Medic 51 has even shared his thoughts on shift work and the negative culture that exists in EMS today. Not every agency takes a hard line like “if you don’t like the work you can find another job”, but enough managers believe that employees who voice concerns are all just whining about the job. This is not new to EMS.

The reactions I have read from people on social media sites are all directed towards the individuals, how they are always complaining and causing problems. They were also waving the “if you don’t like it…” standard, and many people flocked to the same conclusion. Even the statements from the Louisville Metro Council are off the target, citing overtime expenses and budgetary concerns.

The news hinted at the issue, stating that Louisville Metro EMS has 24% fewer people on working than they did two years ago. Sixty Three fewer people to fill the shifts. Sixty three more positions that they have to force people to work.

Art Hsieh, posted a quick thought on EMS1.com. As a well respected, published author on EMS topics I was shocked that he didn’t take the thought as far. He did leave us with the statement “I’m wondering what else is happening in the back story that’s not being reported.” He knows there is more to the firing and mandatory holdover complaints than what we are seeing.

The issue that should be on the front page, is safety. Do you really want a paramedic trying to do the dopamine calculation when they’ve been awake for the past 20 hours? I do not want to address multiple jobs, lack of pay, off duty activities (even though I am aware that these can all contribute to sleep deprivation), I just want to know why it is acceptable to hold EMS workers every shift, up to 16 hours. There are tales on the streets of Louisville that people have been held to 20 hours due to lack of coverage.

Between the driving an ambulance, calculating the correct dose of a medication, performing life saving interventions, there are many opportunities where our actions affect  patient outcome. Sleep deprivation will affect your ability to make decisions. Why are we not addressing THIS issue? Am I the only one concerned with safety in EMS?

I have already stated my views on sleep deprivation on a 24 hour shift. Louisville Metro EMS has been on 12 hour shifts for years, along with the mandatory 4 hour hold. There are few clinical personnel who escape being held up to 16 hours every shift.  Lets do some math. There are 24 hours in a day. I work my regular 12 hours, then get held over for four hours. 12+4= 16. I am at work for 16 hours minimum, then I have only 8 hours (assuming I get to clock out at the end of the 16th hour) to get home, eat, sleep, wake up, and get ready for work the next day.

According to the International Fire Chiefs Association report “The effects of sleep deprivation on fire fighters and EMS responders” June 2007, the average adult requires six to ten hours of sleep.

Does anyone truly believe these EMS employees are getting six hours of sleep between shifts? I seriously doubt they are. Add on more mandatory overtime, including extra days that get stretched to 16, 18 or even 20 hours (yes, I have seen this personally crews getting held over to 20 hours) and there is no big surprise that the people are going to make mistakes because of sleep deprivation.

The only real surprise here is that no one at Louisville Metro EMS is trying to solve the problem. Mandatory holds have been in effect since the service merged from two EMS agencies to one.

I think the EMS industry needs to take a hard look at sleep deprivation. Uncomfortable and unpopular choices need to be made to keep our EMTs, Paramedics and patients safe.

One presentation was about burnout in healthcare, EMS in particular. The speaker mentioned that one technique to reduce stress is to find an activity or hobby to help relax and take your mind off work. My hobby is photography. Here are my images from the weekend in and around the Red River Gorge.

Still here? I have started posting stuff on newer social media web sites. You can find ways to keep up with me with any of the following:

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hen in the Course of human events it becomes necessary for one people to dissolve the political bands which have connected them with another and to assume among the powers of the earth, the separate and equal station to which the Laws of Nature and of Nature’s God entitle them, a decent respect to the opinions of mankind requires that they should declare the causes which impel them to the separation.

