CERT Training Initial Impressions - ITS Tactical
 

CERT Training Initial Impressions

By Bryan Black

final_cert_logoI’ve now been to three CERT (Community Emergency Response Team) classes and am halfway through the training.

The education I’ve received has been enlightening to say the least, but there still a nagging in the back of my mind.

What I’m having the biggest moral dilemma with is the CERT policy of not helping someone  in need.

Now don’t get me wrong, CERT is an organization designed to help, and to “Do the greatest good for the greatest amount of people in the shortest amount of time.”

And therein lies my dilemma.

Triage

Triage TagBefore I get into it, let me give you some background information on CERT procedure.

The class before last, we learned about triage and how to properly tag a victim in a disaster.

Triage was first used during WWI by French Doctors and comes from the french verb trier, meaning to separate or sort.

The triage tag, pictured to the right, is one used by CERT and a way to mark victims for treatment and higher echelon care.

Green is the “walking wounded,” yellow is “delayed” (not in need of immediate help), red is “immediate,” and black is “dead.”

These classifications are marked depending on on the victim’s condition.

CERT teaches protocols and assessments to quickly determine a victims status, tag them, and move on to help the next person.

Killers

The first step in a CERT triage is to look at each victim quickly for “the killers,” which are airway obstruction, excessive bleeding and signs of shock.

After the triage, a more thorough but still quick head-to-toe assessment is performed to look for bruising, swelling, severe pain and disfigurement.

The head-to-toe assessment can be done “in place” if the building is lightly damaged, or done in the established triage areas.

Moving back to “the killers,” my dilemma lies with airway obstruction.

Airway Obstruction

During triage, CERT teaches you to triage fast, and “Do the greatest amount of good for the greatest amount of people in the shortest amount of time.”

I’m driving that point in, because that’s the response given to me for many questions I’ve had about the training.

In identifying “the killers,” an airway obstruction is to be handled by using a head-tilt/chin-lift method to open the airway and check for breathing.

Check for breathing, not a pulse. Those are entirely different to CERT and pulse is ignored.

If after a head-tilt/chin-lift the airway is established, it’s taught to find a way to keep the victim’s airway open.

This can be done with a towel propping up their shoulders, thus dropping the head back and opening the airway, or having one of the green tagged “walking wounded” hold their airway open.

Now here comes the clincher. CERT members are NOT to attempt CPR. It’s not taught in CERT, not covered by CERT’s legal protection, and even if you’re certified in CPR you’re not to perform it.

If a person is not breathing, but potentially has a pulse, you’re to TAG THEM DEAD!  This is my moral dilemma. How am I not supposed to want to save someone’s life when I know good and damn well there’s a possibility.

Moratorium On Brains

When I questioned our instructor regarding this dilemma, he responded first with the canned “greatest good etc.,” then elaborated with these responses.

With CPR you have to stay with the victim, breathing for them until EMS can arrive. What happens if you’re in a natural disaster and EMS is unable to reach you for three days? Are you going to continue CPR for three days straight?

By you staying with that victim, there’s many others who are not getting your help, just that one victim. That’s not doing the greatest good etc.

When you approach a victim and they’re alive (have a pulse) but not breathing, and you start CPR and they die, you’ve just killed that person and are now have to face the legality of that. I wanted to say “Since when did the fear of litigation take the place of logic?”

My jaw hit the floor as I looked around the room at all the sheeple nodding in unison as if to say “oh, that makes sense.” I was the only person who even appeared to be bothered.

Counter

It’s needless to say that I don’t completely agree with the above statements, and I can see the point, trust me. That doesn’t mean I agree with it.

First off, if an airway is established that once wasn’t, CERT teaches someone to stay with the victim to ensure the airway stays open.

Secondly, during excessive bleeding CERT members are taught to stay with the victim and properly bandage them to stop the bleeding via direct pressure.

Are both of these not time consuming? Is CPR more time consuming? The answer is “it depends.” Exactly, it depends, why would you not at least attempt CPR?

Why would you not teach it to people who are giving their time to learn how to become first responders and help people?

Perspective

A friend of mine recently told me a story about someone he knew who’s daughter had fallen into a pool when she was very young. The man called EMS, who responded and gave the little girl CPR.

After a short amount of time they stopped, but the father wouldn’t give up. He pushed them out of the way and took over the CPR, only after grabbing a stethoscope, pulling both ends off, and shoving it down her throat to blow into.

The girl eventually started breathing and is a healthy thirty year old woman now because her father refused to “tag her dead.”

Is this an anomaly? Perhaps, but if your time is worth just one life, why would you not give that aid?

That same friend told me of another guy who said discouragingly that out of the 100 or so times he’d done CPR it’s only worked twice.

That’s awesome! Two people who wouldn’t be here today if not for the attempt to perform CPR.

