Howard Levinson recognized an emergency when everyone else thought it was just another firehouse joke.

He quickly performed the Heimlich and the choking paramedic went on to live a wondrous life. 

Every time I hold hands with my wife, Dianne, and watch as our children Emma and Sophie play together, I remember Howard Levinson and how one meaningful connection may have altered fate.  

Ellen Naylor, of The Business Intelligence Source, Inc., wrote this wonderful passage as part of her reply and I think it's a perfect way to close this first pass on network equity:

"Paraphrasing a bit, you are helped because you help others: no strings attached. Instead of focusing on self-interest, you are seeking the common good. Like a boomerang, the help we give comes back to us, though often in a roundabout way."

Be well. Practice big medicine.

Hal

Interesting afternoon

[June 19 08]

Refugees

[May 30 08]

News item: 'Group fights park closures as Sunday deadline nears' - The Advocate/WBRZ News, New Orleans LA May 30 08 “I am concerned that the number of homeless in this region will grow,’’ Bishop Charles Jenkins of the Episcopal Diocese of Louisiana said Thursday. Jenkins said the current “crisis’’ is not just about trailers, but the dignity of every human being.

___

Perhaps it's finally time to begin using the word 'refugees' to describe some of the victims of Hurricane Katrina.

In the days immediately following Katrina, news outlets debated the use of the word 'refugee' to describe the victims of the hurricane.

Quoted in an NPR piece of Sept 5, 2005, civil rights activist Al Sharpton said, "They are not refugees. They are citizens of the United States." In the NPR piece, journalist Mike Pesca went on to write 'Sharpton's point was that it strips a person of dignity.'

Almost three years post-Katrina, I believe it's safe to say the dignity has been stripped from the lives of many hurricane victims in much the same way as irresponsible campers strip the bark from birch trees to start their campfires. They leave the trees still standing but susceptible to the ravages of disease and the seasons.

A total of 17,000 families are still left in trailers in Louisiana. In Mississippi, there are approximately 7500 families still in the FEMA trailers.

Those would be the same trailers the CDC recommended - back in February - that should be evacuated as soon as possible due to concerns over formaldehyde.

It's all fairly abstract - like driving in a big old Chrysler Imperial and having a fender-bender crash. You know it happened out there but it really doesn't affect you in here. Katrina seems like such a long time ago and haven't there been a string of other near-apocalyptic disasters and can't we just stop talking about what happened down there on the Gulf Coast?

The news cameras only visit occasionally now. I read somewhere that the Pass Christian Yacht Club finally re-opened three summers after Katrina obliterated the club and the town around it. When I went to Mississippi, I remember trying to describe what remained of Pass Christian and other towns that sat along the coast. The only thing I could come up with was 'Imagine a beaver dam. Now imagine the beaver dam is fifteen feet high and several miles wide."

There are still thousands of people who live in trailers provided by FEMA who just cannot afford to re-establish their pre-Katrina lives in a meaningful manner. They really can't go home in any way that will ever reconstitute the life they had before the 'worst natural disaster the United States has faced in modern history.'

The media debate over the term 'refugees' was centered on whether or not its use somehow implied they were 'second-class citizens' or worse - perhaps not even Americans.

And now nearly three years after Katrina roared ashore, how else would you describe these people who escaped into the storm with nothing more than the clothes they were wearing, were forced to live in sub-standard housing often in unfamiliar places, and were provided with impersonal government agency-centric scaffolding to support them?

Perhaps FEMA isn't the best agency to handle transitioning thousands of people from a 'temporary existence' in a trailer to being able to put down roots again in affordable, accessible housing.

Still recovering as an organization and continually preparing for the next hurricane catastrophe, FEMA seems an unlikely choice to provide the additional support necessary to assist seniors, special needs residents and the working poor to be able to re-establish their lives in a meaningful manner.

Political candidates take note: It’s always more difficult to do the ‘hard right thing’ when faced with a dilemma. The ‘hard right thing’ to do is to take care of the people still living in those trailers. Not to try and stickhandle through the accountability pylons in the hopes of scoring political points.

The Katrina refugees need to have their faith restored in America. So does the rest of America.

Be well. Practice big medicine.

Socks

[May 4 08]

Cynthia is nine years old. She was rescued from her home after floodwaters reached the second floor. Her mom and dad and sister and their two cats all made it out safely.

However, right at this moment, in the middle of an overcrowded Red Cross shelter, among hundreds of other evacuees, the only thing that matters to Cynthia is that her bed socks were left in the top drawer of the dresser in her bedroom.