We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. — That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, — That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness. Prudence, indeed, will dictate that Governments long established should not be changed for light and transient causes; and accordingly all experience hath shewn that mankind are more disposed to suffer, while evils are sufferable than to right themselves by abolishing the forms to which they are accustomed. But when a long train of abuses and usurpations, pursuing invariably the same Object evinces a design to reduce them under absolute Despotism, it is their right, it is their duty, to throw off such Government, and to provide new Guards for their future security. — Such has been the patient sufferance of these Colonies; and such is now the necessity which constrains them to alter their former Systems of Government. The history of the present King of Great Britain is a history of repeated injuries and usurpations, all having in direct object the establishment of an absolute Tyranny over these States. To prove this, let Facts be submitted to a candid world.

He has refused his Assent to Laws, the most wholesome and necessary for the public good.

He has forbidden his Governors to pass Laws of immediate and pressing importance, unless suspended in their operation till his Assent should be obtained; and when so suspended, he has utterly neglected to attend to them.

He has refused to pass other Laws for the accommodation of large districts of people, unless those people would relinquish the right of Representation in the Legislature, a right inestimable to them and formidable to tyrants only.

He has called together legislative bodies at places unusual, uncomfortable, and distant from the depository of their Public Records, for the sole purpose of fatiguing them into compliance with his measures.

He has dissolved Representative Houses repeatedly, for opposing with manly firmness his invasions on the rights of the people.

He has refused for a long time, after such dissolutions, to cause others to be elected, whereby the Legislative Powers, incapable of Annihilation, have returned to the People at large for their exercise; the State remaining in the mean time exposed to all the dangers of invasion from without, and convulsions within.

He has endeavoured to prevent the population of these States; for that purpose obstructing the Laws for Naturalization of Foreigners; refusing to pass others to encourage their migrations hither, and raising the conditions of new Appropriations of Lands.

He has obstructed the Administration of Justice by refusing his Assent to Laws for establishing Judiciary Powers.

He has made Judges dependent on his Will alone for the tenure of their offices, and the amount and payment of their salaries.

He has erected a multitude of New Offices, and sent hither swarms of Officers to harass our people and eat out their substance.

He has kept among us, in times of peace, Standing Armies without the Consent of our legislatures.

He has affected to render the Military independent of and superior to the Civil Power.

He has combined with others to subject us to a jurisdiction foreign to our constitution, and unacknowledged by our laws; giving his Assent to their Acts of pretended Legislation:

For quartering large bodies of armed troops among us:

For protecting them, by a mock Trial from punishment for any Murders which they should commit on the Inhabitants of these States:

For cutting off our Trade with all parts of the world:

For imposing Taxes on us without our Consent:

For depriving us in many cases, of the benefit of Trial by Jury:

For transporting us beyond Seas to be tried for pretended offences:

For abolishing the free System of English Laws in a neighbouring Province, establishing therein an Arbitrary government, and enlarging its Boundaries so as to render it at once an example and fit instrument for introducing the same absolute rule into these Colonies

For taking away our Charters, abolishing our most valuable Laws and altering fundamentally the Forms of our Governments:

For suspending our own Legislatures, and declaring themselves invested with power to legislate for us in all cases whatsoever.

He has abdicated Government here, by declaring us out of his Protection and waging War against us.

He has plundered our seas, ravaged our coasts, burnt our towns, and destroyed the lives of our people.

He is at this time transporting large Armies of foreign Mercenaries to compleat the works of death, desolation, and tyranny, already begun with circumstances of Cruelty & Perfidy scarcely paralleled in the most barbarous ages, and totally unworthy the Head of a civilized nation.

He has constrained our fellow Citizens taken Captive on the high Seas to bear Arms against their Country, to become the executioners of their friends and Brethren, or to fall themselves by their Hands.

He has excited domestic insurrections amongst us, and has endeavoured to bring on the inhabitants of our frontiers, the merciless Indian Savages whose known rule of warfare, is an undistinguished destruction of all ages, sexes and conditions.

In every stage of these Oppressions We have Petitioned for Redress in the most humble terms: Our repeated Petitions have been answered only by repeated injury. A Prince, whose character is thus marked by every act which may define a Tyrant, is unfit to be the ruler of a free people.

