A paramedic on a 10-10-14-14 schedule has a busy first night with constant calls. At 5 a.m. she is treating an elderly patient with a severe hip fracture and is preparing to administer a small dose of pain medication in the form of 2 mg of morphine IV.

The patient received no relief from the pain at all, which surprised the paramedic, who attributed it to the small dose. At the hospital her partner pulls her aside and asks why she administered magnesium sulfate to the patient.

A firefighter gets down to the end of his 24-hour shift. Normally his department is not very busy at night, but last night he was up from midnight until 6 a.m. with several nuisance fires and alarms.

On his way home he nods off at a traffic light until he is awoken by the honks of several other motorists. He makes it home, but believes he may have nodded off several other times due to being so exhausted.

Good sleep
We have heard since we were children that a good night's sleep was important for one's health and performance the next day.

Unlike many things children are told, this is quite accurate. Sleep is a vital process that most animals need to maintain health and wellbeing. At least 7 to 8 hours is recommended for everyone for mental and physical health, immune system function and energy conservation.

The normal pattern of sleep for humans follows the circadian rhythm. This rhythm is standard wake-sleep cycles over 24 hours that not only matches daylight hours to a large degree, but also one's internal clock.

Unfortunately, up to 20 percent of the nation's workforce does not work a schedule that is amenable to this sleep cycle. These workers include virtually all public safety workers as well as others in healthcare, utilities and transportation.

Essentially all of these shift workers have a high level of responsibility for other people or critical infrastructure, and must make decisions at all times. This is not necessarily ideal for someone who is tired.

This is nothing new to us in emergency services. However, it always seems that some firefighters can handle long shifts and nightshifts better than others.

If you are one of those people who seems to have trouble being a shift worker, there are a number of ways you can try to improve the situation.

Variety of work
It is important to understand that there is an inherent difference between working a 24-hour shift at a slow fire station and working an overnight on an urban medic unit. The slow station will often permit you to get sleep at night whereas the urban medic unit will not.

Unfortunately it can actually be more dangerous at the slow station when you get the short straw and respond to calls all night long when you had no sleep during the day. At least at the busy medic unit you knew you were unlikely to get any sleep and hopefully planned for it (and slept).

The challenge is, do you nap during the day before a night at a slow station or hope and pray and tough it out if it is busy? A single busy night may be reasonable to recover from, but monitor the calls to make sure that formerly slow station is not routinely becoming more active.

Poor daytime sleep
Being able to sleep during the day can be difficult. Make sure the room is dark and the phones are turned off. Family and friends should respect this time and leave you alone. Use earplugs to block out noise from the outside.

However setting up the first daytime sleep is just as important. If you are working a block of nightshifts and plan to not nap at all on the day before the first shift, this can be dangerous. You could be awake for more than 24 hours before you get home, and no one will be as sharp on hour 20 as they would be if they gotten more sleep.

In order to get sleep the first day, you need to be a little tired. I have tried two ways to accomplish this.

For many years, I would stay up until 2 or 3 a.m., then sleep for about 4 hours and get up with my family in the morning. I then would try to nap in the afternoon for 4 hours.

More recently, I have adjusted and instead of getting up at 7 a.m., I sleep straight through until 11 a.m. This larger block of sleep worked better for me. However, everyone is different — experiment to see what works for you.

Intrinsic sleep illness
Consider the possibility that there may be a medical condition that is contributing to poor sleep — namely OSA, or Obstructive Sleep Apnea. This is a condition where during the night someone has multiple periods of apnea — they stop breathing.

Often related to body habitus, it usually (but not always) is associated with being overweight. A sleep study is used to diagnose OSA, and losing weight or the use of continuous positive airway pressure at night can be used to improve the quality of the sleep.

If everything else has been considered and there is still no improvement, there is the possibility that you may be affected with Shift Work Sleep Disorder. This is associated with excessive sleepiness, insomnia during the day and unrefreshed feelings upon awaking.

Treatment for SWSD or any sleep-related issues needs to be tailored to the individual. In some cases, minimizing or eliminating night shifts may be the only option.

While this may work in some areas of public safety, in many cases it may not be possible. What other options are available?

It has been shown that brief naps, 20 to 30 minutes, during down time at work can improve safety and performance. Some employers do not permit this, and in many cases the workload prevents this possibility. But if you find yourself with some down time, consider lying down for a few minutes. It may not make you feel completely refreshed but it may be safer when you drive home in the morning.

Meds: Pros and cons
If your primary issue is sleeping during the day, then taking medication that improves sleep can be considered. These can include diphenhydramine (Benadryl), which is over the counter, an alcoholic beverage, or prescribed medication such as zolpidem (Ambien) or zaleplon (Sonata.)

However, in most cases, drinking alcohol or taking medications can actually adversely affect the quality of sleep and impact performance of the next nightshift. Occasional use may be considered after discussing with your doctor, but they should not be used regularly.

Conversely, medication can be taken to help a sleepy person become more alert. One of the more common substances is caffeine, either in the form of coffee, tea or tablets.

There are some side effects, and caffeine can be somewhat addictive, just ask anyone who is forced to miss their daily cup of joe.

Amphetamines and other illegal and legally prescribed medications have been used for this purpose. However, they are much more addictive and the physical effects can actually be dangerous, so they cannot be recommended.

New medications
A new class of medication, available since 1998, has been studied for use by shift workers. Modafinil, also known as Provigil, is a stimulant with an unknown mechanism of action.

One study found that there was a small but significant improvement in performance over placebo (sugar pill). However one-third of those taking placebo had an improvement also; so it is difficult to determine how much improvement was directly related to the drug.

Individuals who took modafinil still had sleepiness and impaired performance, and it did not facilitate adaption to a night work schedule.

Another study found that there was a decrease in the number of accidents and near misses, but there were still high rates. An additional concern is that it may be difficult to fall asleep during a nightshift, and the medication may give a false sense of security.

Overall it is believed that it may be worthwhile for the isolated need for prolonged wakefulness, but not regular night work.

A new version of the medication has come out recently as modafinil is getting ready to go off patent. Armodafinil (Nuvigil) also has been studied, and 77 percent of those who took the medication felt more alert. However, so did 57 percent of those who took a placebo. It is also quite expensive, more than $10 per pill.

Shift work and working nights is an inherent part of working in emergency services. Everyone responds differently to the stressors of this type of schedule.

It is important to prepare before a night shift by getting enough sleep before the shift, napping during the shift if tired and able to do so, and recognizing when we are too tired to continue working or drive home.

Stay safe.

American voters made a decision in the midterm elections in November this year. The decisions were based on a decision to change the status quo. The U.S. Fire Service apparently made a similar decision earlier in the year, too. The number of line-of-duty deaths recorded in 2010 is near the lowest in the past decade. The number of Safety Officers certified by the National Board of Firefighter Professional Qualifications (Pro-Board) through the Fire Department Safety Officers Association is at a record annual total.

The causes for the reduction in LODDs are not readily measurable. Although the number of deaths is down, the statistics do reflect a status quo or even regression in some ways. Statistics through November show that 68 percent of LODDs occurred away from the incident scene, or responding to the incident scene. Heart attack was the cause of 58 percent (46) of the deaths, vehicle collision 14 percent (11). Twenty-one firefighters who died were over the age of 61. The oldest was 86. Two firefighters were under the age of 21.