Killers Revisited

AirwayAs long as I’m on the subject of CERT policies, lets go back to assessing “the killers.” Those again are airway obstruction, excessive bleeding and shock.

If CERT really wanted to minimize the time that is spent on each victim, and increase that victim’s chances for survival, you’d think they’d be more receptive to the following.

During an airway obstruction, why not throw a nasopharyngeal airway in to address the issue of someone having to stay with the victim to ensure the airway stays open?

During excessive bleeding, why not have a hemostatic agent available if direct pressure doesn’t work? …Tag them dead…

The answers I received to my questions were “whoa, whoa, whoa… that’s too advanced for this class.” Excuse me? A piece of rubber getting inserted into a victim’s nasal cavity is “too advanced?”

Have you ever sucked a piece of spaghetti through your nose? It’s pretty much the same concept, and it should only be used on a semi-conscious to unconscious victim.

Pretty simple if you ask me. Not a whole lot of training involved in that one.

And a hemostatic agent? Too costly maybe? Training someone to recognize when direct pressure isn’t working and to use a hemostatic agent isn’t that difficult. Let’s see, and if that doesn’t work, go to a tourniquet.

Closing Remarks

That was a pretty big tangent to get off on, I know. Don’t get me wrong, I’m not picking apart the entire CERT program, there’s just a few things that I’m really having trouble with.

My original goal of the article was to show the gear we were issued, but I’ll save that for the next article, along with my good experiences of the program.

I feel those are best left for another article when my mind isn’t focused on the negatives.

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Discussion

56 comments
theotherryan
theotherryan

I've gone over triage in Combat Lifesaver. To say the least it is a pretty heartless and dispassionate affair. Also I have had the unfortunate circumstances to see it for real.

On the CPR topic I used to do a lot of back country hiking and skiing with a Doctor. He said out in the sticks he would not do CPR on someone. That if they needed CPR and could not be rapidly evacuated to a hospital they would be dead anyway.

theotherryan
theotherryan

I've gone over triage in Combat Lifesaver. To say the least it is a pretty heartless and dispassionate affair. Also I have had the unfortunate circumstances to see it for real. On the CPR topic I used to do a lot of back country hiking and skiing with a Doctor. He said out in the sticks he would not do CPR on someone. That if they needed CPR and could not be rapidly evacuated to a hospital they would be dead anyway.

ke4sky
ke4sky

Good discussion. I've been involved with CERT here in the Washington, DC area since right after the program was implemented. We have a 3-tiered program in which CERTS are eligible to take additional training at the fire & rescue academy on a space-available basis in addition to required annual refresher training, local and regional exercises such as Capitol Shield.

Level 1 is the standard FEMA classroom course,

Level 2 is taught in ten 3-hour sessions evenings at the fire academy. It is scenario based and taught by fire academy cadre. Subjects include but are not limited to land navigation, signalling; field sign cutting; building search, casualty extraction lifts and carries; lifting, cribbing, ropes, knots, slings and hoists; chainsaw; vehicle extrication; infectious disease awareness; hazmat awareness; nuclear-chem-bio awareness and field expedient decon;

IS-100, 200 and 700.

Level 3 in addition to the above requires IS-240, IS-300, WebEOCUser, intro to public safety radio, fingerprint and criminal background check to be issued an ID card for assignment to an EMAC team.

ke4sky
ke4sky

Good discussion. I've been involved with CERT here in the Washington, DC area since right after the program was implemented. We have a 3-tiered program in which CERTS are eligible to take additional training at the fire & rescue academy on a space-available basis in addition to required annual refresher training, local and regional exercises such as Capitol Shield. Level 1 is the standard FEMA classroom course, Level 2 is taught in ten 3-hour sessions evenings at the fire academy. It is scenario based and taught by fire academy cadre. Subjects include but are not limited to land navigation, signalling; field sign cutting; building search, casualty extraction lifts and carries; lifting, cribbing, ropes, knots, slings and hoists; chainsaw; vehicle extrication; infectious disease awareness; hazmat awareness; nuclear-chem-bio awareness and field expedient decon; IS-100, 200 and 700. Level 3 in addition to the above requires IS-240, IS-300, WebEOCUser, intro to public safety radio, fingerprint and criminal background check to be issued an ID card for assignment to an EMAC team.

Ben Branam
Ben Branam

By categorizing the people in CERT as sheeple, you are giving them a tag as others give us. They are trying to do good, and preparing for things different then most of us are prepared for.

I'm a member of CERT and understand the principles and ideas. Do the most good for the most people is a good idea. If it was one person I would do CPR until help arrived and would refuse to give up. In a mass casualty situation I only have a 2% chance (by your friends numbers) of saving this person. But if I stop the bleeding on someone else the chances are a lot better that I can save someone. Or I may be able to stop the bleeding for three people, or more. That's the hole idea behind triage, and it's been working all over the world since WWI, and continues to work in Iraq, Afghanistan, and anywhere else a lot of people are hurt.

