1. ROUTINE CALLS What can they teach us?

2. MEDICAL BOX 902, 1801 HARVARD STREET, FOR THE 76YOF WITH TROUBLE BREATHING. AMBULANCE 92 IS DUE; NO MEDIC AVAILABLE. Scenario slide 1

3. A92 MARKS UP WITH A CREW OF 3 AND ARRIVES ON THE SCENE. THE CREW KNOCKS ON THE FRONT DOOR, BUT THERE IS NO ANSWER. THE DOOR IS UNLOCKED. Scenario slide 2

4. ONCE THE CREW GAINS ENTRY, THEY FIND THE ELDERLY PATIENT IN THE BEDROOM AT THE BACK OF THE HOUSE, LYING IN BED, UNCONSCIOUS. Scenario slide 3

5. THE SOUND OF BREAKING GLASS IS HEARD FROM THE GARAGE Scenario slide 4

6. 2 MINUTES AFTER THE CRASH IS HEARD, EVERYONE IN THE HOUSE BEGINS TO FEEL SICK. Scenario slide 5

7. AS THE PROVIDERS TRY TO EXIT THE BEDROOM, THEY ARE MET BY A GUNMAN WHO IS SURPRISED BY THEIR PRESENCE. Scenario slide 6

8. WHAT MISTAKES DID THE CREW MAKE?

9. WHAT ADDITIONAL RESOURCES WOULD HAVE BEEN HELPFUL?

10. WARNING SIGNS OF A CLANDESTINE DRUG LABORATORY Types of Calls Outside Conditions Ordinary Materials used in Manufacturing

11. WARNING SIGNS OF A CLANDESTINE DRUG LABORATORY Types of Calls Burns and/or smoke inhalation Man Down Explosions or loud booms Sick Buildings (condemned due to mold or chemicals) Multiple medical patients

12. WARNING SIGNS OF A CLANDESTINE DRUG LABORATORY Outside Conditions Privacy Fence Multiple Surveillance Cameras Large Exhaust Fans Multiple Air Conditioners Covered Windows Unkempt Yard (trashy, lack of lawn care…)

13. WARNING SIGNS OF A CLANDESTINE LABORATORY ORDINARY MATERIALS USED IN MANUFACTURING Pseudoephedrine, a drug contained in over the counter cold medicines Aluminum foil Paint Thinner Lithium camera batteries Mineral Spirits Charcoal lighter fluid Anhydrous ammonia Denatured Alcohol Matchbooks and matchbook striker plates Rock, table, or Epsom salt Camp fuel Gas line antifreeze Muriatic acid Iodine Sulfuric Acid Lye (soap) Ammonium nitrate Dry Ice Acetone Coffee filters, cheese cloth, or napkins Pots, pans, stoves, or pressure cookers Glass jars Blenders Ice Chests Liquefied Petroleum Gas (LPG) cylinders Turkey basters Chemical containers

14. POSSIBLE CDL (CLANDESTINE DRUG LAB)

15. COMPLACENCY KILLS This was a CDLSo was this

16. NOTICE THE SECURITY FENCE

20. TOP TEN HAZARDS Top Ten Hazards 1. Flammable or explosive atmosphere 2. Oxygen-deficient or toxic atmosphere 3. Leaking or damaged gas cylinders 4. Labs in confined spaces 5. Water reactive and pyrophoric chemicals 6. Damaged and leaking chemical containers 7. Electrical hazards and sources of ignition 8. Reactions in progress, which can include containers under high heat and high pressure 9. Incompatible chemical reactions 10. Bombs and booby traps

21. RESPONSE GUIDELINES On Scene Actions Evacuate all structures surrounding the incident, and initiate hazmat zones If drug lab is found after entering, back out immediately and notify other personnel on the scene Retreat to a safe area Call for additional resources Hazmat Police Environmental Protection Agency Use care when interacting with a meth user

22. RESPONSE GUIDELINES DOs Do Maintain Personal Protection Do Limit Time Exposed Do Stay upwind and a safe distance away Do shield yourself behind large objects and buildings \ Do decontaminate yourself and clothing Do treat the area as a crime scene DON’Ts Don’t use electronic devices within the isolation zone Don’t turn on or off any electrical power or light switches Don’t eat or drink in or around the CDL Don’t open or remove containers with chemicals or suspected chemicals Don’t sniff any containers

23. MARYLAND PROTOCOLS POTENTIALLY VOLATILE ENVIRONMENTS WITH LIFE- SUSTAINING INTERVENTIONS (PAGE 204-8 THRU 204-13) Protocol should be used: In conjunction with general patient care practices, which should be followed once the active threat has been mitigated. When the situation is unique, preventing the use of standard practices that could unnecessarily jeopardize the safety of the patient and/or medical provider(s). When Potentially Volatile Environments with Life-Sustaining Interventions (PVE/LSI) protocol is declared

24. ZONES OF CARE/OPERATIONS: HOT ZONE Direct and immediate threat to safety or health Priority: Mitigation of the immediate threat Medical providers must be integrated tactical medic (MD Protocol V. T.) CPR is not indicated

25. ZONES OF CARE/OPERATION: WARM ZONE Indirect threat; limited life saving interventions Priority: evacuation of patients to safe area Potential benefits of treatment weighed against delay of evacuation Casualty Collection Point (CPP) is concealed and covered from the immediate threat Patients are triaged

26. ZONES OF CARE/OPERATION: WARM ZONE Limited medical care follows the mnemonic “MARCHED” M: Massive hemorrhage control usually the greatest threat to trauma patients tourniquets are preferred if not possible use impregnated hemostatic dressing

27. ZONES OF CARE/OPERATION: WARM ZONE Limited medical care follows the mnemonic “MARCHED” A: Airway Management Consider oxygen Chin lift or jaw thrust Nasopharyngeal airway Recovery position (or position of comfort if conscious)

28. ZONES OF CARE/OPERATION: WARM ZONE Limited medical care follows the mnemonic “MARCHED” R: Respirations Apply occlusive dressings to open chest wounds Recognize tension pneumothorax and get patient to ALS for needle decompression

29. ZONES OF CARE/OPERATION: WARM ZONE Limited medical care follows the mnemonic “MARCHED” C: Circulation Hypotension due to head injury or hypovolemic shock = IV therapy Cardiac arrest due to trauma should be considered deceased

30. ZONES OF CARE/OPERATION: WARM ZONE Limited medical care follows the mnemonic “MARCHED” H: Hypothermia Easier to prevent than treat Minimize heat loss

31. ZONES OF CARE/OPERATION: WARM ZONE Limited medical care follows the mnemonic “MARCHED” E: Everything else Consider Mark I/DuoDote for suspected organophosphate/nerve agent exposure Treatment of burns, eye injuries, and pain is dependent on resource availability and are managed according to Maryland Medical Protocols

32. ZONES OF CARE/OPERATION: WARM ZONE Limited medical care follows the mnemonic “MARCHED” D: Documentation Key findings Interventions

33. ZONES OF CARE/OPERATION: COLD ZONE Cold Zone: Traditional Patient Care Protocols Patients are moved from the Warm zone to the Cold zone via an Evacuation Corridor Re-triage Medical care dictated by resource availability and casualty count (including CPR)

34. SUMMARY Remember: Look for warning signs CDLs are very volatile and hazardous Follow response guidelines Review Maryland Protocols