Cynthia has Obsessive Compulsive Disorder [OCD]. Every single night she takes a shower just before bed, then brushes her hair, brushes her teeth, puts on her PJs, then stops at the top drawer of the dresser in her bedroom and selects a pair of bed socks for the night.

She only wears those bed socks in bed. If she needs to get up to go to the bathroom in the middle of the night, Cynthia will pause in order to remove her bed socks before stepping down out of bed.

According to the rules set forth in Cynthia's OCD ritual, those socks cannot touch the floor and will be switched for another wear-anywhere-pair in the morning.

Cynthia's bed socks are not here in the shelter. They are back there, somewhere, in the house in the middle of the floodwaters. Knowing that there is no way to retrieve her bed socks comes the realization she will have to confront her OCD ritual without any assurance of a positive outcome.

Cynthia begins to scream. Not a silent-open-mouth cry of frustration but a hair-standing-up-on-the-back-of-your-neck full-body scream that rises in pitch until everyone in the shelter is painfully aware of the anguish of one little girl whose bed socks are missing, presumed drowned.

She will not be consoled. For more than an hour Cynthia screams and cries before exhaustion finally overcomes the little girl and she falls asleep.

Just a thought for all of you tasked with organizing shelters from the storm[s]. A child battling OCD rituals will likely have difficulty with disruptions to her routine. Even transitional times from one routine to another can be extremely challenging. The complete disruption of routine can be devastating.

"I have been plagued by OCD stuff since late childhood and often felt that if I didn't do a certain pattern repetition that I would die or be responsible for the deaths of others. Progressively I came to doubt it by holding back and finding nothing bad happened.

"But still, as an adult, I have to hold back from straightening things or putting them right side up just because some nutso part of me says that if I don't then deaths will occur. It's so laughably nuts, but those who don't have this can't imagine how that grip in one's guts really dominates reason.

"With OCD one can train oneself to not side with this stuff, not be bullied by it." - Donna Williams interviewing Stuart Baker-Brown in the wonderful Irked Magazine [issue #5] available online.

Nearly 60 million [26 percent] Americans aged 18 and older suffer from a diagnosable mental disorder. Mental disorders are the leading cause of disability in the United States and Canada. Many people suffer from more than one mental disorder.

Anxiety disorders include panic disorder, post-traumatic stress disorder, generalized anxiety disorder, phobias, and obsessive-compulsive disorder. Panic disorder usually develops in early adulthood. One-third of people with panic disorder develop agoraphobia - an acute fear of being in any place or situation where escape might be difficult. Obsessive-compulsive disorder often begins during childhood.

For Cynthia, losing her socks is more frightening than a monster in the closet. Knowing that can make all the difference in her world when a disaster turns it all upsidedown.

A Note from the Writer: I first wrote this piece in 1998 and unfortunately we are still no closer to having Advanced Care [ACLS] Paramedics in Quebec.

There was a pilot paramedic program however that was met with open hostility by several segments of the emergency healthcare spectrum - and several million dollars later with just two new protocols tested and adopted, the original group of 20 paramedics has shrunk to 14 and several of those are said to be contemplating escape routes that will take them over the wall and out of the province to where they can actually save a few lives.

Here we are in 2008 and the situation continues to deteriorate as the provincially-funded Montreal EMS system has chronic issues with poor response times in the suburban reaches of its territory. It is understaffed, under-funded, and perhaps to no one's surprise is under-performing when it comes to crucial issues like actually saving lives.

Mrs. Rosenberg is still dead and there's no telling when someone, anyone, will do something to address the way Emergency Medical Services are provided in the Province of Quebec.

Mrs. Rosenberg is still dead - Legalize Advanced Care Paramedics in Quebec Now

[Updated: Feb 25 08]

Mrs. Rosenberg is still dead.

I was there when Mrs. Rosenberg died. I knew her from the five previous times I had responded to her apartment. She had a bad heart. She didn't like to call for help -- she'd wait until the pain was unbearable before she dialed 911. Even after all the polite lectures I had given her about calling right away when the pain started. Mrs. Rosenberg always said she didn't want to disturb anyone. She was sweet but stoic.

She told me all about her three sons and seven grandchildren. And her husband who had passed away last year. She said it was hard to go on without him but she looked forward to each family visit. She loved her grandkids. She showed me pictures of them - part of an enormous collection of framed photographs she kept on her coffee table. There they were in little league baseball uniforms and school graduation portraits and with girlfriends and wives.

Mrs. Rosenberg always offered me a glass of orange juice. I'd give her oxygen and check her blood pressure and her pulse and hook her up to the cardiac monitor and she'd be sure to offer me my juice. She was everybody’s grandmother. I was there when she died.

