List Archives

Sat Dec 16 19:13:38 GMT 2006

Dear Dr.Goyal,

  I usually use about 4 pairs of strong masculine hands, get an i.v. in. Usualyy these patients are the one who will end up being intubated.The anesthesists use a paralytic. 

  Dr. Zunorain

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Today's Topics:

1. Highly Irritable Head Injury Patient (navin goyal)
2. FDA Panel Votes Against Blood-Substitute Study (S Schecter)
3. Re: was FDA is now the companies take on the decision (S Schecter)
4. Re: The case against tourniquets (oded private)
5. Re: The case against tourniquets (oded private)
6. On the subject of teaching disaster prep (Krin135 at aol.com)
From: navin goyal <drnavingoyal at yahoo.co.in>
Subject: Highly Irritable Head Injury Patient 
Date: Fri, 15 Dec 2006 13:03:57 +0000 (GMT)
To: trauma-list at trauma.org

Dear Mail Subscribers,

Had anyone came accross a highly irritable Head Injury Patient in the trauma resuscitation room with visble injury over the head . The patient does not allow you to take a IV access and using IV sedative is distant thing . And anything you do , you want to do as earlt as possible as you see a bleeding wound in the scalp .How did you go about this patient.

Thank You 

Dr. Navin Goyal
Trauma Fellow
LTM Govt Hospital and medical College,
Sion , Mumbai.
INDIA.

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From: "S Schecter" <schecters at gmail.com>
Subject: FDA Panel Votes Against Blood-Substitute Study
Date: Fri, 15 Dec 2006 08:15:39 -0500
To: "Trauma &amp, Critical Care mailing list" <trauma-list at trauma.org>

FDA Panel Votes Against Blood-Substitute Study Despite Push From Navy,
Test of Biopure's Treatment
Fails to Win Endorsement
By *ZACHARY M. SEWARD* and *THOMAS M. BURTON*
December 15, 2006; Page B2

Bucking heavy pressure from the U.S. Navy, a federal advisory panel
recommended against carrying out a controversial study of Biopure Corp.'s
blood substitute. The treatment carries significant safety risks and often
would have been administered to human trauma victims without their consent.

The Food and Drug Administration usually follows advisory panels' advice,
but it doesn't have to. The decision on testing Hemopure is vital for its
developer, BiopureCorp.,
of Cambridge, Mass. Hemopure currently is only approved for limited
human use in South Africa.

The panel vote was 11 against, eight in favor and one abstention. Biopure's
chairman and chief executive, Zafiris G. Zafirelis, declined to comment on
the outcome immediately following the meeting. "I need to digest the
comments," he said.

Hemopure is controversial because it has been consistently linked to serious
complications in earlier studies, documents show.

Nevertheless, the Navy, whose medics treat wounded Marines in battle zones,
contends that Hemopure may lower the death rate among severely injured
trauma patients by possibly 15% from what it believes will be about a 58%
death rate among patients getting standard therapy. Saline solution, the
standard therapy administered in the ambulance, merely raises blood
pressure, while Hemopure is an oxygen-carrying resuscitative fluid that can
be carried onto the battlefield and doesn't require matching blood types, as
would real human blood.

John Mateczun, the Navy's deputy surgeon general, told the committee that
90% of military trauma fatalities occur before the soldier reaches
"hospital-level care," where they could receive real human blood. "In terms
of benefit, we believe that many lives might be saved in Operation Iraqi
Freedom with this capability," Dr. Mateczun said, referring to Hemopure. "It
would be worth our efforts if it saved only one life."

Among those addressing the panel in Silver Spring, Md., was Sgt. Eddie
Wright, who was struck by a rocket-propelled grenade outside of Fallujah,
Iraq, in 2004. He said he was willing to accept "a slight risk to my health"
for the benefits of Hemopure in combat. "Any risks that I've been hearing
today are not applicable to my situation," Sgt. Wright said.

Some committee members expressed skepticism that results from any trial
among citizens in the U.S. could be applied to the use of Hemopure during
war. They also questioned whether the potential benefits to the military in
combat should be weighed in considering a stateside study.
[image: [chart]]

The FDA had sought to hold the Biopure/Navy hearing behind closed doors in
July. After The Wall Street Journal wrote about the issue of the planned
closed hearings, the consumer group Public Citizen brought a lawsuit and the
FDA rescheduled yesterday's hearing as a public one.

