The department is located near a busy harbor and has many bodies of water in their response area including shipping channels to the ocean, commercial waterways, canals and lakes. Recommendation #2: Fire departments should ensure that public safety divers are properly trained, equipped, and supported to perform public safety diving responsibilities. Discussion: Public safety agencies that perform technical rescue water operations, including SCUBA diving, need to ensure that personnel receive the proper training, equipment, and continued support consistent with national consensus standards and agencies that provide recognized advanced levels of certification to safely perform this level of emergency service capability.
Many communities rely on mutual aid or a combination of jurisdictional resources to provide response capabilities to complex rescue incidents such as high angle, hazardous materials response, trench or confined space, or other technical rescuer professional level operations such as public safety diving. Emergency incident risk benefit analysis did occur on this scene and a quick response by the local fire department successfully rescued one civilian from the surface of the lake by fire fighters.
Discussion: Organizations that provide water search and rescue operations need to ensure that all members who respond to or may respond to water rescue incidents should be sufficiently trained to the level that they are expected to operate. Recommendation #7: Fire departments should provide annual and periodic health, wellness, and fitness examinations with specific medical evaluations for fire fighters expected to perform technical rescues such as SCUBA diving. The purpose of periodic medical evaluations is to ensure that fire fighters have the ability to perform duties without presenting a significant risk to the safety and health of themselves or others. Discussion: Fire departments should strictly prohibit any member of the fire department from responding to a call if they have been drinking. Recommendation #10: Fire departments should consider performing a preplacement and an annual physical performance (physical ability) evaluation for all fire fighters to ensure they are physically capable of performing the essential job tasks of fire fighting. NFPA 15007 requires fire department members who engage in emergency operations to be annually evaluated and certified by the fire department as meeting the physical performance requirements identified in paragraph 8-2.1. The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease Control and Prevention (CDC), is the federal agency responsible for conducting research and making recommendations for the prevention of work-related injury and illness.
Immediately following mock emergencies, staff members meet to debrief and discuss problems in how the team responded. Implementing an office emergency preparedness program removes the anxiety of dealing with unusual issues, keeps necessary medications and equipment current and in working condition, and identifies problems prior to an actual emergency so that they can be resolved. However, emergency situations in medical offices do not engender the same type of Pavlovian reaction.
Though perfection is impossible, all clinicians and staff members must practice their response to medical emergencies in the outpatient setting so they are prepared should an actual emergency arise. The emergency physician subsequently called to compliment our clinic for the pre-hospital care.
The program begins with a review of all available emergency equipment in the office utilizing an engaging scavenger hunt format.
Additionally, Condition C cards with common emergency situations and the appropriate interventions are located in each exam room and stored with the emergency equipment. We try to perform these mock emergencies at least two times per year.Our emergency preparedness program involves five key steps, depicted here. An alternative would be to incorporate all of these steps into a half-day session and to offer CPR certificationCHECKLIST: EMERGENCY SUPPLIES FOR FAMILY MEDICINE OFFICESThe following checklist of recommended emergency supplies includes many expected items, such as oxygen and nitroglycerin, as well as several items not commonly found in family medicine offices, such as an automated external defibrillator In deciding whether to include a particular item in your practice, consider your staff members' ability to use the item appropriately and your office's access and proximity to emergency services. Some thing to rely on in the course of the news is that early management Team if risk assessment form the emergency affects Data.
The victim held a certification as an emergency medical technician for the state of Rhode Island in addition to Hazardous Materials Operations Level and Fire Fighter Level 1 from the Rhode Island Fire Academy. The department sent the gear to a private forensic casualty investigation firm and an equipment evaluation was performed.