She dialed 911 after enduring crushing chest pain all night. She said she didn’t want to wake anyone up. Mrs. Rosenberg was gasping for breath. She didn't offer me any juice. I told her to hang in there as we waited for the Urgences Sante [Montreal EMS] ambulance crew who would take her to the hospital. I told her to think about her grandchildren and to keep on breathing. She did her best. I gave her oxygen. I talked to her. My partner checked her vital signs-they were terrible. We only had to look at Mrs. Rosenberg to know she was dying.

Her electrocardiogram indicated a significant arrhythmia. I could have established an intravenous line. But I didn't. Mrs. Rosenberg lost consciousness a few moments later. Her breathing was ragged and slowing down. I could have prepared an endotracheal tube to secure her airway. But I didn't. I assisted her breathing with a bag-valve-mask. My partner affixed the defibrillation electrodes to her chest - just in case. We could have intervened a long time before this moment to prevent this from happening. But we didn't.

Although I'm a paramedic and trained to provide advanced life support care under the direction of a physician, I am not permitted to so in the Province of Quebec. We don't have legal standing in the province - the only jurisdiction in the G8 that has failed to recognized advanced care paramedics. It is illegal for me to attempt to save a life using advanced life support. Even everybody's grandmother's life.

I was there when she died. It wasn't pretty. Urgences Sante sent a physician to assist because Mrs. Rosenberg had lapsed into cardiorespiratory arrest. The physician arrived after we had completed 15 minutes of CPR. Unless advanced cardiac life support is initiated within the first six to eight minutes after cardiac arrest there is almost no chance of recovery. Such was the case for Mrs. Rosenberg.

The physician arrived, verified the electrocardiogram, and told us to stop our resuscitation efforts. Just like that.

Mrs. Rosenberg died on the livingroom floor in full view of the photographs on her coffee table.

It’s been more ten years since Mrs. Rosenberg died.

I wrote about her death in the newspaper. I read about her passing on the radio. I shared her death with thousands of people across this land.

Wherever I talked and/or taught I told folks about Mrs. Rosenberg and how she died, gasping for breath, on the floor of her livingroom within view of the dozens of photos of her children and grandchildren.

She died because I refused to break the law. I probably could have saved her.

I could have inserted an endotracheal tube into her airway. I could have established an intravenous line in her arm. I could have administered drugs to combat the deadly arrhythmia in her heartbeat.

I don’t know for sure that Mrs. Rosenberg would have made it home again.
 

All I know is, like every other Advanced Care Paramedic in Quebec, I didn’t do anything more than the law allows.
 

She died.
 

Almost ten years have passed and Mrs. Rosenberg is still dead.
 

She’s going to be dead a very long time before paramedics are recognized as an essential part of the emergency health care system in Quebec. We’re the only jurisdiction in North America that doesn’t recognize advanced care paramedics as an integral component of the emergency medical services system.

Be well. Practice big medicine.

Resurrection medicine

[Feb 8 08]

In Quebec, we don’t have Advanced Life Support paramedics because, despite the embrace of all things secular, when it comes to our provincial Emergency Medical Services [EMS] system we have placed our faith in God – and the skills of the resurrection specialists working in our hospitals' ERs.

If God is smiling down upon you, you just might survive the ride in the ambulance that delivers you into the hands of his emissaries in the ER.   

With one of your feet already firmly planted in death’s door, the nurses and physicians of the ER will do their darndest to successfully pull you back towards the light. And once you’re confirmed to be back among the ranks of the living, there will be high-fives all around in the crash room as yet another soul has been saved.               

And if you die, well, you died because you were destined to do so despite the best efforts of the team waiting in the Emergency Department.  

You just cannot have an effective Advanced Life Support Emergency Medical Services [EMS] system in a society that has bought a lifetime prescription to the notion of supporting a monopoly on who should save lives. 

In Quebec, physicians save lives. Ambulance technicians deliver patients to the physicians. That is the way it has always been with only a few notable exceptions:  

There were the years that Urgences Sante [Montreal & Laval’s provincially-owned and operated ambulance service] decided the ambulance technicians were not delivering the patients quickly enough to the physicians so they placed physicians on the road in ‘doctor’s cars.’

That didn’t work because there just weren’t enough physicians to answer all the calls for critically ill/injured patients and then dispatchers found themselves in the unfamiliar territory of having to play God and deciding which patient deserved to be seen by a physician at the scene.  

And the economics of having physicians on the road was creating a bang-for-buck black hole. You could afford to put three ALS paramedics on the street for what it cost to put one physician in a doctor's car with his ambulance technician driver. And the doctors were permitted to sign-off their shift a half-hour before it actually ended in order to ensure they were safely back at home base just in time for their next engagement.