Hemopure has shown an elevated level of medical "serious adverse events" in
a large study of the blood substitute in orthopedic-surgery patients, 353 of
whom got Hemopure and 340 of whom received donor blood. Government documents
show the Hemopure patients had 25 deaths, versus 14 in the blood group; 54
cases of heart failure and fluid overload, compared with 22 who got blood;
and 14 heart attacks, against four in the donated-blood population. The same
sorts of imbalances arose when Hemopure was compared with other
resuscitative fluids, including saline solution, in other surgical studies.

The FDA's reviewer on the proposed Navy/Biopure study, Laurence Landow, has
consistently opposed the Navy's plans. Dr. Landow has declined to comment on
the issue.

The FDA has acted with apparent inconsistency on the blood-substitute issue,
blocking the Navy study while allowing a competing trauma study by Biopure
competitor Northfield
LaboratoriesInc.
to proceed. The Northfield trial finished enrolling patients this
summer. Northfield is expected to release some results this month.

The importance of Hemopure to Biopure was underscored as the company
released financial results for the year ended Oct. 31. It said that it
expects its independent accountants to include a "going concern" warning in
its annual report because Biopure said it has only enough money to survive
through August and needs to raise additional funds even though it just
completed an offering of stock and warrants that raised $16.6 million.

For the fourth quarter, Biopure reported a net loss of $6.3 million, or 13
cents a share, narrowed from a year-earlier net loss of $8.2 million, or 34
cents a share. Revenue rose to $431,000 from $328,000. Biopure shares fell
four cents to 59 cents in 4 p.m. Nasdaq Stock Market composite trading.

From: "S Schecter" <schecters at gmail.com>
Subject: Re: was FDA is now the companies take on the decision
Date: Fri, 15 Dec 2006 08:22:34 -0500
To: "Trauma &amp, Critical Care mailing list" <trauma-list at trauma.org>

http://www.corporate-ir.net/ireye/ir_site.zhtml?ticker=bpur&script=419&layout=0&item_id=942537

Snip..."Although the committee advised against RESUS moving forward, we view
its comments today as constructive criticism and generally supportive of the
product's development for the emergency pre-hospital treatment of trauma
patients," said Biopure Chairman and CEO Zafirelis G. Zafirelis."...snip

From: "oded private" <tangentcarrot at hotmail.com>
Subject: Re: The case against tourniquets
Date: Fri, 15 Dec 2006 15:30:38 +0200
To: trauma-list at trauma.org

When there are not enough hands, there is still an alternative to 
tourniquets. Modern pressure dressings such as the "emergency bandage" by 
"first care products" can be adjusted to provide sufficient direct pressure 
to the wound without a hand holding it and without cuasing global limb 
ischemia. It takes an even shorter time to aplly it then to apply a 
tourniquet.

