“Acceptable Losses”

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When preparing our departments and personnel for the next terrorist event, a new concept has emerged that needs to be addressed before the event happens. This is the concept of "acceptable losses." What are the ramifications of this idea, and how does it relate to the fire service?

During military battles, field commanders are prepared to accept the loss of up to 33% of their troops during combat. A percentage is really ambiguous, and this needs to be put in proper perspective. For lack of better words, one out of every three soldiers, Marines, airmen and sailors are considered written off when considering battlefield casualties. During World War II, the United States in its bombing raids over Europe on the average incurred these losses, and sometimes even more.

I just completed a class called "Emergency Response to Terrorism" at the University of Miami School of Medicine. This was a pilot course and several command officers and company officers throughout the greater Miami-Dade County area were asked to evaluate and give input so it could be improved. This was like many other courses I have taken on this subject, except this one had a very hands-on approach. On the last day, all participants took the role of rescuers, then changed roles to victims in an attempt to learn what victims might feel in these types of events.

During the first day's lectures, "acceptable losses" were discussed. How does this term impact the fire service? In a terrorist attack of some magnitude there will be many victims. The first-arriving units will be greeted by myriad sick, injured and dying patients. This will become a mass-casualty incident (MCI). Triage procedures from that point on drastically change, as we all know. Instead of the worst being treated first, the firefighters, EMS workers and other first responders must now look at all patients and treat the most viable first. Those patients who in all probability will die must be written off so that the rescuers can attend to patients who might have a chance to survive with immediate treatment.

Most fire departments have adapted a system of rapid triage using MCI triage cards with perforated ends that are color coded - black indicates dead, red means immediate treatment and transport, yellow is for delayed treatment and green is assigned to the walking wounded or "walking well," using the new terminology. Initially, first responders will walk among the victims and tag them according to their probable survivability.

Some departments have adopted a rapid triage method called START (Simple Triage And Rapid Treatment) in which three criteria are used for rapid evaluation: Respiration, Perfusion and Mental status, or RPM. An algorithm printed on a card the size of a business card is given to every firefighter to help in remembering this technique. Basically, it says you examine the patients; if they are not breathing, you open the airway; if they still aren't breathing, they become non-salvageable and you move to the next patient. If they begin breathing, you assess the rate and categorize the patient, and go to the perfusion criteria. Further categorization takes place and you move to the mental status category, examine further and make the last category selection. Each examination should take no more than 30 seconds.

To make the process even faster, each unit has several spools of colored ribbons. The tags are placed on the victim's in the secondary triage station. Colored ribbons are tied around a patient's extremities, and an extrication group comes in and removes these patients in the order of urgency using this system.

To understand this system and how it works, a fire department at the very least should practice these techniques in an MCI drill with many patients. In Miami, for example, area nursing schools allow us to use their students as "victims." Our training division moulages the "victims" and tells them what signs and symptoms to display.

What initiated my thinking about this was a discussion of chemical agents. For example, in a mustard gas attack, any patients burned on 50% or more of their bodies will die within four hours, regardless of how they present, according to the instructor. In practical terms, this patient - although conscious and alert - will be given a black card with "Morgue" written on it. There will be no discussion; this person is written off, and the rescuer moves to the next victim. Can you imagine how this will make a person feel during their last moments on earth? We discussed this and we are attempting to change the word "Morgue" to "Expectant," as if this is going to ease the feeling of utter helplessness for that victim.

As cold as this concept sounds, it is indeed reality, and we must attempt to prepare our firefighters on how to deal with it. Most experienced EMS crews have already had some incidents with multiple victims, where they have had to make difficult decisions in a hurry. The truth, however, is that most firefighters have not had to make these kinds of decisions.

With tensions high, we must address the possibility that our firefighters, police officers and first responders will immediately be thrust in this arena without warning and, in some cases, with very little experience in responding to this type of event. If one isn't mentally prepared to adapt quickly, he or she will be rendered useless and may actually become part of the problem. How do we train our people to address the new concept of providing the "greatest good for the greatest number of people" in the face of mass carnage?

I remember the opening scenes of the movie "Saving Private Ryan," and the emotions it elicited in me watching the D-Day landing. Understand that I was a combat Marine in the 1960s, so I had some exposure to this sort of thing. I also spent 15 years as a paramedic on a very busy unit and have seen significant numbers of victims and carnage. The movie still had me staring with incredible awe at what I saw. This same type of exposure can be seen as a training exercise to our firefighters. Movies of mass-casualty incidents can be used to help the firefighter understand what he or she might see. During the class I took, the instructor showed military films of the victims of Saddam Hussein and the effects of nerve gas, mustard gas and cyanide. In some scenes mothers and children were killed so quickly they died still holding hands. These kinds of images, although seemingly macabre, are necessary to help prepare our personnel mentally. Hopefully, this will allow them to function better in a horrific setting. Rescuers must at least have an idea of what they may have to face.