Remind me to tell you about the doctor who decided to go windboarding while on-duty. He achieved near-legendary abuse-of-power status among legions of underpaid, overworked, disrespected street medics. But I digress. Ambulance technicians deliver patients to the physicians, who in Quebec hold the monopoly on saving lives and deciding on who else will be allowed to save lives.

So, while there are Advanced Life Support paramedics based on ambulances, firetrucks, and helicopters everywhere else in the G8, here in Quebec, physicians have decided ALS paramedics are just not necessary for the chain of survival.  

That’s your chain of survival, folks. To quote Jim Duff, “It’s the system that begins with a 911 call and ends when the hospital moves you out of intensive care — or to the morgue.” 

Now if you live in Quebec, you’re probably thinking, ‘wait a sec – I keep hearing the word ‘paramedic’ being used to describe ambulance technicians these days.’ Aaah, that was one of the most cynical spin-jobs ever successfully carried out in these parts.

Same old basic life support-trained and equipped ambulance technicians with a new title - and sadly for the streetmedics, a new uniform that's so ugly it has spawned a protest group on FaceBook ['Ambulancier contre la chemise laide']. No kidding.  

There was an Advanced Life Support paramedic pilot project in Montreal but after several million dollars and just two new protocols tested and adopted, the original group of 20 paramedics has shrunk to 14 and several of those are said to be contemplating escape routes that will take them over the wall and out of the province to where they can actually save a few lives. 

Fourteen ALS paramedics out of 824 – that’s what, almost two percent of the ambulance technicians trained to the level of Advanced Life Support. On any given day that might mean there’s one or two ALS ambulances out there on the road. I’m not sure who decides what calls they respond to but I suspect that at the head of that chain-of-command you’re going to find a physician with links to the Monopoly Head Office.  

Interesting that in Ontario the approach has been decidedly different. There are ALS paramedics right across the province.  

Dr. Ian Stiell, a senior scientist at the Ottawa Health Research Institute, and Emergency Department physician at the Ottawa Hospital led the Ontario Prehospital Advanced Life Support (OPALS) Study. OPALS was a controlled clinical trial conducted in 15 cities before and after the implementation of a program to provide paramedics with advanced life support (ALS) training on how to help patients with out-of-hospital respiratory distress. 

The results of that study indicated that as many as 2,000 Canadians could be saved if more paramedics were trained in ALS.  

Interviewed as part of a CTV story reacting to the results of the study, Stiell said: "If you want to save more lives, we need to provide advanced life measure to any patient having trouble breathing."  

In the same CTV piece, former Montrealer Anthony di Monte, the Director of the Ottawa Ambulance Service said, "This study proves that advanced care paramedics can make an important difference for those suffering from life-threatening respiratory difficulties."

Perhaps one day soon we will begin placing our faith in the people who have the wisdom, experience and courage to work the frontlines of emergency medical services instead of having them continue to serve as the pick-up and delivery service for the ERs.

In the meantime, you can try praying for a miracle. 

There should never be a monopoly on saving lives or helping people in an extraordinarily difficult moment of their lives.

* Advanced paramedic training saves lives: study

Updated Wed. May. 23 2007 10:55 PM ET CTV.ca News Staff

Taxation without resuscitation

[Jan 25 08]

In Cote Saint-Luc, residents pay taxes to both their city and to the City of Montreal. The share paid to the City of Montreal includes the amount required to pay for fire services, which everywhere else on the Island of Montreal, also includes medical first response services.

Not so in Cote Saint-Luc. The City has decided it's all or nothing when it comes to providing emergency medical services for their residents. So, if Cote Saint-Luc EMS is not available to respond, the Montreal Fire Department is not permitted to send their trained firefighters to possibly save a life before an Urgences Sante ambulance crew arrives.

All or, literally, nothing. Taxation without resuscitation.

As I understand the breakdown of the Cote Saint-Luc tax bill, four cents of every dollar goes to pay for EMS and Public Security. The bill sent by the City of Cote Saint-Luc to the Agglomeration Council for services rendered by EMS was for $553,000. That's for one station serving 31,395 people.

If the Montreal Fire Department required $553,000 for each of its 66 stations, the bill to provide medical first response by firefighters would be almost $36M per year.

Instead, the cost of the Montreal Fire Department program which, by the end of 2008, will serve residents in the following boroughs and municipalities, is estimated to be in the $7M to $10M range.