>From: MARK FORREST 
>Reply-To: "Trauma & Critical Care mailing list" 
>
>To: "Trauma & Critical Care mailing list" 
>Subject: Re: The case against tourniquets
>Date: Thu, 14 Dec 2006 18:43:45 +0000 (GMT)
>
>Dear Karim et al,
>Two tourniquets (SATS) sit in my kit bag and we still actively teach their 
>use, so I suppose that I should raise a few more questions before removing 
>them! Let's stir the discussion up a little.
>
>Firstly your case, there are clearly a number of issues.
>time to theatre (and tourniquet removal) was significantly longer than 
>ideal
>you suggest that little if any direct or indirect pressure was applied 
>before resorting to tourniquet
>after such a long tourniquet time did you consider employing a crush 
>protocol for renal protection, once haemostasis was achieved?
>I fully agree that the tourniquet should be the last option in massive limb 
>haemorrhage and that most can be controlled by simpler measures, but this 
>is not always the case for all sorts of reasons.
>We teach 'D.D.I.T.' - as in 'did it' to our medics and docs. They try 
>direct pressure (aggressively) twice, before moving on to indirect 
>pressure, if control still remains impossible and the haemorrhage remains 
>considerable, then they are taught to move onto tourniquet. The patients 
>get an obvious safety label or are marked with TIME and LOCATION and our 
>labels have a short explanation for clincians.
>We teach that if transfer time will be prolonged then the tourniquet should 
>be realeased at 30 minutes for 30 seconds (this may pop the clot, but will 
>hopefully reduce limb iscahemia). If bleeding stops then we leave the 
>tourniquet. If bleeding resumes then the tourniquet is re-applied for 3 
>minutes then a further 30 secs release, this is repeated three times every 
>30 minutes (sticking to all the '3's reduces confusion to a degree!!)
>
>This pattern of release and re-application is also used in the 'staged 
>release' protocol for crush syndrome and suspension trauma mentioned by 
>Mark Hellaby.
>
>(Staged relelase: Apply tourniquets to both limbs before crush release: 
>after extrication then release one leg for 30 secs, if no problems then 
>reapply for 3 mins then repeat twice more (6 times for two legs).
>Any instability then re-apply tourniquet or if prior to another release, 
>wait a further minute and re-assess.)
>
>Reviewing the recent literature, the main issues with tourniquets appear to 
>be poor effect (especially on the thigh versus the arm) and the 
>recommendation of lower pressures in wider cuffs. There is not a wealth of 
>work on crush syndrome and renal damage after short periods of tourniquet 
>use (under 2 hours).
>
>Similarly, if this is a real problem, then other than the cuff width, I 
>cannot understand why a 2-3 hour cuff application during the trauma for 
>elective surgery would not produce huge numbers of such cases. I have 
>little doubt that they will have elevated CKs, limb oedema and probably 
>even moderately deranged renal function but they are not all coming to 
>critical care for renal support. Why is this different? Total limb 
>ischaemia is limb ischaemia.
>
>Dissmissing combat versus civilian practice is also not so easy. Many 
>pre-hospital scenarios are in isolated or difficult locations and the 
>trauma carer may be managing serious polytrauma alone, for some time. A 
>tourniquet frees you up to move onto other issues. Another example where I 
>have use touniquets for short periods is during difficult extications form 
>RTCs where patient access amy be minimal for significant periods. Obvious 
>maasive haemorrhage cannot be controlled by pressure in some of these 
>situtations, becasue you have to move out of the way, to allow continuous 
>activity duing the extrication.
>I am also a little suprised by the Mine workers evidence that they can 
>maintian quality direct pressure during transfers. Now that we scoop and 
>run, there is often a considerable amount to do during a high speed 
>transfer of polytrauma victims eg airway/resp support, cannulation, 
>traction or pelvic splints, analgesia etc(we can debate again how much of 
>it is life saving another day eg cannulation and fluid). Once again, there 
>may not be enough hands to go around!
>
>Surely the issue is not that we should abandon tourniquets but emphasise 
>that they should be used when all else fails or is impossible and that 
>they should be left on for the shortest possible period. In addition, there 
>are numerous other potential indications as mentioned by myself and others.
>
>DON'T CROSS THEM OFF THE CHRISTMAS LIST JUST YET!
>
>Regards
>Mark Forrest
>ATACC MD
>
>
>----- Original Message ----
>From: Karim Brohi 
>To: trauma-list at trauma.org
>Sent: Sunday, 10 December, 2006 1:55:21 PM
>Subject: The case against tourniquets
>
>
>Recently, the US and UK military have "rediscovered" tourniquets. Their 
>use
>has been published in meetings around the world and is now spreading to
>civilian practice. ATLS and other groups have spent years campaigning to
>remove tourniquets from civilian practice, for good reasons, and now they
>are back - with not a shred of evidence to support this reversion.
>
>Maybe we need reminding of why tourniquets were abandoned in civilian
>practice - so here's a case from a couple of weeks ago. A young man is
>brought to another hospital after a multiple stabbing incident. Most are
>superficial but he has arterial haemorrhage from a wound in the distal
>medial thigh. A tourniquet is placed in the upper thigh and he is
>transferred to us. On arrival he is taken straight to the operating room
>for revascularisation but total time with the tourniquet is 2.5 hours.
>
>The popliteal artery injury is small and only requires direct suture 
>repair.
>However the distal limb shows signs of swelling and a 4-compartment lower
>leg fasciotomy is performed. The patient is transferred to the ward but
>despite the early fasciotomy has a large rise in his Creatine Kinase and
>develops renal impairment. Further he has a complete foot drop from
>ischemic injury which may or may not recover.
>
>The patient's haemorrhage would have been easily controllable by pressure
>either at the site of injury or by digital pressure over the common femoral
>artery at the femoral head. 2.5 hours is not a particularly long ischemic
>time and there was no associated vein injury. Venous congestion,
>fasciotomy, ischemia to calf and thigh misculature, ischemic nerve damage
>and renal failure were all contributed to, or arguably entirely the result
>of tourniquet use.
>
>The military operate under entirely different conditions. A second pair of
>hands to provide manual pressure may not be available and hence a
>self-applied tourniquet may indeed be life-saving. These are blast 
>injuries
>and often control haemorrhage from distal amputation. But they may well 
>not
>be limb saving - indeed the amputation rate is twice that of previous wars.
>(Yes more lives are being saved and yes there is improved torso armour etc
>etc). Further anecdotal UK experience suggests that soldiers are often
>applying them with too little force and therefore causing venous 
>obstruction
>and increasing blood loss from the limb. Watching 3 marines walking down
>the street in San Diego with one leg between them was sobering.
>
>And for all the talk of not having a second pair of hands, there is a 
>wealth
>of evidence from landmine victims that non-medical, in fact uneducated
>villagers in remote, rural settings can control haemorrhage with digital
>pressure and transport victims long distances for medical therapy (using
>donkeys, not CCAT military transports) - and villagers can teach other
>villagers to do it). The Tromsoe Mine Victim Resource Centre
>(http://www.traumacare.no/) has been doing this in Cambodia, Afghanistan,
>North Iraq, Burma and Afghanistan for years. Read what they have to say
>about tourniquets and the cases and images of increased haemorrhage
>following their use.
>
>To use a military term, we are suffering from severe mission creep as
>tourniquets seep back into civilian practice. Their use was banned for a
>reason, which we are in danger of forgetting - and relearning. The 
>military
>have their own reasons for using them, but we need to see real data about
>their effectiveness for limb salvage. For the military, tourniquet use
>should be a last resort, in the knowledge that morbidity, disability and
>amputation are increased with their use. They should not be advocated in
>civilian practice at all.
>
>Karim
>
>--
>trauma-list : TRAUMA.ORG
>To change your settings or unsubscribe visit:
>http://www.trauma.org/traumalist.html
>--
>trauma-list : TRAUMA.ORG
>To change your settings or unsubscribe visit:
>http://www.trauma.org/traumalist.html