Nor have We been wanting in attentions to our British brethren. We have warned them from time to time of attempts by their legislature to extend an unwarrantable jurisdiction over us. We have reminded them of the circumstances of our emigration and settlement here. We have appealed to their native justice and magnanimity, and we have conjured them by the ties of our common kindred to disavow these usurpations, which would inevitably interrupt our connections and correspondence. They too have been deaf to the voice of justice and of consanguinity. We must, therefore, acquiesce in the necessity, which denounces our Separation, and hold them, as we hold the rest of mankind, Enemies in War, in Peace Friends.

We, therefore, the Representatives of the united States of America, in General Congress, Assembled, appealing to the Supreme Judge of the world for the rectitude of our intentions, do, in the Name, and by Authority of the good People of these Colonies, solemnly publish and declare, That these united Colonies are, and of Right ought to be Free and Independent States, that they are Absolved from all Allegiance to the British Crown, and that all political connection between them and the State of Great Britain, is and ought to be totally dissolved; and that as Free and Independent States, they have full Power to levy War, conclude Peace, contract Alliances, establish Commerce, and to do all other Acts and Things which Independent States may of right do. — And for the support of this Declaration, with a firm reliance on the protection of Divine Providence, we mutually pledge to each other our Lives, our Fortunes, and our sacred Honor.

Sounds like the public wants answers. EMS directors/chiefs/ what ever you call your person in charge, you need to educate the people you protect. You need a PIO and a good relationship with the media. No one in your area should be asking google why their ambulance did not have any paramedics.

CPSE serves as the governing body for the organizations that offer accreditation, education, and certification services to first responder and fire service industry professionals and agencies.

The study was funded by a grant from the FEMA and the Department of Homeland Security. The study, called Report on EMS Field Experiments used mock scenarios to access the time to patient intervention, using various crew configurations. From the Abstract:

The results and conclusions will directly inform the NFPA 17101 and NFPA 1720 Technical Committees, who are responsible for developing industry operational and deployment standards.

They used varying crew configurations, including

• 2-person engine crew
• 3-person engine crew
• 4-person engine crew
• One ALS provider on an engine & one ALS provider on an ambulance
• Two ALS providers on an ambulance
• One ALS provider on an engine & a BLS ambulance
• BLS engine company & One ALS provider on an ambulance

My first reaction to this paper was outrage. On the surface and in the EMS community it looked like the fire service was just trying to prove that fire based EMS was the best and only method for delivering prehospital care to the community. The rift between Fire Based EMS and third service EMS seems to be getting farther apart each time a national agency that supports fire service publishes a paper on how they can do EMS better than anyone else.

The IAFC had recently pushed out a white paper titled Fire-based and Private-EMS: Important Information for Metro Chiefs which just fueled the fire between services.

I read a majority of the Report on EMS field experiments. A main argument from the online EMS community was that this report does not consider patient outcome from the interventions. The study was never designed to evaluate weather having more paramedics on scene leads to better patient outcome.

The conclusion was that four person first response crew is better than smaller crew sizes in trauma and cardiac arrest. In the patient access and removal scenario, a larger first responder crew in conjunction with a two person ALS ambulance was the most efficient for completing the tasks. The study also found that having one ALS provider on the first responder crew and one on the ambulance lead to faster completion of tasks in both the cardiac and trauma scenarios. The summary concludes with the following paragraph:

These experimental findings suggest that ALS provider
placement and crew size can have an impact on some task start times in trauma and cardiac scenarios, especially in the latter tasks leading to patient packaging. To the extent that creating time efficiency is important for patient outcomes, including an ALS trained provider on an engine and using engine crew sizes of four are worth considering. The same holds for responder safety – for access and removal and other tasks in the response sequence, the availability of additional hands can serve to reduce the risks of lifting injuries or injuries that result from fatigue (e.g., avoid having small crews repeatedly having to ascend and descend stairs). Cost considerations for EMS response and crew configurations were not considered in this study.

The EMS portion of the Firefighter Safety and Deployment of Resources Study was designed solely to assess the personnel number and configuration aspect of an EMS incident for responder safety, effectiveness, and efficiency. This study does not address the efficacy of any patient care intervention.