Villeray-Saint-Michel-Parc Extension [pop. 142,825]

Rosemont-La Petite-Patrie [pop. 133,618]

Mercier-Hochelaga-Maisonneuve [pop. 129,110]

Ahuntsic-Cartierville [pop. 126,607]

Riviere-des-Prairies-Pointe-aux-Trembles [pop. 105,372]

Plateau-Mont-Royal [pop. 101,054]

Saint-Laurent [pop. 84,833]

Montreal North [pop. 83,911]

LaSalle [pop. 74,763]

Saint-Leonard [pop. 71,730]

Pierrefonds-Roxboro [pop. 65,041]

Dollard-Des-Ormeaux [pop. 48,930]

Lachine [pop. 41,391]

Anjou [pop. 40,891]

Pointe-Claire [pop. 30,161]

Outremont [pop. 22,897]

Westmount [pop. 20,494]

Kirkland [pop. 20,491]

Beaconsfield [pop. 19,194]

Mont-Royal [pop. 18,933]

Dorval [pop. 18,088]

Ile-Bizard-Sainte-Genevieve [pop. 17,590]

Hampstead [pop. 6,996]

Sainte-Anne-de-Bellevue [pop. 5,197]

Montreal West [pop. 5,184]

Baie-D'Urfe [pop. 3,902]

Montreal East [pop. 3,822]

That works out to roughly $150,000 per station in the Montreal Fire Department. And that includes costs for vehicle replacement and depreciation due to the increased wear and tear that comes with a higher call volume.  

The Montreal Fire Department emergency medical first response system makes sense. It makes sense in terms of consistently getting trained first responders to people in urgent need in a meaningful amount of time. It makes sense in terms of providing serious bang for taxpayers' bucks.

And ultimately, it makes sense to blanket the entire city with an effective way to save peoples' lives on a round-the-clock 365-days-a-year basis.

. . .

The "they said-we said ads" about response time are not bringing real 24/7 emergency medical response any closer to being a reality in Cote Saint-Luc.

There should never be a monopoly on saving lives or helping people in an extraordinarily difficult moment of their lives.

Priorities

[Jan 3 08]

I am stubborn. My wife warned me not to try and change that lightbulb on my own. She told me I ought to ask our neighbour from across the street to lend me a hand. I waited for her to go over to one of her friends for tea and muffins and then I decided to give it a go.

"I have fallen and I cannot get up," I said in slow and determined fashion to the emergency operator who answered the call I placed to 911. I remembered that series of television ads and winced at the realization I had just used the same line to call for help.

"No, I am not having any difficulty breathing. Yes, I hit my head but no, I did not lose consciousness. No, my neck doesn't hurt. No, no chest pain to speak of. Yes, I do have some terrible pain in my hips. I am 81-years-old. No, I do not take any prescription medications of any kind. No, I am unable to get up on my own. The pain in my hips is quite intense and it gets worse when I try to move.

"Yes, I understand there might be a lengthy delay before the ambulance gets here. I know it's very cold outside and I understand you must be very busy. I would not have called if I could get up on my own. I fear I have injured my hip otherwise I would not be calling for help.

"Pardon me for asking but I thought we had first responders in our town who might be able to help me before the ambulance crew is available. Oh, I see. They only respond to higher priority calls. Well, I do understand. I will do my best to stay comfortable until the ambulance crew arrives. Yes, I will certainly call you back if anything changes or I feel worse in any way."

The light of the afternoon faded into the early darkness of a winter evening and the ceramic tile floor quickly lost any of the heat it had retained. I struck up a conversation with the cat but the cat lost interest and walked away. I watched the time on the microwave clock move slowly minute by minute. I fought the urge to pee.

I concentrated on looking at the photographs of our children and grandchildren we had proudly hung on the livingroom wall. I couldn't remember the phone number at my wife's friend's house. I wanted to cry.

I couldn't believe that I was all alone, had called for help, and no one was on their way yet. I wondered what level of priority my call for help was for that first responder team.

Were they only concerned about life and death? Were they so busy they could not even spare a moment to check on a resident of the community who had confirmed he was in a spot of trouble?

Had they no idea how important it was to provide a physical presence for someone in a time of extraordinary need?

And so, I lay alone on the kitchen floor with a badly bruised hip for more than forty minutes before the ambulance crew and my anxious and bewildered wife arrived simultaneously.

___

Right. The preceding was just me, Hal Newman, trying to imagine what it would be like to be all alone and waiting for emergency medical assistance after having been classified as a priority Two or Three call on a day chockfull of priority One calls.

Calls of every priority should be responded to and not only by an ambulance crew.

Actually, I believe it would be rather interesting to have a first response team specially trained to respond to calls of a lower priority to determine whether or not those patients actually need to be attended to by the much scarcer ambulance-based paramedics.

There should never be a monopoly on saving lives or helping people in an extraordinarily difficult moment of their lives.