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From: "oded private" <tangentcarrot at hotmail.com>
Subject: Re: The case against tourniquets
Date: Fri, 15 Dec 2006 15:32:58 +0200
To: trauma-list at trauma.org

And for the sake of decency- I have no relationship with 'first care 
products".

>From: "oded private" 
>Reply-To: "Trauma & Critical Care mailing list" 
>
>To: trauma-list at trauma.org
>Subject: Re: The case against tourniquets
>Date: Fri, 15 Dec 2006 15:30:38 +0200
>
>
>When there are not enough hands, there is still an alternative to 
>tourniquets. Modern pressure dressings such as the "emergency bandage" by 
>"first care products" can be adjusted to provide sufficient direct pressure 
>to the wound without a hand holding it and without cuasing global limb 
>ischemia. It takes an even shorter time to aplly it then to apply a 
>tourniquet.
>
>>From: MARK FORREST 
>>Reply-To: "Trauma & Critical Care mailing list" 
>>
>>To: "Trauma & Critical Care mailing list" 
>>Subject: Re: The case against tourniquets
>>Date: Thu, 14 Dec 2006 18:43:45 +0000 (GMT)
>>
>>Dear Karim et al,
>>Two tourniquets (SATS) sit in my kit bag and we still actively teach their 
>>use, so I suppose that I should raise a few more questions before removing 
>>them! Let's stir the discussion up a little.
>>
>>Firstly your case, there are clearly a number of issues.
>>time to theatre (and tourniquet removal) was significantly longer than 
>>ideal
>>you suggest that little if any direct or indirect pressure was applied 
>>before resorting to tourniquet
>>after such a long tourniquet time did you consider employing a crush 
>>protocol for renal protection, once haemostasis was achieved?
>>I fully agree that the tourniquet should be the last option in massive 
>>limb haemorrhage and that most can be controlled by simpler measures, but 
>>this is not always the case for all sorts of reasons.
>>We teach 'D.D.I.T.' - as in 'did it' to our medics and docs. They try 
>>direct pressure (aggressively) twice, before moving on to indirect 
>>pressure, if control still remains impossible and the haemorrhage remains 
>>considerable, then they are taught to move onto tourniquet. The patients 
>>get an obvious safety label or are marked with TIME and LOCATION and our 
>>labels have a short explanation for clincians.
>>We teach that if transfer time will be prolonged then the tourniquet 
>>should be realeased at 30 minutes for 30 seconds (this may pop the clot, 
>>but will hopefully reduce limb iscahemia). If bleeding stops then we leave 
>>the tourniquet. If bleeding resumes then the tourniquet is re-applied for 
>>3 minutes then a further 30 secs release, this is repeated three times 
>>every 30 minutes (sticking to all the '3's reduces confusion to a 
>>degree!!)
>>
>>This pattern of release and re-application is also used in the 'staged 
>>release' protocol for crush syndrome and suspension trauma mentioned by 
>>Mark Hellaby.
>>
>>(Staged relelase: Apply tourniquets to both limbs before crush release: 
>>after extrication then release one leg for 30 secs, if no problems then 
>>reapply for 3 mins then repeat twice more (6 times for two legs).
>>Any instability then re-apply tourniquet or if prior to another release, 
>>wait a further minute and re-assess.)
>>
>>Reviewing the recent literature, the main issues with tourniquets appear 
>>to be poor effect (especially on the thigh versus the arm) and the 
>>recommendation of lower pressures in wider cuffs. There is not a wealth of 
>>work on crush syndrome and renal damage after short periods of tourniquet 
>>use (under 2 hours).
>>
>>Similarly, if this is a real problem, then other than the cuff width, I 
>>cannot understand why a 2-3 hour cuff application during the trauma for 
>>elective surgery would not produce huge numbers of such cases. I have 
>>little doubt that they will have elevated CKs, limb oedema and probably 
>>even moderately deranged renal function but they are not all coming to 
>>critical care for renal support. Why is this different? Total limb 
>>ischaemia is limb ischaemia.
>>
>>Dissmissing combat versus civilian practice is also not so easy. Many 
>>pre-hospital scenarios are in isolated or difficult locations and the 
>>trauma carer may be managing serious polytrauma alone, for some time. A 
>>tourniquet frees you up to move onto other issues. Another example where I 
>>have use touniquets for short periods is during difficult extications 
>>form RTCs where patient access amy be minimal for significant periods. 
>>Obvious maasive haemorrhage cannot be controlled by pressure in some of 
>>these situtations, becasue you have to move out of the way, to allow 
>>continuous activity duing the extrication.
>>I am also a little suprised by the Mine workers evidence that they can 
>>maintian quality direct pressure during transfers. Now that we scoop and 
>>run, there is often a considerable amount to do during a high speed 
>>transfer of polytrauma victims eg airway/resp support, cannulation, 
>>traction or pelvic splints, analgesia etc(we can debate again how much of 