The National Fallen Firefighters Foundation's Everyone Goes Home Firefighter Life Safety Initiatives call for the certifications of firefighters. Perhaps the fire service is implementing and adopting this Initiative. The training required for certification may be a factor in the reduction of fireground deaths. However, 8 percent (6) of the LODDs involved firefighters losing their lives due to building collapse, being overtaken by advancing fire conditions or becoming disoriented.

The FDSOA, NIOSH, the IAFF and the IAFC all worked to reduce the number of LODDs in 2010. The FDSOA through safety officer training certification, NIOSH by investigating LODDs and making remedial recommendations and the IAFC's Rules of Engagement and the IAFF's Fire Ground Survival Program both show a commitment to reducing firefighter fatalities.

Technological improvements may be another LODD reduction factor. Several firefighters report "new" use of seat belts because of the strong reminders that come in the form of warning lights and buzzers in newly delivered apparatus.

Increased awareness of air management has changed the way departments treat low air warning alarms. Changes in roadway operations is apparent in most photos and videos, in the form of roadway safety vests on most (if not all) responders.

All of these improvements in safety operations and awareness may be contributing factors in the relatively low number of LODDs in 2010. Perhaps the "no fear" culture of the fire service is changing and we are entering a time when risk management prevails and we employ intellectual aggressiveness.
We still must address our biggest cause of LODDs — heart attack. We must look at age as a factor that increases risk. The Fire Service Joint Labor Management Wellness-Fitness Initiative should receive a renewed effort.

The fire service is committed to reducing LODDS, but the efforts must seriously review the statistics and make the necessary changes.

Too many candidates get sucked into concentrating too much on the check-off list for their tactical without realizing it. In the process, they lose control of the fire and their score gets hammered.

What's your best tactic for rescue or knocking down the fire? An aggressive attack on the fire! Go fight the fire with your resources. In the process you will get the necessary boxes checked off on the rating sheet, could put out the fire and get a top score.

Yes, you want to cover all the bases to make sure the boxes are checked off on the rating sheet, but again, isn’t the best tactic for extinguishment and rescue an aggressive fire attack?

However, concentrate on a solid plan. Many candidates put too much into play out of sequence early on in the exercise and make the problem bigger than what the raters have actually given them. Often, candidates will give assignments to units to place positive pressure ventilation, a crew to pull ceilings, assign more than one unit to carry out search rescue and other tasks, call the canteen truck, and add a rescue problem that wasn't given to them.

This is before they have the first line on the fire, a RIT team assigned, utilities pulled and a crew sent to the roof for ventilation. The fire gets away from them and they are out of equipment and resources before they realize what happened. How long can you tread water?

These are major areas the raters will be checking off on your scoring sheet that can rack up big points. You must come out swinging. Once you have proven you can handle the call from the beginning, you're nailing it. As soon as the raters know you got it, they will help you over the top to that next badge. It's a beautiful thing when it happens.

Have a plan
Here's a simple example of a fire problem: You give an on-scene size up at a fire involving a residence with fire blowing out a bedroom window. You order your engineer to hook up as you and your firefighter start pulling lines. If you followed this sequence, you have just lost the fire!

The problem here is you went from size up directly into tactics. Most candidates start off on the right foot with a size up of the fire. Then they make a fatal mistake in going directly into tactics without a plan. They confuse tactics with a plan. Once given the fire problem, focus all your energies on developing a plan.

Without a plan, you are out of control. What was your plan on this fire problem? By just taking a few more moments, you would have one. When confronted, candidates that go immediately to tactics regroup and say, "My plan is to confine and put out the bedroom fire." O.K., but if you didn't say it, you didn't have a plan. Size up, plan, and then tactics.

Incidents involving heavy fire involvement of single-family dwellings, constructed of lightweight building materials present several significant fire suppression and fireground safety issues to arriving companies. The first arriving incident commander must conduct a 360-degree size-up of the situation as the first step in developing a safe, effective and efficient incident action plan.

Incident commanders and firefighters must be especially cognizant when hostile fire has significantly attacked the building's attic area and roof support assembly.

• Describe the building construction of the fire building.
• Based on the observed fire conditions, what would be your projection for fire travel within the structure?
• Based on the conditions observed as the arriving commander, what should be your initial mode of operations: offensive, marginal or defensive?
• There are three key functions for the incident commander: communication, control and coordination. How would you assess the commanders' performance of these three key functions? What did they do well and what would you improve upon?
• What are your thoughts regarding the amount of time that the fire was allowed to free burn while initial tactical operations were being set up on Side A of the structure?
• What changes, if any, would you have made in the first five minutes of the scenario if you were the incident commander?
• The interior fire attack was conducted using Class A foam as the extinguishing agent. What is your understanding of the advantages of Class A foam or Compressed Air Foam as an extinguishing agent compared to plain water?

At every heavy rescue and extrication program, we are taught to remove glass as needed and in as controlled a manner as practical and possible. However, how many times do we go to the session and WHAM and SMASH go the side and rear glass because it’s impressive to watch or fun to do?

But is that what we should be doing? When displacing the vehicle glazing materials, usually referred to as glass management, we want to remove the glass in an orderly, managed process.

Before one window is shattered, it is important to know the types of glass firefighters will encounter and the additional forces that can be present at a motor vehicle accident. The two types of glass to which we have become accustomed, laminated and tempered safety glass, are still the most widely used.

Laminated glass is a sandwich, a series of layers of glass and plastic laminated together. Tempered, or safety, glass will break into small granular fragments when shattered.

However, there are a few new variations in use. Enhanced protective glass is basically a form of laminated glass found in the side and rear windows. Dual-paned glass and polycarbonate glazing are also used.

Some of these materials require a change in our methodology and tools for removing such windows.

And factor in the issues of rear glass hatches in SUVs and minivans. These glass hatches have a nasty habit of flying apart when broken because of the tension placed on them by the multiple hatch struts and the energy absorbed by the vehicle during the crash.

Laminated glass is found in windshields but is increasingly found in the side and rear windows as well. This type of glass must be cut from the vehicle to be removed, which can be facilitated by cutting the peripheral edge with an axe, a glass saw, or even a reciprocating saw.

This operation produces glass dust, which is a respiratory hazard. For this reason, we must add dust masks to the personal protective equipment for glass management.

Tempered glass is usually found in side and rear windows. To break this glass, use an impact tool that imparts a large amount of force into a small concentrated area. Then clean out the window opening by pulling the glass onto the ground with a tool, not with gloved hands.

Vehicles can load the glass with energy from the crash; when it’s broken it can almost explode when that energy is released. We must protect our patient with a protective cover and use hard protection to funnel glass pieces away from the patient.

Photo David Dalrymple

Make sure your eye protection is in place and you are wearing a dust mask. Also, watch out for glass in hatches of vehicles.

It can have up to four gas struts pushing on the glass and creating even more tension. This too might explode when broken; be aware that the struts may also push toward rescuers.

Ideally, the laminated glass that was cut and removed should be folded and slid in under the vehicle out of rescuers way. If at all possible, tempered glass should be removed to the outside of the vehicle, away from the patient and the interior rescuer.

However, some vehicles — especially SUVs and minivans — might have a lot of windows or a rather large window, which produce many glass particles.

Glass particles can be slippery, almost like marbles. It is a good practice to sweep these under the vehicle so that rescuers are not walking on it and stabilization devices are on not on it.

There are two new materials available to help rescuers manage glass. One is Packexe Smash and it is available in North America from ESI equipment. It is a clear film dispensed from a special applicator. The film adds enough strength for tempered glass to be cut.

On the flip side, laminated glass dust can be greatly reduced by applying the film first and then cutting through the area where the film is applied. If the glass is wet, it can be wiped dry with a microfiber cloth before the film is applied.