The department relied on mutual-aid departments to perform technical rescue SCUBA diving operations and lacked SOPs for the integration of the mutual-aid responders into the command system. A single community might not possess sufficient resources to effectively and safely provide a response level that would satisfy all the components of a safe, efficient, and effective emergency incident response.
Once the emergency incident shifted beyond the capabilities of the local fire department, the mutual aid SCUBA diving team should have performed a risk-benefit analysis by team members who are trained at that level of technical knowledge and the risk evaluation information provided to the incident commander.
The members did not receive formal training for surface water rescue incidents which would have provided a safe training foundation for members of the department who frequently provide water rescue services for the local jurisdiction. Guidance regarding the content and scheduling of periodic medical examinations for fire fighters can be found in NFPA 1582 Standard on Comprehensive Occupational Medical Program for Fire Departments.13 In addition to providing guidance on the frequency and content of the medical evaluation, NFPA 1582 provides guidance on medical requirements for persons performing fire fighting tasks. To ensure physicians are aware of these guidelines, we recommend that fire departments provide contract and private physicians with a copy of NFPA 158213 and a SCUBA diving medical clearance form.
While infrequent, emergency situations do occur in office settings, and this program equips us to provide the best possible care for our patients. Although most medical training, including family medicine training, involves learning how to deal with emergency situations, that education has a tendency to wane after graduation. Once physicians are in private practice, with the demands of seeing patients, maintaining emergency certification becomes a lower priority than dealing with day-to-day issues. Both nursing and medical staff participate in finding and reviewing the medications and equipment that might be needed in an emergency situation (see the checklist of recommended emergency supplies). The goal is to have someone call a Condition C in a timely manner, followed by a rapid response by staff with the appropriate emergency equipment.
Additionally, we orient all new staff members to our emergency procedures upon hire, and we review staff members' CPR certification regularly. The victim was off-duty and had responded to the scene in his personal watercraft with his personal dive gear. The department allows off-duty fire fighters to be placed back on duty during emergency incidents at the discretion of the chief. The department provides emergency water rescue services through fire department response with a 13-ft utility boat on a trailer housed with an engine company and has access to a larger boat through an agreement with the harbor master agency. Squad 1 responded with Marine 2 (a 13-ft utility boat used for water rescue stored at a station staffed with three personnel).
The responding resources included five members of local fire department dive teams in addition to two more rescue boats. The level of knowledge, skills, ability, equipment and support required for a public safety SCUBA diver are outlined in NFPA 10069, and NFPA 1670 Standard on Operations and Training for Technical Search and Rescue Incidents, 2009 edition.11 Public safety diving requires emergency response teams with specific knowledge, skills, ability, equipment and continued support beyond basic fire fighter or emergency responder requirements to resolve unique or complex rescue situations. Fire department executives should perform a risk-benefit analysis and strategically plan for an emergency response that ensures the safety of all responders. NFPA 1670 Standard on Operations and Training for Technical Search and Rescue Incidents11 describes the levels for water rescue training as awareness, operations, technician, and dive level responsibilities. The department responds to approximately 12 emergency incidents per year involving water rescue and should provide the appropriate level of training for expected areas of emergency response. Medications are not priced here as quantities will vary based on needs assessment, office size, and proximity to an emergency department.Obstacles addressedOne of the main obstacles to effective emergency care that we identified through our mock code situations was a lack of awareness by front office staff of patients in the waiting area.
During a recent mock emergency, we discovered that multiple medications in our emergency box were expired. As a result, we revised our system of monitoring medications used for emergencies and assigned a staff member to this task.An additional obstacle to running mock emergencies in a busy practice is pushback from staff who say it interrupts patient flow and disrupts those working in the clinic.

Because our office is staffed mostly by volunteers and not all items can be stored within a crash cart or emergency box, the scavenger hunt helps ensure that all staff members are able to access these items in an expedient manner and that the practice is fully equipped.
The department did not have a formal or recognized technical rescue SCUBA diving team, and relied on mutual aid divers to perform technical rescue SCUBA diving resources through a formal mutual aid agreement. The fire department responded to the emergency incident with their fire-rescue boat towed behind a support vehicle. The chief requested all responding dive team members and resources to respond to the command post at the boat ramp to organize the dive team operation. For the more infrequent number of incidents requiring technical rescuer professional level operations such as SCUBA diving teams, preplanning and strategic level risk-benefit analysis can identify the level of response that can be safely performed and alternatives such as mutual aid or multi-jurisdictional, multi-agency capabilities that can be utilized. The fire department did not have a formal SCUBA dive team and relied on mutual aid for this advanced level of technical rescue capability.
The fire department responded to the emergency incident with their fire-rescue boat (13-ft utility boat) towed behind a support vehicle.
Attitudes changed, however, after a true medical emergency transpired, and our staff witnessed that things went smoothly. The victim responded to the scene and was placed on duty as is the practice with this department concerning off-duty response and participation on emergency incidents. An example of an evaluation form to assess skills of public safety divers is provided in Appendix 1.
As in other special operations, risk management is a part of public safety diving operations.10 The safe and effective rescue or recovery of a water incident victim is dependent on a well coordinated relationship with other agencies sharing responsibility for providing service. Emergency incident risk-benefit analysis is performed on the scene, by the first arriving responders, and continued throughout the incident by the command structure.
Technical rescue SCUBA diving candidates should be required to pass a more comprehensive medical evaluation that is administered by a physician familiar with diving medicine. An equipment evaluation was performed by Craig Jenni with Dive & Marine Consultants International, Inc., Boca Raton, FL.
Given this patient volume, we felt that everyone on our staff needed to be prepared to deal with medical emergencies. Although the victim checked in with command via a portable radio, and was told by command to respond to the command post, command reportedly did not know that the victim had entered the water until after being told by L-1 on Marine 2. Joint training exercises and scenario based training identifies the strengths and weaknesses in the response and provides areas to improve safety and effectiveness. A physician with a strong background in diving medicine and familiar with NFPA 1582 can help provide the technical rescue SCUBA dive team a more comprehensive evaluation of members and candidates.10 The Divers Alert Network14 is one resource technical rescue SCUBA diving teams can use to locate physicians familiar with diving medicine. In addition, because we have many volunteer staff who have retired from previous careers, are more than 60 years of age, and have medical issues, we felt it prudent to have measures in place to care for those who help us care for patients.We recognize that our model may require adaptation for use in other offices depending on the number of staff (including physicians, other providers, and nursing staff), role assignment, proximity to an emergency department (ED), response times of local emergency medical services (EMS), the level of care providers are capable of administering (basic versus advanced life support), and state laws regarding who may provide emergency services.
The victim did not respond and the mutual-aid boat placed two divers in the water to rescue the victim.
If the victim had responded to the command post as instructed, the command staff could have had an opportunity to evaluate his fitness for duty. The victim was found on the surface and some air was in his BC vest, but his weight belt had not been jettisoned which would have been one of a series of emergency procedures to ascend to the surface.

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