>>it is life saving another day eg cannulation and fluid). Once again, there 
>>may not be enough hands to go around!
>>
>>Surely the issue is not that we should abandon tourniquets but emphasise 
>>that they should be used when all else fails or is impossible and that 
>>they should be left on for the shortest possible period. In addition, 
>>there are numerous other potential indications as mentioned by myself and 
>>others.
>>
>>DON'T CROSS THEM OFF THE CHRISTMAS LIST JUST YET!
>>
>>Regards
>>Mark Forrest
>>ATACC MD
>>
>>
>>----- Original Message ----
>>From: Karim Brohi 
>>To: trauma-list at trauma.org
>>Sent: Sunday, 10 December, 2006 1:55:21 PM
>>Subject: The case against tourniquets
>>
>>
>>Recently, the US and UK military have "rediscovered" tourniquets. Their 
>>use
>>has been published in meetings around the world and is now spreading to
>>civilian practice. ATLS and other groups have spent years campaigning to
>>remove tourniquets from civilian practice, for good reasons, and now they
>>are back - with not a shred of evidence to support this reversion.
>>
>>Maybe we need reminding of why tourniquets were abandoned in civilian
>>practice - so here's a case from a couple of weeks ago. A young man is
>>brought to another hospital after a multiple stabbing incident. Most are
>>superficial but he has arterial haemorrhage from a wound in the distal
>>medial thigh. A tourniquet is placed in the upper thigh and he is
>>transferred to us. On arrival he is taken straight to the operating room
>>for revascularisation but total time with the tourniquet is 2.5 hours.
>>
>>The popliteal artery injury is small and only requires direct suture 
>>repair.
>>However the distal limb shows signs of swelling and a 4-compartment lower
>>leg fasciotomy is performed. The patient is transferred to the ward but
>>despite the early fasciotomy has a large rise in his Creatine Kinase and
>>develops renal impairment. Further he has a complete foot drop from
>>ischemic injury which may or may not recover.
>>
>>The patient's haemorrhage would have been easily controllable by pressure
>>either at the site of injury or by digital pressure over the common 
>>femoral
>>artery at the femoral head. 2.5 hours is not a particularly long ischemic
>>time and there was no associated vein injury. Venous congestion,
>>fasciotomy, ischemia to calf and thigh misculature, ischemic nerve damage
>>and renal failure were all contributed to, or arguably entirely the result
>>of tourniquet use.
>>
>>The military operate under entirely different conditions. A second pair 
>>of
>>hands to provide manual pressure may not be available and hence a
>>self-applied tourniquet may indeed be life-saving. These are blast 
>>injuries
>>and often control haemorrhage from distal amputation. But they may well 
>>not
>>be limb saving - indeed the amputation rate is twice that of previous 
>>wars.
>>(Yes more lives are being saved and yes there is improved torso armour etc
>>etc). Further anecdotal UK experience suggests that soldiers are often
>>applying them with too little force and therefore causing venous 
>>obstruction
>>and increasing blood loss from the limb. Watching 3 marines walking down
>>the street in San Diego with one leg between them was sobering.
>>
>>And for all the talk of not having a second pair of hands, there is a 
>>wealth
>>of evidence from landmine victims that non-medical, in fact uneducated
>>villagers in remote, rural settings can control haemorrhage with digital
>>pressure and transport victims long distances for medical therapy (using
>>donkeys, not CCAT military transports) - and villagers can teach other
>>villagers to do it). The Tromsoe Mine Victim Resource Centre
>>(http://www.traumacare.no/) has been doing this in Cambodia, Afghanistan,
>>North Iraq, Burma and Afghanistan for years. Read what they have to say
>>about tourniquets and the cases and images of increased haemorrhage
>>following their use.
>>
>>To use a military term, we are suffering from severe mission creep as
>>tourniquets seep back into civilian practice. Their use was banned for a
>>reason, which we are in danger of forgetting - and relearning. The 
>>military
>>have their own reasons for using them, but we need to see real data about
>>their effectiveness for limb salvage. For the military, tourniquet use
>>should be a last resort, in the knowledge that morbidity, disability and
>>amputation are increased with their use. They should not be advocated in
>>civilian practice at all.
>>
>>Karim
>>
>>--
>>trauma-list : TRAUMA.ORG
>>To change your settings or unsubscribe visit:
>>http://www.trauma.org/traumalist.html
>>--
>>trauma-list : TRAUMA.ORG
>>To change your settings or unsubscribe visit:
>>http://www.trauma.org/traumalist.html
>
>_________________________________________________________________
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>
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From: Krin135 at aol.com
Subject: On the subject of teaching disaster prep
Date: Fri, 15 Dec 2006 14:07:38 EST
To: trauma-list at trauma.org