The other material is an extrication wrap made by Protecto. The wrap material is an adhesive rubber compound on one side with a smooth brightly colored film on the other side. The material comes in a roll that firefighters can pre cut or cut-to size on scene.

The up side to this material is it can be used as sharp-edge protection as well. Both of these materials really can make a difference in glass-management tasks. And both materials can handle glass management and sharp-edge protection.

Whether or not you invest in glass-management products, it is critical to invest the time to plan and execute how you approach removing glass at vehicle collisions. A smart approach protects both rescuers and patients.

On May 22, 2011 one of the worst tornados in U.S. history, an EF-5 that measured more than a mile wide, ripped through Joplin, Mo., leaving 161 dead and an estimated $2.8 billion in damages. The city is mourning its losses and rebuilding.

Everyone in the fire service knows that an unexpected, mass-casualty disaster can strike any community. And everyone in the fire service knows that one of the best ways to prepare for future incidents is to learn from past incidents.

So we put the question, "What have you learned from Joplin?" to three fire-service experts. And we ask that you tell us what you learned.

Meet the Experts

Chief Richard B. Gasaway has served 33 years as a fire and EMS professional, including 22 years as a fire chief and 19 years training fire service leaders throughout the United States and Canada. In addition to his dedication to leading and training emergency service personnel, Chief Gasaway has a second passion in his pursuit to understand how the brain works. Dr. Gasaway has immersed himself in the study of brain science, relating the findings of numerous research studies, including his own doctoral research, to help improve emergency service personnel situational awareness and decision making under stress.

Chief Adam K. Thiel is fire chief in the National Capital Region and a former state fire director for the Commonwealth of Virginia. He has 20 years in the field and serves as FireRescue1's editorial advisor. Chief Thiel's operational experience includes serving with distinction in four states as a chief officer, incident commander, company officer, hazardous materials team leader, paramedic, technical rescuer, structural/wildland firefighter, and rescue diver. He also directly participated in response and recovery efforts for several major disasters including the 9/11 terrorist attacks, Hurricane Gustav, and Hurricane Isabel.

Jim Yeager has been with TEEX since 2003, and currently serves as a training manager. In 2011 he was responsible for managing 40 training and exercise in Disaster City, across the nation and internationally. In addition he works with international US&R teams and assists them in meeting INSARAG standards. He has been a member of Texas Task Force 1 since 1997 and has served as a canine handler, logistics specialist and is currently a search team manager. He has responded to over 60 search and rescue missions to include the Space Shuttle Columbia, Hurricanes Katrina, Rita, Ike and the Joplin tornado.

Richard Gasaway: "The tragedy that struck Joplin served to underscore several very important situational-awareness lessons. The one take-away I hope every community will consider is the importance and value of planning.

Many first responders focus on developing the skills to be proficient for high-risk, low-frequency events such as structure fires. This is good.

However, first responders in every community or region should also unite and engage in the process of planning for horrific events such as the massive destruction of a tornado.

It is nearly impossible to predict how things will play out in real time when such a catastrophe strikes. However, getting the key players together to discuss the potential of seemingly incomprehensible scenarios can be extremely valuable even if the script never plays out as it was planned.

One of the best lessons that can come from planning for large scale incidents is the development of what I term incident situational awareness (SA), one of three forms of situational awareness essential for responders (personal SA and team SA being the other two). Incident SA means, in part, being aware of the broader incident and the role that other responders are playing in it.

Every response agency has its own mission and goals to accomplish during a disaster. While many of these goals are complimentary, some of them may be competing.

Possessing an awareness of the mission and goals of other agencies and responders will improve teamwork and effectiveness across all responders. It will also reduce miscommunications and conflict.

Incident SA is vastly improved by planning that involves the agencies that will meet under such tragic circumstances.

I close by offering a quote from President Dwight D. Eisenhower: "In preparing for battle I have always found that plans are useless but planning is indispensible."

My heartfelt sympathy is extended to all affected by this tragedy, especially the first responders who bore the double stress of personal loss while stepping up to serve."

Chief Adam K. Thiel: "The amazing recovery of the Joplin, Mo. community — after last year's tragic tornado destroyed an estimated 7,500 buildings and claimed 161 lives — is a lesson for us all. It's hard to believe it has only been a year, since the lessons from Joplin have already — to their great credit — been widely shared throughout the emergency management field.

In my own region, based on lessons learned and shared from Joplin, we're taking steps to better prepare for several contingencies. One of the major ones is the potential need to evacuate an entire hospital, something we flirted with — and narrowly avoided — during "Snowpocalypse" (the 2009/2010 blizzards).

We often think that our job as firefighters and EMS providers stops in the emergency room of the local hospital; Joplin taught us to re-visit that assumption. What if your local hospital had to close on short notice due to a tornado or other catastrophe?

It certainly got us thinking.

We've purchased, with the aid of federal grant dollars, small utility vehicles to facilitate rapid patient movement across and through large hospital campuses. These UTVs are deployed across the region and maintained by local fire-EMS agencies that will contribute them to a regional response when needed. They are also useful for the many special events we handle on a year-round basis.

In addition, we've purchased and cached large numbers of simple army litters for quickly moving patients through crowded hallways, around, over and through debris, and outside to waiting UTVs — and ultimately to ambulances or ambulance buses. We have also cached supplies of essential products — bottled water, IV solutions, dressings, etc. — across our region to help receiving hospitals handle the potential influx of patients if a neighboring facility has to be evacuated or closed.

If you haven't had the chance to read and review all the material coming from Joplin, you're missing out. One of the best ways we can honor those who lost their lives in this tragedy is by seeking opportunities to use the lessons learned in our own communities."

Jim Yeager: "There were five major things we learned from our response to Joplin.
We learned about the power of storms. It's always an important reminder to see the damage a tornado can do for us to plan our training exercises.

We deployed under EMAC human remains detection dogs; this is a non-standard package for us. We have now developed pre-designated equipment lists to support these deployments.

We also learned that it is critical to have access to trained and certified human remains canines and to know their capabilities and limitations so that we can meet the full spectrum of search needs.

We used some new technology to push information to the team in the field that we had not used before. This gave the team access to intelligence that allowed us to better perform our jobs on the ground. In addition we used the technology to capture information and send it back to our headquarters in real time. This helped us paint a better picture so they could better support us in the field.

And last, it was nice to see the pioneer spirit in the people of Joplin. After the storm they accounted for friends and neighbors and started cleaning up."

In the fire service, accountability is usually thought of as a system incorporated into fire ground operations that keeps track of personnel on scene. While this is certainly important, it is only just one aspect of it.

Accountability encompasses a lot more than just keeping track of people. Let's consider how the fire service is accountable to the general public.

The fire service is funded primarily by taxpayers. Tax-supported services will be found in large, small urban settings as well as rural settings. There are fire departments that are supported only by donations raised each year and perhaps some money from insurance companies and relief associations.

Regardless of where the money comes from, there is a factor of accountability from the fire service to their financial supporters. We are there to serve their best interests with fire protection and emergency service response. In essence, we are an insurance policy for that specific area and to the people who live there.

Crossing the line
The general public supports their local fire department on a whole, but there are times when they become outraged at what firefighters may be doing. I am referring to what is being released on social media outlets by way of video.

This video certainly has an element of humor to it, and in the fire station, it is understood as part of the culture of being a firefighter. Broadcasting this video and many others like it on social media outlets is where the fire service does itself an injustice.