The clock begins ticking when someone calls for help. The primary consideration should be who can get there quickest to render aid - not which response organization has a 'claim' to the territory.

It's not about what uniform the responder is wearing. Every EMS organization should take an enormous leap of faith forward, work with all of the stakeholders and establish a model that ensures everyone in the community gets the EMS they deserve.

Be well. Practice big medicine.  

Why public buildings need defibs

[Nov 29 07]

On average, when someone suffers sudden cardiac arrest, irreparable brain damage occurs within four to six minutes.

On average, the time between recognition of a life-threatening event and the arrival of a trained and equipped emergency medical responder is more than eight minutes.

Do the math.

I guess that until you save someone’s life with an automatic external defibrillator [AED], it is hard to grasp the incredibly positive impact these devices can have. I know first-hand what it is like to use an AED to save another person’s life.

A 50-year-old woman had collapsed at the office. Her colleagues had recently been certified in CPR as part of a workplace safety initiative. They immediately called 911 and began cardiopulmonary resuscitation.

I was part of the first response team that arrived at the woman’s side a few minutes later. We were equipped with an AED. The machine functioned perfectly and after the second shock was delivered, we could feel the patient’s pulse.

By the time she was loaded into the ambulance, the woman was breathing on her own. After several days in the hospital, she went home to her family.

A little more than a year later, I received a card from the woman and her family thanking me for giving her a “second chance at life.” The card contained a photograph of her entire family gathered together for a special birthday celebration on the date we had used the AED to save her life.

I will always remember that card because it described all the family celebrations she was able to attend and all the people who had been touched because her life had been saved. The card ended with a quote that said “to save one life is to save a universe.”

Can you imagine how much safer it would be if every office building, arena, bank branch, place of worship, school and shopping mall had automatic external defibrillators readily available?

I’m not in the business of selling defibrillators. I just know how effective they are and I believe they ought to be right below the smoke detector and right next to the fire extinguisher on as many walls as possible.

Whenever someone tries to tell me it’s not worth the effort, I tell them the very same Second Birthday story I just shared here. There is no downside to working together to try to save as many lives as we can with a well-proven, easy-to-use, and relatively inexpensive tool.

Be well. Practice big medicine.

No monopoly on saving lives

[Nov 17 07]

Nixon came back as a horse

[Nov 9 07]

Concentrate on the task at hand. Keep your eyes on the prize.

Whoever said that must have been familiar with handling horses.

I am taking horse handling lessons so that I can participate in the whole horse love affair that Di and the kids have going on.

I don’t want to ride so I thought it would be useful to become comfortable with handling the big beasties.

Wednesday morning provided a tangible reminder of why it’s incredibly important never to lose concentration even for just a second while handling a horse.

I was bringing a four-year-old big guy named [no kidding] Nixon out of the paddocks to go back to the stable and I made the cardinal sin of allowing Nixon [I’ve taken to calling him ‘Dick’] to get slightly ahead of me on the incline down to the stables.

I saw him look at me and knew what was coming even before his hindquarters came around hard and caught me right on the hip.

I was intelligent enough to let go of the lead line and so I managed to get some really good air before landing on my side a few metres away. Christian - my instructor and the owner of the Centre Equestre Le Club [in Vaudreuil 450-458-2769] said that when he saw me I was still in the air and gaining altitude.

I believe that if my shoes were not tied on as well as they were they would have stayed on the path right where Dick hit me -- just like the shoes I used to find at the point of impact at a pedestrian v car scene.

I got right back up because I didn’t want Dick to think he could toss me around like that [like who am I kidding?] and led him back into the stables without further incident.

I continued with my chores – mucking the stalls, hauling hay bales and shavings, doing the feed rounds and then when I finished my morning and sat down in the van I realized my whole right side was hurting.

Popped a few advils and went to bed and awakened the next morning feeling as if a truck had hit me on the hip and butt. At age 47, I just don’t have the same bounceback as I did when I was younger.

But other than the feeling that Nixon somehow came back as a horse and kicked my ass, I’m just fine and looking forward to Saturday afternoon at the stables.

Reflections on Life, Death and EMS

[Oct 27 07]

I bought a poppy this morning and pinned it to my baseball cap. Too early in the season for some I've been told. Much too late for others I know.

The ghost battalion of street medics. Death by stress, suicide, or misadventure. Casualties of battles fought on the road and in their heads. Demons picked-up along the way like black-spirited hijackers waiting for a time to take control.

Politically incorrect to imagine direct links between sudden unexpected death and life wearing the caduceus on your collar or tattooed on your shoulder.