This is an interesting concept that might prove useful in helping to get 
folks to think about breaking down some of the 'silo thinking' that government 
and corporate types continue to foist on folks. Mr. Percell has a financial 
interest but I don't.

Paul Percell _www.disasterprep101.com_ (http://www.disasterprep101.com) 

The Secrets of Teaching Disaster Preparedness

Headlines are full of hurricanes, earthquakes, bird flu, terrorism, and 
other dangers of the world in which we live. However, most civilians aren't 
prepared to face a disaster or even a family emergency. This begs the question 
"Why not?" This article is intended for those who want to change this fact by 
teaching others, including their own families, to be better prepared, safer, 
and more self-reliant. We've identified several "learning obstacles" that 
prevent individuals and families from being as emergency ready as they should be. 
We'll list them here quickly then cover each in more detail and discuss ways 
to jump these learning hurdles.

Since we're talking about educating families - the cornerstone of all 
reaction plans - let's use the acronym F.A.M.I.L.I.E.S.:

Fear - "It's too scary to think about."
Attention Span - "I'm too busy to learn or do anything new."
Media - "There's always a weatherman in the hurricane."
Info Levels Now - "A 72-hour kit is all I need."
Lifestyle Ties - "I don't want to change the way I live."
Income - "I can't afford to buy the gear or take the steps."
Ego - "I'm so important that others will look after me."
Selflessness - "I'm not worried about me, I want to help others."