Firefighters have some idle time in the fire station that will allow for some recreational activities to take place such as fitness, cooking and perhaps a few pranks. While the topic of pranks in the fire station can be debated, they still exist and do add value to the camaraderie of the crew working together.

However, those pranks do not need to be broadcasted to the world to see. By doing so, it allows the general public to start questioning what exactly they are paying for if we are producing pranks during our idle or down time.

The consequences
The more negative attention the fire department receives translates into rescinded funds.

It also leads the general public to mistrust us. If we are constantly producing videos or pictures of pranks in the fire station, the trust factor of our service delivery will be questioned.

So how does this handicap a fire department?

The small dominos that are being lined up are in the form of financial aid and policy creation. The less money given to the fire department, the less we can do in terms of maintenance, replacing old equipment, and even perhaps personnel.

The more policies we have to create in reaction to our idle or down time only reduces the ability to enjoy our job and build moral among the crew.

Keep what happens in the fire station in the fire station and this way we can still be accountable to the general public in a positive way.

"Safety" and "wellness" are the hot buzz words across all public safety disciplines, and for good reason. With injury rates continuing to rise, wellness continuing to decrease and career longevity not lasting through to retirement, there is a problem.

As a consultant and trainer, I step into all types of departments and agencies. I get to look at each organization's leadership, communications, best practices, injury data, system design, and equipment.

Over the years, the terms "safety" and "wellness" have become too vague for our needs. We need to reduce soft-tissue traumas and injury, as it is the single-most expensive financial outlay for a department and the most debilitating for a responder.

A defining moment
Ask a group of emergency responders what wellness is and you will get varied and often contradicting answers. What is safety? Is it safety scene safety, near miss tracking and safety gear?

In EMS, each department has at least one to two people whose full-time job is devoted to clinical excellence. Each department has a whole staff devoted to billing and separate divisions dedicated to everything from fleet to logistics.

These clearly delineated departments do their jobs very well. But how many personnel are devoted 100% to soft-tissue injury reduction and ergonomics, also known as patient-handling excellence?

I have worked with departments that have over 65 percent of their workers' compensation claims from soft-tissue injury. When we calculate the overtime, staffing shortages, morale and new hire expenses we often see that these departments are spending almost 45 percent of their budgets on something that should not be a problem.

As public-safety professionals, we must admit that there is a problem; happily, this problem has an easy answer. As technology continues to improve in leaps and bounds, our ability to safely transport and move patients will get more effective.

I know of three different companies that will bring to market this year some patient-handling products that will rock the fire and EMS world, and I can't wait to see their impact.

The ultimate tool
As our reliance on tools and technology increases, our physical ability decreases. Your body is the ultimate tool and my frequent rebuttal at conferences to snarky questions about patient handling is, "Are you using the tool or is it using you?"

It doesn't matter how advanced tools become. Without a physical training that includes balance of strength, mobility and flexibility, your chance of getting hurt moving patients is still high.

Does your department have an officer whose job it is to observe ergonomics on the street? Does your organization retrain on proper lifting and equipment handling every year? Do you have training modules on soft-tissue injury-reduction techniques, which is not DVD-based but hands-on learning?

Sadly we already know the answer to these questions, and it is why injury rates are and will remain so high.

When an individual or individuals who are already in training and supervisory roles are trained to become pre-hospital ergonomic specialists, we will see organizational and behavioral change. And when their job specifically requires them to observe, coach, teach and reinforce safe and efficient patient handling, we will see organizational and behavioral change.

It's this kind of change that facilitates the reduction in soft-tissue injuries, which can be accurately measured.

Call them safety officers. We have seen organizations promote individuals from within that have always pushed their peers to be fit and healthy.

Provide them with the additional training and knowledge. Then, watch how a safety officer who has a specific focus on reducing one of the costliest problems in public safety can turn your department around, empower it, and field a healthy and fit group of responders.

Not wanting to wait till FDIC, Rosenbauer debuted its completely new cab and chassis at a viewing for sales people, local firefighters and some members of the media at Texas Motor Speedway two weeks ago.

After a two-year research and development phase, the company decided to manufacture its own cab and chassis at a new recently rented 34,000 square-foot factory.

Rosenbauer wanted to be in total control of the manufacturing process not just building the body, but the whole vehicle itself.

The present design will be available in six cab configurations and five options for cab interiors with seating up to 10 firefighters. The cab is constructed of 3/16-inch aluminum and is available with a wide grill and optional round or rectangular headlamps.

The most noticeable difference on the cab is its one-piece windshield, which Rosenbauer said gives a greater unobstructed view. The company also increased space for foot and hip room for the driver and officer. The floor in the cab is completely flat on all options or cab configurations.

The vehicle comes with Weldon’s V-Mux electrical system, Hendrickson front suspension, a high-performance air conditioning unit providing 67,000 BTUs of cooling power, as well as wider doors and steps for easier entry and egress, and a wraparound dash for driver ease of operation.

Along with the Cummins EPA 2010-compliant engine package, which is available up to 600 horsepower, the vehicles will come with either 3000 or 4000 EVS Allison transmissions and will be available in single- and tandem-axle models with up to 60,000 pounds of axle weight.

I am sure we will see some additions and modifications made to the vehicle in the coming months before the first vehicles leave the factory.

But according to Rosenbauer, over 25 vehicles have already been sold. One of the first is going to the Goldsboro Volunteer Fire Company in Caroline County, Md.

A family-owned business founded in 1866, Rosenbauer has built global partnerships with 11 manufacturing locations worldwide building innovative, safe firetrucks. For more information, click here.

According to Ron Fink, the first part of every New Year he feels like the H&R Block folks at tax time. By the end of the year he feels more like the old Maytag repairman of television fame.

I spoke recently with Fink, one of the co-owners of Fire Line Equipment in East Earl, Pa., on the topic of preventive summer maintenance for fire apparatus. Surprisingly, Fink said that there's little in the way of preventive vehicle maintenance that differs between seasons. More important, he said, "Have an annual PM program and stick to it."

NFPA 1911: Standard for the Inspection, Maintenance, Testing, and Retirement of In-Service Automotive Fire Apparatus, 2012 Edition is the guiding standard on this topic. When the technical committee on fire apparatus revised NFPA 1911 in 2007, it merged two other fire apparatus standards, NFPA 1914: Standard for Testing Fire Department Aerial Apparatus and NFPA 1915: Standard for Fire Apparatus Preventive Maintenance, into the document to create one unified apparatus maintenance standard.

According to Stephen Wilde, a member of the NFPA 1911 technical committee, "Anyone doing any type of fire apparatus preventive maintenance, inspections, etc., should take a look at [NFPA] 1911 because it's a great reference. I also think that there are still many people who are not aware of what NFPA has done with this document."

Wilde, who's also the president of the board for the emergency vehicle technician certification commission, said, "The 2007 edition of NFPA 1911 represented the first NFPA standards document that told the AHJ (authority having jurisdiction) that they had the option of going above requirements listed in the standard, but it could not delete or ignore requirements in the standard."

• The fire apparatus shall meet all federal, state or provincial, and local laws for motor vehicle inspections (NFPA 1911, 4.5.1).
• All inspections shall be conducted in accordance with the manufacturer's recommended procedures (NFPA 1911, 4.5.2).
• It shall be the responsibility of the AHJ to develop and implement a schedule for the operational checking, inspection, diagnostic checking, and maintenance of the fire apparatus and its systems and components described in this document, based on manufacturer's recommendations, local experience and operating conditions (NFPA 1911, 4.5.3).
• A complete inspection and diagnostic check of the fire apparatus shall be conducted at least as frequently as recommended by the apparatus manufacturer or once per year, whichever comes first (NFPA 1911, 4.5.5).