It is our responsibility and duty to prepare those under our command with every tool we have to insure there are no "acceptable losses" within our ranks. This means not only providing them with the necessary tools and equipment, proper personal protective equipment (PPE), but with all training necessary to give firefighters the greatest chance of survival, when even that outcome appears grim.

Following the event, the trauma of working in that type of environment does not stop. The effects will be cumulative and broad reaching. Years later, the post-traumatic stress may take a toll on rescuers in many and bizarre ways, from substance abuse to cancers and other deleterious problems. Critical incident stress debriefing (CISD) teams must be in place before the event to be of any use.

On a personal note, just after 9/11, our Urban Search and Rescue (USAR) team members returned from their mission in New York. As they got off the bus, you could see the "thousand-mile stare" on some of their faces. Our CISD team spoke with many of them and at least informed them of what they might have to face in the future. I think of all the victims in New York and of what they may experience as the years go by, and it is not a pleasant image.

The solution is training, training and more training. The more we expose our firefighters to what could happen and how we will deal with it when it happens, the more efficient they will become. You play as you train, so this is a paramount principle. Full-scale drills, as cumbersome and seemingly chaotic as they might be perceived, are vital. This is not just a hazardous materials incident, an EMS incident or one of pure firefighting. It is a combination of all three. Traditional and existing standard operating procedures (SOPs) must be modified so that the firefighter and rescuer can work in a very chaotic situation. The time to change these is now.

These tumultuous times are not going away any time soon, and the worst thing we can do is to be lured into a false sense of security and the bane of all public safety agencies, complacency.

Courage Under Fire

After much debate and discussion, the federal government and state governments have decided to start smallpox vaccination programs. This in itself took a lot of courage. The President and the Department of Homeland Security should be commended for this effort.

Unfortunately, there is a backlash of controversy. In Florida we are seeing gross vacillation in the implementation of this program. The plan has been outlined, the vaccine procured and the plan put in place. The program consists of three phases. Phase one is the vaccination of health care and hospital workers. Phase two calls for vaccinating first responders, firefighters, EMS workers and police officers. Phase three is the public. All will be on a voluntary basis.

At one point, the program was supposed to begin on Feb. 10, 2003. Now enter the lawyers and naysayers, preaching the doom and gloom of mass inoculation. The worker's compensation people, insurance companies and my favorites, the personal injury lawyers, have clouded the issue so much that no one wants to make a decision.

What happens when people start to call in sick with slight fevers and malaise? Who is going to pay for this and the like? The lawyers are salivating at the money they may make when there is an adverse reaction and that person sues the doctor, the hospital, the inoculators and perhaps even Edward Jenner, the person who developed the first smallpox vaccine in 1796. Of course, Jenner is dead, but sue anyway, there may be an estate they can steal. Hospitals and fire departments are wrestling with these immediate problems.

This is all well and good, but I feel we are losing sight of the big picture here. If there is a smallpox release, hundreds of thousands of non-immunized people are going to die and be seriously ill in a relatively short period. If the majority of them had been vaccinated, this would not happen. Can you imagine the cost of this when it happens?

We must develop some intestinal fortitude now and understand the terrorists do not care about lawsuits or worker's compensation. They just want to kill people and as many as they can as fast as they can, and in the most heinous manner. The longer we wait to sort out these "potential" problems, the more the odds increase that we will be hit unprotected.

Hopefully, our city and state leaders will understand this and start the program NOW. Great strides have been made over the past two years. We should not undo what effort has been done because of petty political issues and, in some cases, outright greed. President Bush understands this and has already been inoculated. Our fire-rescue workers need this protection and they need it now. Granted, not all firefighters will elect to receive the vaccine, but I hope they will weigh the good with the bad. If and when the attack happens, is not the time to have a sudden epiphany and realize I need the vaccination. By then, it is too late.

State and local officials must be educated on the clear and present danger this threat is to their citizens and constituents, and the importance of starting this program as quickly as possible. Medical directors and fire chiefs should be an integral part of this process, and, if needed, state in clear, concise terms how important this is to their government heads, department heads, employees and ultimately the citizens we all serve.

Michael J. Essex

Chief Concerns is a forum addressing issues of interest to chief fire officers. Opinions expressed are those of the writer. We invite all volunteer and career chief fire officers to share their concerns, experiences and views in this column. Please submit articles to Chief Concerns, Firehouse Magazine, 445 Broad Hollow Road, Melville, NY 11747.


Chief Michael J. Essex is special operations officer for the Emergency Response Division of City of Miami Fire-Rescue. The division includes the technical rescue, hazardous materials and dive rescue teams. Essex also is the department's SWAT-Medic commander.

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