Why is it important to increase the level of civilian preparedness training 
over what we have through sites like ready.gov? That question can be a series 
of articles on its own, but the 4-part short answer is one, most free 
websites have only the bare minimum info; two, the fewer victims we have in a 
disaster the better off we'll all be; three, all business continuity plans rest on 
the ability of employees to return to work; and four, the term "civilians" 
includes the families of first responders. The more prepared the family, the 
more able is the responder to report for duty.

As we cover each learning obstacle below, you'll find a brief description of 
the problem followed by a few specific tips on how to deal with that 
particular issue. When teaching, remember that people have different learning 
styles. Visual learners do best by watching. They are receptive to videos, 
PowerPoint, or live demos. Auditory learners prefer verbal communication such as 
podcasts, or books on tape. Kinesthetic learners benefit from hands-on 
experience. Try to incorporate a little of each into your presentations.

Fear
Fear is probably the number one reason people don't prepare. Too many people 
focus on the dangers they may face in disasters, rather than the benefits of 
self-reliance. Worse, many so-called experts dwell on nothing but the threat 
since they have little to no new preparedness information. Let's look at 
ways to teach
readiness while avoiding fear:

1. Take a tip from insurance salespeople. They focus on the benefits of the 
policy rather than the reasons you might need one. Accentuate the positives 
of preparedness, not worst case scenarios. 
2. Use "mundane" threats to get people to prepare for more dire situations. 
For example, people living on the coast understand hurricanes and are 
receptive to helpful tips regarding evacuation. However, you might get a negative 
reaction with a "nuke in the harbor" scenario.
3. Teach preparedness without mentioning a threat. For example, focus on 
financial planning. It's more economical to buy groceries in bulk and cook at 
home, and it's also healthier. Guess what? This means you'll have more food at 
home in a shelter-in-place situation. Also, encouraging families to take up 
camping as a hobby inadvertently helps prepare them for an evacuation.

Attention Span
With microwave ovens, ATMs, email, and so forth, we live in a world of 
instant gratification. We have become a society whose mantra is "Just give me the 
condensed intro, not the whole pamphlet." We rarely take time to do a 
thorough and detailed job of anything, and the notion of adding things to the list, 
even something life-saving, is out of the question.

1. Most people don't realize that being prepared for disaster takes only 
subtle modifications to your life and doesn't require extensive study or 
training.
2. People in this category appreciate "helpful hints," so break things down 
into bite-size pieces. Use simple (though detailed and thorough) checklists 
and bulleted lists rather than wordy text or long speeches. For one such 
list, see "50 Emergency Uses for Your Camera Phone" at 
<http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2006-December/_http://www.disasterprep101.com/news.htm_ (http://www.disasterprep101.com/news.htm) >.
3. Show them how some aspects of preparedness can save time. For example, 
having more food in the pantry saves shopping time. Also, being current and 
comprehensive with your insurance policies and personal documentation will save 
months worth of time getting your life back on track after a disaster.

Media
News channels can be a double-edged sword. They're great for emergency 
warnings, but sometimes contradict themselves. For example, weather stations will 
pass along evacuation warnings in advance of a hurricane, but then they'll 
send a reporter out in the middle of it to give a live report. Some people see 
this and think hurricanes are no big deal. We've seen the same in minor 
chemical spills. Let your preparedness students know that:

1. Things are always smaller and friendlier on TV than in real life. A 
picture of a snake isn't the least bit alarming. However, turn one loose in 
your classroom.... (No, don't actually do this!)
2. News sources live and die on ratings, viewers, and subscribers, and 
therefore take risks. However, these are usually controlled risks, since, for 
example, the weather reporters are usually in a side area and not in the direct 
path of the eye of the hurricane. So don't do what they do, do what they say.

Info Levels Now
Most "emergency" sites on the internet with "readiness information" have 
nothing but variations of the 72-hour kit checklist. The other end of the 
spectrum finds all the "survivalist" info concerning edible plants and living off 
the land. These two extremes can mislead the public in two distinct ways. One, 
the simplistic info might tell people that a 72-hour kit is all they'll need 
and the government will come protect them. Two, the other extreme relates to 
fear since it tends to tell people that "things will be so bad that you'll 
need these survival skills." The extremes should be avoided. Shoot for the 
more realistic middle ground.