Going beyond standards
As we can see, individual departments and their apparatus maintenance providers have a lot of flexibility in developing their preventive maintenance schedules.

"I agree that the most important thing is to develop a PM schedule and then stick with it," Wilde said. "And that's where the NFPA 1911 comes into play. Say one of my customers comes to me and says I want an oil change on my fire truck, I will say to them, 'We don't do oil changes. We do preventive maintenance according to the manufacturer's recommendations for your apparatus and NFPA 1911.'"

Many departments typically address the annual preventive maintenance requirement for their apparatus during the first third of the year. Hence, Fink and his colleagues feeling like tax preparers in March. This is also the time when many departments are getting third-party testing done for aerial apparatus and pumpers.

"At Fire Line, we advise our clients to get their third-party testing on a piece of equipment completed two-three weeks prior to the date we have their apparatus scheduled for its annual PM," said Fink. "That way when we get the unit for its PM appointment, we can take care of any repairs that are needed to comply with the third-party testing results. We can take care of the repairs and the PM with one appointment."

Preventive maintenance light
For their volunteer clients, Fire Line typically recommends a full-scale PM once every two years due to fewer road miles and operating hours on their apparatus. On the off-year, those vehicles get PM light, which includes visual inspections, fluid changes and chassis lubrication, but does not get into more labor- and time-intensive tasks such as replacement of filters.

In all honesty, today's fire apparatus is better prepared for hot weather than we humans. The big-ticket item on everyone's list is without a doubt the air conditioning for the crew cab.

I'm still not sure how my colleagues and I survived those years riding in CF-Mack fire trucks without air conditioning during the hazy, hot and humid central Virginia summers. I'm sure I speak for fire mechanics and Emergency Vehicle Technicians nationwide when I say don't wait until the weather forecast for tomorrow is 90 degrees to find out that your unit's air conditioner is not working.

In addition to the air conditioning, Wilde offers advice for items that require close inspection during PM on your apparatus prior to the onset of hot weather.

• Inspect engine oil and transmission fluids to ensure that neither fluid is contaminated (engine oil by engine coolant; transmission fluid by vehicle fuel).
• Ensure that one of the two required brake system inspections (NFPA 1911) takes place on the apparatus prior to the onset of summer heat, which is brutal on large-vehicle braking systems.
• Ensure that the engine coolant's concentration is within normal limits to protect the engine from higher heat, and that it's not contaminated with engine oil.
• Ensure that the radiator cooling fins are clean and free of any grit or debris that may have accumulated during winter driving.
• Exercise and lubricate all discharge valves and suction intakes. Pay particular attention to the pump cooler valve and the engine auxiliary cooler valve as these have likely not seen a lot of action during the cooler months.

As the saying goes, "The best surprise is no surprise." Get that PM done before the dog days of summer and you'll be less likely to be dealing with the summertime blues.

With 2008 under way, it's time for us to reflect on the year past and to begin developing our plans for the future. Here are eight straightforward ideas that company officers can use right now to help their crews stay ahead in 2008.

1. Be an informer
Passing on relevant information about decisions, plans and activities to the people (your firefighters) who need it to do their work is vital. You can't expect them to accomplish goals that they know nothing about. Discuss the daily objectives at the morning briefing, including any training, inspections, pre-fire plans or scheduled community education. You can never provide too much information to your people.

2. Promote the team
Crew cohesion, or working together as a team, is an important human factor in firefighter safety and for getting things done. Problems with crew cohesion have been identified with several near-misses and tragic accidents. Look for and promote good work practices that safely and effectively accomplish team objectives. Stress the importance of how individual capabilities contribute to the team's success.

3. Create a training plan to keep your crew ready Your training goal should be to prepare your firefighters to be ready to operate safely and effectively at any intensity level, anywhere, anytime, and to return home alive. Readiness training demands teamwork, dedication and sustained practice. Create a flexible and believable training plan that addresses the training needs for your crew while prioritizing those training needs, focusing on safety first.

4. Address problems as they occur
Be willing to confront problems head on and have those tough conversations with your firefighters. A team that is comfortable talking openly with each other, and willing to air their disagreements or problems, will move forward together. Identify and remediate all performance issues immediately, understanding that everyone operates at a different level.

5. Define your expectations and keep them believable
It's pretty simple. Let your crew know what you expect of them. Here are a few examples: Be safe by responding safely, following operational policies, maintaining and operating equipment properly, and practicing personnel accountability. Be proficient by training for readiness and improvement, arriving on scene ready to work, communicating effectively, and following the chain of command. Be professional by practicing a positive image all the time, everywhere you go. Be nice to each other and everyone you meet. If your team makes an effort to follow these basic expectations, you will have a safe and rewarding year.

6. Motivate them
Recognize the likes and differences of your firefighters to help you motivate them to be a more productive team. Appeal to their individual emotions and values to generate enthusiasm for their work. Invite their participation when making decisions, and allow them to have responsibility in carrying out their work activities.

7. Recognize and praise them, at the right time
Provide praise and recognition for excellent (not ordinary) performance. If it's really good work, put it in writing. Be specific about what you are praising. Give praise for weak performance that’s improving. Recognizing their efforts shows your appreciation for the work they do.

8. Support and mentor them
Act friendly and considerate. Be patient and helpful. Do things to facilitate your firefighters' skill development and career enhancement. Be responsive to their requests for assistance or support, and set an example for proper behavior. Be their leader.

Take some time and see if you can add a few ideas to the list. Even if you can only address a few of these recommendations you'll be on the road to developing a fresh attitude and healthy approach for a new and exciting year.

I am sure that if you listened to the transcripts of several EMS agencies' conversations across the county, many of them would have common threads in them.

Those threads would include a senior official stating that their current EMS station was moving toward the point of being in disrepair, providing little to no protection to those clinicians that were stationed there.

Another would say that their community had grown so quickly that their current station is unable to keep up with the demand of their citizens and another station needed to be built.

On the opposite end of the table, another agency stakeholder would state that he/she agreed with the evaluation of the situation; however, funding wasn’t going to be available for a while, and if the fuel prices continue to increase it may be even longer than previously predicted.

As a reader of this column, I would venture to guess that you too have had similar conversations with your personnel, which is one of the reasons you are here looking for ideas that will help your funding shortfalls.

When considering locations to obtain funding for EMS, the US Department of Agriculture is not somewhere I would immediately consider, but in the instance of building up the rural delivery of pre-hospital emergency medicine, the USDA steps up to the plate and hits a homerun with their Community Facility Grant Project.

By going to their website you will find more information related to this project.

The USDA Community Facility Grants program says it is designed to “assist in the development of essential community facilities. Grant funds can be used to construct, enlarge or improve community facilities for health care, public safety, and community and public services.”

There are several factors that are combined to determine the total grant funding that can be approved for a requested project.

For grant applicants, population and median income are two of the largest factors in determining qualified applicants. Based on the guidance for their document, towns greater than 20,000 have minimal chance of receiving funding under this grant program. “Grant assistance may be available for up to 75% of project costs. Grant funding limitations are based on population and income, economic feasibility, and availability of funds.”

This project will fund projects that also receive other USDA “CF financial assistance such as direct or guaranteed loan, applicant contributions, or loans and grants from other sources.”