The results also provide valid measures of total crew size efficiency in completing on-scene tasks some of which involve heavy lifting and tasks that require multiple responders to complete.

The authors are trying to provide proof that more people on scene can lead to safer practices and fewer injuries on the job. I say bravo, any attempt to make our jobs safer and reduce injuries will be welcomed. I also believe that there is need for more prehospital studies on efficacy of multiple ALS providers on scene on patient outcome, before we place a paramedic on every fire engine in the country.

Living in the grand city of Louisville, our weather is as erratic at best. I ride in to work and its eighty degrees, then overnight it changes and the ride home in 30 degrees. I just adore the Ohio River Valley.

I already had most of the gear I needed to commute by bike, but I was missing one vital piece of clothing. A lightweight wind breaker with a little warmth. I had been wearing sweatshirts, but they do not provide any wind relief and the act just like a sponge when it comes to light rain and mist.

My old partner at the private ambulance is a rock climber, hiker and generally enjoys the outdoors (his major was in outdoor recreation). He showed me a website where we gets great deals on accouterments. SteepandCheap.com. They have incredible deals, but they only offer one deal at a time. I have checked the site periodically and finally made a purchase last week. I bought the Sierra Designs Kenosha Nano Jacket.

Photo from Sierradesigns.com

The jacket retails for $89.00. I was able to pick it up for $32.00 on Steep and Cheap.  I had the chance to use the Kenosha Nano the other night. It was exactly what I needed and I did not have to break my piggy bank to get the proper clothing. Thanks Brian for the website!

Here is a video with interviews of the people involved in the Arizona training fire flashover. Have a look and come back.

A friend of mine on Facebook posted the first video with the notion that PPV is extremely dangerous and kills firefighters. The video was the proof of the argument.  

The video above, which I didn’t find until recently, expresses exactly what I thought about the situation. Dave Marshall, the training officer at the time, stated “I think what happened is, we didn’t recognize that the fire environment was as close to the flash-over point as it was” and he is absolutely correct.

They were extremely lucky that no one was killed, and there were only minor injuries.

Positive Pressure ventilation is a tool. Like any other tool it can be used incorrectly.

Image from Tempest Technologies

IFSTA Essentials of Firefighting 5th edition provides some help with how to use PPV.

• As long as the pressure is higher inside the building, the smoke is forced through the ventilation exit opening.  

I am not sure where their ventilation exit opening was, though it looked like it was the same window where they were spraying water from the outside.

• A blower is placed about 4-10 feet outside the open entry point so the cone of air from the blower completely covers the doorway opening. 

The smoke billowing out from the door way after the blower is started tells me that the entire door was not covered by the cone of air.

• To maintain the positive pressure inside, it is important that no other exterior doors or windows are opened during the positive pressure ventilation operation.

With acquired structures it can be difficult to make sure all the windows and doors are in place. During this video you can see broken windows on the front porch where smoke is exiting the structure.

• PPV requires good fireground discipline, coordination and tactics 

Additionally it requires excellent situational awareness. The on scene instructors became complacent and were not monitoring the fire. They were extremely fortunate that everyone was able to walk away and learn a valuable lesson from this event. Take this to heart, learn from their mistakes. Make sure everyone goes home, every day.

My Opinion, don’t use PPV unless you know where the seat of the fire is located. I am a firm believer in the use of vertical ventilation when possible. Attempting to use PPV in a fire of unknown origin is a good way to get the foundation ready for a new house.

This is part 2. You can read part 1 here.

November 19, 2004. Cottonwood, Arizona. A training fire goes wrong when forced air ventilation is applied to the structure during suppression activities. Video from The Bravest Online. Click on the link above and watch the video.

We do not have many details on the fuel load or the location of the fire, we can watch it progress through the changes in the smoke.

01:06 they send three firefighters into the structure with a charged hose line. The smoke appears brown and grey, with a little bit of force pushing it out the entry door.