1. "72-hour" kits are the absolute minimum. Recommending only a 72-hour kit 
is like telling a family on a vacation road-trip to get only enough gas to 
get to the next exit where there might be another station.
2. If you teach outdoor survival skills, remind people that these skills 
aren't the very next option after their 72-hour kit runs out. They're there for 
the most severe cases in isolated incidents.
3. Bridge the gap between these extremes by providing instruction on how 
families can use simple measures to stay safe and secure for up to four weeks, 
either during an evacuation or extended shelter-in-place. A good example is 
the four weeks of food and water stored in the pantry. Four weeks is a more 
realistic figure and fills the void between simple kits and survival skills.
4. For more thoughts, see "The Disaster Dozen: The Top Twelve Myths of 
Disaster Preparedness" at http://www.disasterprep101.com/news.htm.

Lifestyle Ties
Essentially, this is another form of fear. It's the fear of changing one's 
lifestyle to incorporate readiness, and it's the fear of losing one's current 
lifestyle in the wake of a disaster. Two points come into play here.

1. One of the main goals of true readiness training is the preservation 
of our lifestyle as we know it, and not just mere physical survival. Therefore 
when discussing disasters, cover their aftermath and what it will take for 
families to return to normal. Don't cut the subject short.
2. Realistic preparedness doesn't involve major changes, but incorporates 
subtle modifications to the things we already have and do. For example, the 
simple habit of topping off your vehicle's gas tank three times a week is easy 
to develop and ensures you have as much fuel as possible in an emergency. 
Simple task, powerful results, no appreciable change in your lifestyle.

Income
Many people see ads for high-priced "disaster" goods and gear and assume 
that protecting their family will be a major financial investment. This isn't 
necessarily the case. If done correctly, protective measures can actually save 
a family money, or at least zero itself out on your household budget.

1. In our discussion of the 4-week pantry we pointed out how storing this 
much food could actually save time and money.
2. You don't need to buy expensive gear. In fact, we recommend finding 
things you need at thrift stores or yard sales, and in other cases, making your 
own gear. For example, our "mess kits" were made with leftover plastic dishes 
from microwave dinners.
3. Part of any comprehensive family preparedness training should include a 
section on frugality, or how a family might save money by reducing expenses 
and through better household budgeting.

Ego
Ego can also be called self-esteem, and this can either go high or low. In 
the case of high self-esteem, some people may think, "I'm so important that 
others will take care of me." Low self-esteem carries its own peculiarities as 
well. These folks might think, "No one will help me," or "Nothing exciting 
ever happens here, so why prepare?" Though not directly ego-related, many 
people hold that same belief that "Nothing will happen here. Things happen to 
other people."

1. Since we want to avoid generating fear, don't fight the "I'll be taken 
care of" attitude with stories of how bad things could get. Instead, use this 
high self-esteem by pointing out that one reason people don't prepare is 
because their friends don't. Therefore, tell this group the truth that they can 
help get others to prepare by being prepared themselves, and setting an example.
2. People with low self-esteem should be shown that self-reliance really is 
possible for them. These folks have low confidence levels. Once they see 
examples of how easy it is to be far more prepared and protected than they are, 
they'll appreciate their new confidence and may continue their education on 
their own.

Selflessness
Many people are so concerned about others that they neglect themselves. This 
is one of the reasons we see incidents of PTSD (Post-Traumatic Stress 
Disorder) in people that were never in the actual emergency. This type of distant 
stress is caused when these folks see bad things happen to other people but 
they can't do anything about it.

1. A good reminder for this group is that you're more able to help others if 
you yourself are well prepared. And guess what? "Others" includes pets!
2. In the stocked pantry example, you've helped others by already having 
your supplies, which makes for shorter lines and more stock on the shelves when 
the unprepared make that last-minute scramble for supplies at the grocery 
store.
3. You also help others by setting the example that preparedness is socially 
acceptable, much in the same way that we wear our seatbelts so our children 
will. The most important point of all is that your main goal is to teach 
both the importance and techniques of disaster preparedness in order to make our 
world safer. So, we have one last acronym for you; the word T.E.A.C.H.

- Treat each family member as unique.
- Emphasize the benefits and not the threat.
- Allow for different learning styles and speeds.
- Confidence building is goal number one.
- Help others to help themselves, and to then help others in turn.

About the author: Paul Purcell is a security analyst and preparedness 
consultant and is the author of "Disaster Prep 101" (www.disasterprep101.com.) 
Copyright 2006 Paul Purcell. Permission is granted to reprint this article 
provided all portions stay intact.

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