Limitations to the USDA Community Facility Grant project include:
1. The payment of any annual recurring costs, including purchases or rentals that are generally considered to be operating and maintenance expenses.
2. The construction or repair electric generating plants, electric transmission lines, or gas distribution lines to provide services for commercial sale.
3. The payment of costs to construct facilities to be used for commercial rental where the applicant has no control over tenants and services offered.
4. The construction of facilities primarily for the purpose of housing State, Federal or quasi-Federal Agencies.

For those agencies that serve the rural populations that have minimal operations for healthcare delivery within their borders, this is an excellent opportunity to look at ways to fund the future of medical treatment to your citizens.

For more information about how to apply for this grant process you must contact your local USDA Rural Development office. You can find these resources here.

Recently my community of Kent Island, Md. suffered a tragic loss of four young men. These close friends, ages 18 and 19, went for a ride mid-day and were involved in a fatal motor vehicle accident.

There are no real answers as to how or why this occurred, but now my community is faced with addressing the aftermath.

In addition, the impact of this tragedy has affected my local fire service as one of these young men was a member of the Kent Island Volunteer Fire Department and another was the younger brother to an active member of the United Communities VFD, where I serve.

Both of these departments responded to the accident scene. Unfortunately there was nothing that the rescue crews could do, delivering a second emotional blow to our fire service members.

Call for assistance
Upon learning of the accident, an immediate response of assistance, support and comfort descended upon our community. The administrations of both departments began the process of pulling resources, reaching out to the families of these young men, and supporting our members who were impacted by the incident.

While these deaths were not a result of fire department activities, they truly affected our entire fire service family. The stressors created by this incident were very visible and if left unchecked, could possibly affect the delivery of effective fire, rescue and emergency medical services to our residents.

Departments must be ready to deal with tragedy when it strikes close to home and must have a plan as to how they will address issues as they arise.

Whether or not it is a line of duty death, the same basic principles apply: Have a plan in place, practice the components of the plan, learn from each time you administer it and make adjustments from the experiences you have. Most importantly, stick with the plan as best as possible, openly communicate all aspects of the plan and empower team members to discharge the various tasks and actions that need to be performed.

The best learning environment is achieved when individuals are engaged in the activities being taught and mentored through the assorted steps in the process. Sharing the workload not only makes the job easier, but it provides depth within an organization by having more people who are able to get things done.

Resources available
If your department does not have a plan for these types of occurrences, then please contact the NFFF and ask for our materials that contain sample plans, SOPs and departmental best practices. If you do have a plan, then these materials might be a great way to evaluate the overall effectiveness of your strategies against what other departments are doing.

At my department we are continuing our efforts to communicate with each other and work through issues around our firehouse kitchen table, a natural comfort zone that firefighters use to strengthen their resilience when tragedy strikes.

But some of us will need more extensive help and that is why the NFFF has been working for the past four years to develop a new Behavioral Health Model to support the first responder community. One core element of this new model, stress first aid, involves peer support and was adapted from the combat operations stress first aid model used by Marines Corps and Navy personnel.

I will close by expressing my deepest sympathies to the families of these four young men: Tyler Elzey, 19, Harrison Rhodes Smith, 18, Cory Pessagno, 18, and Michael John Ringenbach, 19, to their friends and neighbors and to the Kent Island and United Communities volunteer fire departments who were most impacted by this loss.

They may be gone, but they will never be forgotten. May they rest in peace.

Becoming a student of building and content hazards does not mean that you have to go out and get a builder's license, but you do have to keep up with what is happening in terms of building construction. I am sure you have heard the Francis Branningan quote many times over: "The building is your enemy, so know your enemy."

With that in mind, let's learn a bit of history about building hazards.

Wooden shingles have "been the cause of incalculable loss of property because of its susceptibility to ignition from sparks and through its efficiency in communicating fire it has been the known culpable factor in the rapid spread of most of the largest conflagrations on record."

That is a quote from the 1926 NFPA brochure called "The Menace of the Wooden Shingle." Obviously, the fire service has known about the hazards wooden shingles represent, but hasn't been able to change the minds of builders at large, since wooden shingles still represent a fire problem today.

Modern fire load
The home furnishings industry has been changing the furnishings in our homes from a natural-based material to plastic-based material. We knew the dangers that were inherent by adding plastics in large quantities to homes, but again, we were unable to change the minds of the manufacturers.

We pushed for legislation that would put residential sprinklers in all new homes, but again we were beaten down by the home builders in most cases. While these battles need to be waged for the safety of civilians and firefighters, we have to realize that we must also prepare ourselves for living with the changes that are being thrown at us.

Let's take a look at how today's furnishings burn, compared with those of a just a few years back. This is a major wake-up call to firefighters that fires burn differently today than they did a generation ago. Today's fires burn hotter and faster.

Learn from the video and pass it on to others in your department to learn from as well.

The fire service was not a big fan of the engineered I-beam, but it didn't make much difference. Today, they are out there in large numbers and it will continue to grow. We need to learn about how quickly these beams can fail when exposed to fire. A number of studies have been done on just this topic, so learn from them.

The NIOSH website includes many LODD reports that can be reviewed for learning. The site is easy to navigate and search, so spend some time reviewing past incidents and be better prepared because of it.

As a fire service, we need to be involved in standing up for what we know is right. We also have to realize that many battles will not be won. The best things we can do is to make sure we are aware of the hazards that exist, and try to prepare for the battle ahead with this information in mind.

As the year draws to a close, it is worth reviewing some of the legal issues to hit the fire and emergency medical services in 2011.

Social media is a big deal for emergency service organizations
Emergency service organizations, states, dispatch centers and non-profits are implementing social media in ways that have positively impacted public safety. At the same time, social media channels present a variety of liability risks that must be managed.

Organizations that use social media to engage in two-way conversations with the public are particularly at risk. For example, emergency service organizations that allow members of the public to post in their social media channels may face First Amendment liability when they attempt to remove or edit offensive posts.

These organizations may also face liability if members of the public place calls for help using social media channels and receive no response.

When using social media to communicate with the public, emergency service organizations should use social media like a news feed, not a telephone, providing information but not receiving it.

Organizations must also have published attorney-reviewed social media policies that use disclaimers to discourage citizens from using social media as an alternative to the 911 system.

Restricting social media use among paid employees also has risks. Disciplining employees for comments or other postings they make in social media channels outside of work may create First Amendment liability.

Recent actions from the National Labor Relations Board ("NLRB"), the federal agency responsible for employee-labor relations, suggest that a social media policy that is overly restrictive of employee speech violates the National Labor Relations Act even if the offensive policy is never enforced.

Organizations with paid employees should review internal social media policies to determine whether a particular restriction is necessary to preserve the core operations of the organization.

Provisions that punish employees for making offensive or annoying comments in social media channels during non-working hours will generally not pass muster.

It is extremely important to consult with an attorney licensed to practice in your state prior to terminating any employee for their use of social media.

And the labor laws, they are a changing...
The laws governing the relationship between employers and unions are being revisited in a dramatic fashion after years of stagnation.
At the national level, Obama administration policies are shifting the employer-labor balance in favor of the unions. Recent NLRB complaints, NLRB appointments and executive orders have signaled a sharp union-friendly departure from the Bush administration.

Although most emergency service workers' unions fall under the purview of the state labor laws, many states model their labor laws after the federal law and NLRB interpretations are influential.

At the same time, some Republican-controlled states are attempting to sharply curtail the collective bargaining rights of public sector unions.

Wisconsin, Ohio, Tennessee and Indiana have considered restricting or already restricted collective bargaining rights.
Even in those states that have not modified the laws, government officials are becoming increasingly resistant to any pay increases for both union and non-union paid responders.