01:33 we can see just off to the right of the screen, some one opens a hose line on the exterior of the structure (side delta). I imagine the ignition room is on the C/D corner, but I cannot be certain. If the stream of water is entering to room, this will effectively push the heat, smoke and fire towards the crew advancing from the front.

01:54 We see the smoke become darker and it’s volume appears to have increased. This usually means there is more particulate in the smoke and the fire is growing.

02:20 Firefighters on the exterior place the PPV blower on the porch. The smoke is now dark grey and is billowing out of the structure. The crew on side delta has been continuously spraying water in to the room on side C/D.

02:25 The PPV blower is started. Immediately we see the dark grey smoke pour out of the door where the suppression team entered. First indication that the PPV blower is not covering the entire opening of the doorway.

02:31 The structure flashes over, with two firefighters inside.

02:35 The ventilation team stops the PPV blower and removes it from the porch.

02:41 the evacuation sirens are sounded.

So, what went wrong?

I’ll post my thoughts in the next post.

This video is posted on The Bravest Online youtube account. There are many things wrong with this idea of training firefighters. First I will critique the video and then provide the references and data.

The video opens with a firefighter running out of the Sea Container carrying a bucket while the observers laughing as the firefighter barely misses being burnt by the flames. We do not know what was in the bucket, but it is safe to assume it is a flammable or combustible liquid fuel. We do not know what the total fuel load in the container is, but it appears to have some solid fuels towards the back (furthest from the camera).

The instructors advise the firefighter to hold off adding the second pale of fuel until the flames die down in the container. After Randy throws the second pale of fuel in the container, the narrator is heard saying “Total Flashover, there it is” and an additional person adds “anybody in there, they’re dead”. They got the second statement correct at least.

Let’s look at the NFPA definitions of Flashover.

NFPA 101 Life Safety Code 3.3.79 Defines Flashover as “A stage in the development of a contained fire in which all exposed surfaces reach ignition temperatures more or less simultaneously and fire spreads rapidly throughout the space.”

NFPA 402 Guide for Aircraft Rescue and Fire Fighting Operations 1996 Edition “Flashover. All combustibles in a room or confined space have been heated to the point that they are giving off vapors that will support combustion, and all combustibles ignite simultaneously.”

Throwing flammable liquids in a fire does not constitute a flashover.

The trainees are encouraged to “Go in there and get it” and to “Cut that water off and crawl”. The primary purpose for the liquid flammable was to, “make it hot.”

When going through NFPA 1403 instructor training we were taught that flammable  liquids were not allowed. NFPA 1403 Section 6 Non-Gas-Fired Live Fire Training Structures (2007 Edition) very nicely writes out their recommendations as listed below.

NFPA 1403  6.3.6 Except under the conditions of 6.3.7, the use of flammable or combustible liquids, as defined in NFPA 30, Flammable and Combustible Liquids Code, shall not be used in live fire training evolutions in structures.

NFPA 1403  6.3.7 Limited quantities of combustible liquid with a flash point above 38° C (100° F) shall be permitted to be used in a live fire training structure that has been specifically engineered to accommodate this fuel.

They do allow for structures engineered for limited quantities of combustible liquids to be used in live fire training. Maybe they have a statement from the manufacturer that says this sea container was engineered to use liquid combustibles in training fires, but I seriously doubt this exists.

The United States Fire Administration reported from  1986-2009 there were 231 firefighter fatalities during training, an average of 9.625 every year.

The NFPA reports that in 2009 7,935 firefighter injuries occurred during training.

• 230 Thermal or Chemical burns
• 65  smoke or gas inhalation
• 70 from burns and smoke inhalation

That’s three hundred sixty five (365) injuries from burns and/or inhalation. We can do better than this. Safety is everybody’s priority.

We should not be complacent when it comes to training, especially live fire training in acquired structures. There is no excuse for injuries or fatalities during training evolutions. Training officers and fire chiefs have been convicted of manslaughter due to negligence. Don’t become a statistic. Don’t be like the firefighters in the video.