Yesterday I received news that a young firefighter/medic had taken his own life. Another gatekeeper of the cracks who somehow managed to slip into the abyss that exists in the shadows between the ranks of fellow EMS providers.

'He was a gentle soul who was genuinely caring and a real pleasure to work with'... and he was practiced in the art of self-isolation enough to drift in ethereal misery until he finally capped his own existence. 

----

Jamie Flanz was murdered two springs ago. His passing had no connection to the EMS world other than the fact that his obvious state of death probably didn't require a streetmedic to declare the absence of life signs.

He was a good medic and was a gentle, reassuring presence with many of our most senior patients. He put in many a shift at the last minute because I called and asked for his help.

It is the transient and intense nature of EMS that lifesavers often come and go without much in the way of heralding their arrival or their departure. They touch lives and impact universes and then they move on to live the rest of their lives.

There are, apparently, no guarantees on how long the rest of their lives will be. Maybe some of them have an inkling of sunset rapidly approaching and decide to go out flaming while others simply pull the bedcovers up over their heads.

----

Almost a decade ago, I responded as back-up to a call for a 50-year-old patient in cardiac arrest. While rolling I thought I heard the dispatcher say the patient had been found with a plastic bag over her head. I remember thinking to myself “that can’t be right.” The dispatcher didn’t repeat the message and I thought it was because the medic crew was thinking the same thing I was and didn’t question the information provided.

I rolled onto the scene just a few moments after the crew and followed the sound of their voices into the apartment. I passed a somber group of folks gathered in the hallway around the front door. “They’re in there,” a middle-aged man with an L.L. Bean lumberjack-style shirt and a tear-stained face said to me. Heard Jen tell Boris, “No how. No way. EMS1 will be in here in a sec to confirm.” Then to Dispatch, “We’re going to need the police here. Cancel the ambo crew.”

I walked into a bedroom to find the crew looking at the body of a fifty-something-year-old woman recently deceased. She was dressed in stylish pyjamas and was wearing matching sleeping covers over her eyes. Her fingers were blue and her hands were frozen in mid-air as if she had shaken hands with Death when he had arrived. There was a plastic bag covering her hair—crinkled and crumpled and standing straight up like some macabre white plastic chef’s hat. There was an empty bottle of vodka next to the bed and several empty pill bottles scattered among the bed covers. Two sealed envelopes had been found by her brother (the L.L. Bean shirt) who had discovered the scene and had pulled the bag from her face before calling 911.

We sealed the apartment. Shooed the brother and the building manager and the guy from the apartment across the hall out of there. We waited on the police officers who took our report and then asked us to wait outside. They emerged a few moments later with some of the dead person’s identification. “Her name was ------ …” There seemed to be a wave of air that came out of nowhere and hit me right in the gut. I felt an enormous weight slam into my shoulders that forced me down to my knees. I heard myself mutter, “Sweet Jesus.” And then I was kneeling on the carpet in the corridor fighting the urge to hurl vomit and bile out of my mouth.

Jen and Boris were by my side in a heartbeat. “Hal, are you all right?!” I was unable to answer at first—too intent on listening to all of the air rush out of my lungs through my clenched teeth. “Yeah. I’m okay.” Wrong answer. I tried to get back up to my feet but my sense of balance had been thrown into temporary disarray. “OhmyGod. I just spoke to her on Friday afternoon.”

She was a colleague of mine—an experienced emergency care provider who worked for a parallel health care organization. We interacted on a regular basis and had forged a strong bond during the Montreal Ice Storm Disaster of 1998. I had seen her practicing the art of caring with elderly clients forced into a shelter by the combination of darkness, cold, and ice. She had been particularly effective with the Holocaust survivors who had retreated into some tormented memories none of us could penetrate. Her combination of compassion and gutsy courage had gotten through to folks living a nightmarish flashback of forced evacuations all those years ago.

My pager went off right then while I was struggling to regain vertical mode. The message read, “Shall I send out a SMART alert?” (SMART is an acronym for our Stress Management Response Team). I radioed Dispatch, “Yeah. For me.” I was really upset that I hadn’t recognized her… as if I somehow should have realized it was her even though I had no idea where she lived. As if one might expect to encounter a friend dressed in her death-best outfit. It was an irrational reaction to a surreal scene. The lead police officer came over and asked if I was okay. “Yeah. I’ll be alright. A couple of wicked bad dreams and I’ll be ready for the next tragic response.”

I cleared the scene and then drove over to that parallel health organization where I broke the news to her colleagues. It was a rough scene. Naomi Cherow, part of SMART, arrived a few minutes after me. Naomi took the lead and walked the staff through a very tough evening of sadness, anger, and lingering unanswerable questions.