In many cases, officials have relied on volunteers to minimize the impact of funding and personnel cuts.
As states continue to experience budget shortfalls, there will likely be continued shifts in this area which organizations must monitor.

Mutual aid agreements
The continued trend of waning volunteerism and cuts to paid departments have emphasized the need to revisit or readjust mutual aid agreements. Although some states have adopted statewide mutual aid systems by statute, many communities rely on agreements with surrounding departments not only to manage large incident but for day to day coverage.

Although the components of mutual aid agreements will be addressed in a future article, effective agreements must clearly define the relationship between responders from different organizations, allocate risks and create functional mechanisms for reimbursements.

Specifically, mutual aid agreements should deal with the chain of command, workers' compensation coverage, reimbursement for expenses and equipment damage, EMS and hazmat billing rights and payment of overtime.

This article is not intended as legal advice and there is no substitute for competent legal counsel licensed to practice in your state.

Setting up a successful public access defibrillator (PAD) program should be on the forefront of every fire and EMS agency’s agenda. The American Heart Association notes that for every minute a person is in a cardiac arrest, their survivability decreases by 10 percent. Having easy-to-use PADs that are quickly accessible by the public increases the probability of delivering life-saving defibrillation sooner.

Here are the top five things to consider when starting a PAD program, along with some of the strategies I used to start a PAD program that has grown to more than 1000 PADs over just a few years.

Involve the stakeholders
With any successful startup program, getting the key players involved at the beginning is critical. Start by inviting those organizations and individuals who are the stakeholders – those with a vested interest in the success of starting a PAD program. This group should include fire, law enforcement, EMS, 9-11 communications, hospitals, cardiologists, the local American Heart Association, and other interested parties.

Start with regularly scheduled meetings and open discussions on the importance of PADs to the survival of cardiac arrest patients. You may begin the initial meeting by walking the group through the continuum of care that each member provides, starting at 911, through prehospital responders, to hospitals, and finally outpatient care. This helps everyone understand the many vital roles needed to help increase survivability. This group may grow and develop subgroups as other key tasks or steps are identified.

Funding
After the stakeholders have bought in to the program, one of the next steps is locating funding. Funding will be integral to starting and maintaining the program. A well connected stakeholder group may be able to tap into their individual networks to locate funding, and this task may also turn into a subgroup of the stakeholders. Funding may come from a variety of other sources, including community grants, endowments, fundraising events, matching funds, or other programs.

Hospitals may also have access to funding sources or use other methods to lower costs. For example, in one successful program, a hospital used its purchasing power to lower the costs for PADs. They did this by purchasing in PADs in volume at 100 units at a time, and also by helping to negotiate a lower price. This lead to a lower cost through a volume discount and lower shipping costs per unit. The hospital also offered to use their staff to help augment the program, store, and even tracking individual PADs. Their CEO was an early member of the stakeholder’s committee, and he quickly understood the importance of PADs to saving lives. He was used as part of the negotiating team to help get the lowest possible price for the PADs.

PAD selection and training
The team should determine whether the program will use a single model of PAD, or whether a variety of brands will be used. An argument for a single model is that as the program grows certain things become easier (and cheaper) due to economy of scale such as training, system upgrades, recalls, purchasing batteries and patches. Having one brand may also create a direct pipeline to the company for maintenance and support. Since CPR training includes PADs, if one particular brand of PAD is selected, then models for that particular device can be incorporated into training. This ensures realistic training based on the system.

The team should also ensure the PAD model integrates with the brand of device that prehospital responders are using. This will allow for similar defibrillation technology and protocols from PAD to responders, and ultimately the receiving hospital.

During this step, the team can also begin to focus on the location and placement of the initial PADs in the community. The team should consider sites where mass gatherings are common, areas with large populations over 50 years old, schools, and sites that take EMS longer to respond.

Marketing
This can be ongoing from the beginning of the process, and is important for creating “buzz” in the community. Once word is out, you may be surprised at the demand for the program from individuals and businesses.

Some marketing ideas can also be turned into fundraising opportunities. Two ways to get the word out and involve the community are mass CPR training days, and a contest to name the PAD program. The front of the PAD cabinet is also a prime marketing location and can be used to further market the program with contact information and logo placement.

The PAD program can also rely on local media for marketing. Depending on the situation, consider asking for coverage of successful cardiac arrest “saves,” or giving awards to citizen heroes for taking action.

System Integration
Early on, prehospital providers may be reluctant to embrace the program. Some may view it as encroaching on their turf and won’t fully understand the value PADs bring to increasing survivability. You should clearly explain that PADs will keep patients alive and offer responders a better opportunity to provide their skills to potentially survivable patients. Here are some integration considerations:

• The dispatching center should have a database that will notify the call taker if a PAD is located at the site, and also provide instructions for use. Some computer aided dispatch programs (CADs) have the capability to flag addresses with PADs located on the property.
• Some groups may not embrace the change because they may be required to perform new roles or change their operation, i.e. police may have to carry PADs in their patrol vehicles. It is important to overcome these arguments, as police often beat firefighters and EMS to the scene and can start defibrillation even sooner.
• First responders should understand the importance of PADs and also be able to transition from a PAD to their device for transport. There needs to be guidelines and training on switching from a PAD to a more advanced cardiac device, and also when should they continue using the PAD.
• This goes back to the importance getting key players from various agencies together so they can communicate the importance of the program back to their organizations.

Conclusion
These are only some of the areas to focus on prior to setting up a PAD program. These programs are easy to start and garner great success by increasing patient survivability from sudden cardiac arrest. If fire and EMS agencies do not step up and provide the necessary leadership to start a PAD program, some other organization will fill that role and take a significant new standing in your community. A successfully implemented PAD program is one of the only tools presently available for a city or EMS system to increase the rates of patient survivability from sudden cardiac arrest.

Feel free to contact me for any questions on PAD programs. I've helped start several programs, including one which received the national heart safe community award.

SUMMARY
Carbon monoxide is the most frequent cause of poisoning in industrialized countries. Reports indicate that over 500 people a year are killed by unintentional poisoning, with about 15,000 people seeking treatment at hospitals. Firefighters play a key role in responding to and rescuing patients suffering from carbon monoxide poisoning. Symptoms of mild poisoning include headaches and flu-like effects. However, larger exposures can lead to significant toxicity of the central nervous system and heart.

OBJECTIVE
Upon completing this educational curriculum on carbon monoxide poisoning, by Bryan E. Bledsoe, DO, FACEP, the student will be more aware of the importance of carbon monoxide detection and carbon monoxide treatment in the fire-ground setting.

Download the curriculum materials below.

This educational module is sponsored by Masimo Inc., and is endorsed by the National Association of EMTs, and the International Association of Firefighters.

Copyright 2008 by Cielo Azul Publications.

NICETOWN, Minn. — When an overly curious firefighter found himself unable to get free from a drainpipe he'd wandered into, a group of adorable kittens swung into action.

Fellow firefighters spent hours trying to coax their shift mate out of the pipe, but he wouldn't budge.

"We tried everything, but Big John just wouldn't come out," said one distraught firefighter. "We thought … I'm sorry, give me a minute … it was all so emotional. We thought Big John was lost forever. All I can say is (sniff, sniff), thank God for kittens."

The kittens quickly formed a chain linking front paws to tails and made their way into the drainpipe.

The experience left the firefighter traumatized, but he credited his rescuers for their calm performance.