I went home and had a couple of wicked bad dreams.

The next night I had a couple more.

Then on the third day a baby boy drank chlorox and by the time I got home I was focused on ensuring all the methyl ethyl bad stuff in our home was securely locked away from the prying fingers of our daughters. No more bad dreams. Although I did have a dream wherein I saw my late colleague sleeping peacefully on a sofa in one of the Ice Storm evacuation shelters. She was surrounded by elderly Holocaust survivors. I could tell they were survivors because of the numbers tattooed on their forearms. One of them said, “She’s our angel.”

I don’t understand suicide. Never have. I can’t imagine anything that could drive me over the threshold of the living and into the valley of the dead. With no opportunity to hook a u-turn and head back home if the experience didn’t pan out the way I thought it was going to go down. It must be a torturous decision to make. I don’t know what drove my friend to the edge of the void and then into the vast beyond of emptiness. I only hope she is at peace wherever her soul has gone.

Be well. Practice big medicine.

the lightning man

[Aug 21 07]

I have often been referred to as a 'human lightning rod' because of a tendency to be the connector of dots at the center of turbulence.

I beg to differ. I am the lightning man.

I have been tracking severe thunderstorms for as long as I can remember. My family and friends benefit from my obsession with superheated air in the receipt of timely emailed reminders to bring in the lawn furniture and small pets.

In all the time I have been following lightning, it never occurred to me that maybe, just maybe, lightning was tracking me.

Camping with my family recently in south-central Quebec, just north of the border with Maine, I watched the sky as the clouds began showing signs of aspiring to develop a majestic soundtrack and an accompanying lightshow. Of course, the weather forecast was calling for just a slight chance of rain but I was fairly convinced we were going to see some big-time lightning by nightfall.

We had a wonderful day on, in, or near the lake and Di and the kids were playing Blokus on the picnic table by lantern light when that little lightning detector in my head started pinging. I wandered down to the lake and looked out to the horizon. Nothing seemed particularly threatening out there and I thought perhaps the clean country air had messed with my inner tracking systems.

Not.

A few seconds later there was a massive display of forked lightning that ripped across the far skies. I tried to calculate distance but with no discernible cloud line and no ripple of thunder it was a guess at best. I figured we had about a half an hour before this storm was overhead.

So I began wandering around the campsite picking up all of the items that could become projectiles in a high wind. I took great pains not to alert the girls but I was definitely trying to get Di's attention that something wicked this way cometh. No such luck. They were eating banana boats cooked in the fire and still completely engrossed in their puzzle game on the picnic table.

It wasn't until the storm was about five miles out and there was a blast of lightning bright enough to capture their attention that the rest of our camping party worked out it was time to batten down the hatches.

As I've told this story since, I imagine the scene as the medical examiner investigated the scene of the worst multiple lightning fatality on a campground in years. "I just don't understand. What do you suppose was so damned important on that picnic table? It's not like they didn't have lots of warning."

The storms rolled in at 21h and didn't roll out until after 03h. We contended with all manner of storm-induced silliness including wind gusts strong enough to pull the tent stakes up out of the ground. And we're talking about a serious tent that has weathered some pretty ugly stuff over the years. At some point Di and I had to go outside to pull down our kitchen tarp lest its lines become fouled in those of our tent.

Emma and Sophie slept through it all. Blissful ignorance of things that go flash and then boom in the night.

Last week I roadtripped to Bethany, West Virginia and ended up staying at the home of Larry and Carol Grimes. Larry is the Chairman of the English Department at Bethany College and was one of my treasured professors when I attended Bethany many moons ago. I told the Grimes the story about the camping and the lightning and the picnic table and ended the conversation by saying that if I didn't experience another severe thunderstorm for the rest of the season it would be all right by me.

You guessed it. At 01h I was awakened by a bright flash and then stayed awake for more than an hour as a powerful thunderstorm settled in over the town. It might have been my imagination but the lightning flashes on the side of the house closest to where I was sleeping seemed brighter and more frequent.

Next stop on the roadtrip was Winchester, Virginia. One evening we had dinner in Fairfax and were driving back out to Winchester when we encountered an incredible electrical storm. Blast after blast of sustained lightning illuminated the sky and the interstate. You know that background hum you feel more than hear when lightning chews up the ozone around you just before the rush of deep thunder that sounds like it's coming up from the ground instead of down through the air. And yet somehow we drove through the heart of the storm without catching anything more than a few drops of rain on the windshield. The thunderstorm's presence was almost comforting and helped guide my way through the unfamiliar territory.

I shouldn't be surprised nature provided a backlight for the borrowed GPS system. I am, after all, the lightning man.