"I was pretty spooked when I first felt one of those kittens grab my foot...and I'm not proud to say I may have let out a wail and scratched at him," said Big John. "But when the lead kitten, Mr. Cuddles, reached me and started to purr, I knew everything would be OK."

Once Big John was calmed, Mr. Cuddles secured the firefighter with his front claws and the chain of kittens slowly retreated out of the pipe, pulling Big John with them.

Reunited with his teary-eyed brothers, Big John said the drainpipe looked like a fun, cool place and he wanted to see what was inside it.

"Honestly, I didn't give much thought to why I was going in there or how I was going to get out," said Big John, when asked how he ended up in the situation. "I just saw a shiny reflection moving around and went after it."

Asked about the heroic rescue as the kitten team licked themselves clean, Mr. Cuddles said, "Meow."

"Meow," repeated one of the firefighters. "Can you believe how humble these kittens are? They probably don't even realize they're heroes and think they are just doing their job."

Those who believe in stripping government of all or most of its power and allowing free markets to chart our course will not like what I'm about to say.

Many of us in the fire service watched in horror as the fire and explosion at a West, Texas, fertilizer plant played out. So far, 10 of the 14 dead have been identified as first responders, many volunteer firefighters. They died either fighting the fire that preceded the blast or while evacuating residents.

It's a miracle more firefighters were not killed.

Investigators are still trying to piece together what happened, but it is well-accepted that the fertilizer plant had some quantity of ammonium nitrate that burned and exploded. The explosion was described by witnesses as being like a nuclear bomb and more scientifically by the U.S. Geological Survey as registering 2.1 magnitude on the Richter Scale.

Level of protection

When the Associated Press reported on the level of regulations the plant faced, it said in its opening paragraph, "There were no sprinklers. No firewalls. No water deluge systems. Safety inspections were rare…"

The Associated Press went on to report that the company self reported to regulators that it didn't have any flammable or explosive materials on site. This was given to the U.S. Environmental Protection Agency after EPA forced the company to update its risk-management plan.

I wish I could say I was surprised to learn this. And neither will I be surprised in the coming months if I learn that more strict and enforced regulations would have prevented or minimized this incident.

This happens a lot. It might be mass casualty incidents at factories in India where exits are locked and no fire-suppression equipment is available. It might be a nightclub in Brazil where pyrotechnics are lit and sprinklers and extinguishers are absent. Or, it might be a rental property here in the United States where landlords fail to have working smoke alarms in their buildings.

Getting leaders to listen

I've had the good fortune to travel to developing countries as part of the fire service. I've listened to those foreign firefighters complain that they cannot get their local leaders to prioritize fire safety.

I've also had the good fortune to have spent several days in the British Virgin Islands, getting to know the man who was sent there to build a fire department from scratch. One of his most difficult, but most important, missions was implementing fire codes, which he cobbled together from existing European and U.S. codes.

The reality is that without solid and enforced fire codes, business owners are not likely to invest in real fire protection. Some of this can be chalked up to their pressure to make money.

Yet, I suspect a lot of this problem is one of human nature — we find it hard to believe that we will actually be the victims of a tragedy. Even among firefighters, how many really believe that they can be injured or killed in the line of duty?

But whether greed or a false sense of security, without proper oversight, fire safety probably won't happen — self-policing doesn't work. And government is the entity best suited for that role.

You can make the argument that over regulation will kill business and economic growth. But I put to you that the opposite will kill firefighters and civilians.

Whether dragging victims from a building or simply humping hose around the fireground, firefighting demands certain types of physical training in order to perform the job safely and effectively.

Traditional firefighter conditioning has revolved around cardiovascular training such as jogging or treadmill work. But the real world dictates that firefighters must have cardiovascular function with nearly 50 pounds of gear on their bodies.

This changes the equation drastically when it comes to being in shape. It dictates that maximal strength and the highest level of anaerobic endurance must be obtained.

To some extent maximal strength can dictate how much endurance you have. If your maximum-effort dead lift is 200 pounds and you're asked to carry a 200-pound person, you won't be moving that person far before running out of energy.

On the other side, if your dead lift is 600 pounds, then a 200-pound person can be moved with relative ease because it only requires 33 percent of your maximal strength.

3 problem areas
Statistics show that most firefighters' physical injuries involve the lower back, knees and shoulders. This is where strength training takes a specific route to bring up strength and decrease injury.

Lower-back injuries often come from lifting heavy patients. Any firefighter who has run ambulance calls has come across residents who weigh between 300 and 500 pounds, or more in rare cases. Obviously firefighters need to be strong enough for that type of duty.

Injuries occur here due to weak lower back muscles, little-to-no hamstring strength and improper technique while performing a task. The first issue is to bring up the lagging muscle groups, then teach form in order to be mechanically sound.

Exercises

• Reverse hyper extensions – This builds important lower erectors and glutes while tractioning the lower back.
• Glute ham raises – This strengthens the hamstrings, glutes, lower back and calves. Working them with this exercise teaches all the posterior chain muscles to work together as they do on duty.

Knees
Knee issues can be more complicated, but often firefighters beat their knees up by having weak hips and hamstrings. When jumping, jogging and carrying equipment at a fast pace, the hips and hamstrings must take their share of the work. If they are lacking in strength, the knee extensors attempt to complete the work. Over time this over use of the knee starts to take its toll.

Pain and injury occurs here due to weak hamstrings, hips, vastus medialus muscles and improper form. Once the hamstrings get stronger, knee pain and injury decreases.

Exercises

• Glute ham raises – This builds the hamstring in a functional environment.
• Straight leg deadlifts – This strengthens the hamstrings in a way they will be required to work.

Shoulders
Shoulder pain, tendonitis and injury usually start with a weak upper back. The upper back — which includes the lats, rear delts, rhomboids and sub scapular muscles — needs to be strong in order to hold the shoulder joint in place under strain and to maintain correct posture while performing various tasks.

Exercises

• Rear delt row – This directly builds the rear delt and sub scapular muscles.
• Bent over row – This builds the lats and also the rhomboids, traps.
• Lat pulldown – This builds the lats, rear delts and most minor muscles groups of the back.

Cardiovascular endurance
Working on your cardiovascular endurance is important in maintaining your overall health and aiding your recovery. Many firefighters remain on the job well into their 50s; and some, especially volunteers, remain past 70.

High-impact activities, such as jogging, over time will increase injury and wear on the knees, back and hips. Therefore it is important to gain endurance with the least amount of negative impact on the skeletal system.

Sled dragging is one of the best overall tools to develop conditioning while building muscle in important areas. There is virtually no joint impact and with the proper weight can be just as intense as running is on your heart, lungs and lactic acid tolerance.

Dragging the sled backwards is similar to dragging people out of buildings.

Kettlebell swings are a very tough cardiovascular drill and very quickly improve the conditioning level of firefighters. I have seen U.S. Army Rangers buckle to the floor with 60 pounds in less than 5 minutes while doing swings, while it was no biggie for these guys to run more than 10 miles.

A strong lower back and abdominal base must be built before using this exercises with anything more than 25 pounds. The benefits of using a kettlebell is no joint impact and a great workout for the cardiovascular system and much of the entire muscular system.

Training on the job
It is important for firefighters to train at an optimal level of volume and intensity when on duty or scheduled for duty within 24 hours.

Firefighters must still be able to perform their job at any moment while on their shift. Totally wrecking the crew will not be optimal for a possible fire or other emergency. This is why training must be individualized for each person.

These issues are 90% of the problems I have seen in the four years of working with a large fire department. The variety of ages and body types means that training will require different starting points and constant revision to keep individuals progressing.