You could relate it to tactical patience. If I wait someone could die in a shooting, but if I move to cover first, and then engage, there is a better chance of me stopping the shooter.

It's a crappy thing to be involved in, and I hope you never have to use your CERT skills.

Stay Safe,

Ben

Ben Branam
Ben Branam

By categorizing the people in CERT as sheeple, you are giving them a tag as others give us. They are trying to do good, and preparing for things different then most of us are prepared for. I'm a member of CERT and understand the principles and ideas. Do the most good for the most people is a good idea. If it was one person I would do CPR until help arrived and would refuse to give up. In a mass casualty situation I only have a 2% chance (by your friends numbers) of saving this person. But if I stop the bleeding on someone else the chances are a lot better that I can save someone. Or I may be able to stop the bleeding for three people, or more. That's the hole idea behind triage, and it's been working all over the world since WWI, and continues to work in Iraq, Afghanistan, and anywhere else a lot of people are hurt. You could relate it to tactical patience. If I wait someone could die in a shooting, but if I move to cover first, and then engage, there is a better chance of me stopping the shooter. It's a crappy thing to be involved in, and I hope you never have to use your CERT skills. Stay Safe, Ben

Jason
Jason

Bryan - Hey, no easy words here, I know you understand triage and the reasons for it so I won't go into them. Basically you have to decide if some will die, maybe even somebody right in front of you, or if MORE will die. You say you don't know if you could walk away from someone you could maybe help. You have an emotional problem with this, which is a natural consequence of being a human being. However, the question you finally have to answer is: Are you going to let MORE people die to make yourself feel better? It's hard, but that's what it is. This is from a paramedic, so I've been there.

I will say that the notion of not helping black tags at all is not normal, and is probably not what your local fire & EMS are doing. Basically you help reds, then yellows, then greens & then blacks; and in reality people sort of fudge blacks up above greens if they can get to them right away. Basically if there are 20 victims and 30 responders, everybody gets help. But we aren't always so lucky.

Jason
Jason

Bryan - Hey, no easy words here, I know you understand triage and the reasons for it so I won't go into them. Basically you have to decide if some will die, maybe even somebody right in front of you, or if MORE will die. You say you don't know if you could walk away from someone you could maybe help. You have an emotional problem with this, which is a natural consequence of being a human being. However, the question you finally have to answer is: Are you going to let MORE people die to make yourself feel better? It's hard, but that's what it is. This is from a paramedic, so I've been there. I will say that the notion of not helping black tags at all is not normal, and is probably not what your local fire & EMS are doing. Basically you help reds, then yellows, then greens & then blacks; and in reality people sort of fudge blacks up above greens if they can get to them right away. Basically if there are 20 victims and 30 responders, everybody gets help. But we aren't always so lucky.

Voodoo
Voodoo

Jason, Thank you for your comment and perspective. I do understand the scenario you've described where many others could potentially die by me helping that one person in front of me, but it's still a hard pill to swallow. I just hope in that kind of situation there are so many responders that having to follow CERT protocols about this isn't an issue. I sincerely hope, as you've stated, that local Fire and EMS don't have the same protocols CERT does in regards to handing out black tags. There are so many people I present this scenario to that say "Well, CPR only works blank% of the time." That's great... why even bother teaching it at all then! Regards, Bryan

Jason
Jason

Regarding your comment about CPR: CPR is not actually designed to resuscitate someone, and will rarely do so. CPR is designed to keep oxygenated blood moving around so that organs remain viable until/while advanced interventions - defibrillation, drugs and/or airway management - are being delivered. Done right - meaning 0 interruption in compressions for any reason (i.e. no stopping compressions to give breaths, place airways, etc.), it can maintain brain and other tissue viability for a surprisingly long time. With good CPR and full advanced interventions, the best save rates anywhere in the country are overall something like 15% for medical arrests. For traumatic arrest, they are much lower. These rates are for people without a pulse. Regarding survival for trauma patients in general: Elsewhere on your site you mention that 90% of preventable trauma deaths are from limb hemorrhage or tension pneumothorax; meaning that only in 10% of injured persons will anything other than direct pressure, tourniquet or needle decompression make any difference in their survival. For the rest, either they would have lived without you, or nothing you did could have saved them. (Note that these numbers are specifically for victims of penetrating injury; serious blunt injury outcomes are even worse, since they tend to produce bleeding or other problems internally, which you can't do anything about.) Working these people means investing huge amounts of personnel time and medical resources for a marginal return; whereas the external bleeds, simple airway management, simple shock people provide high returns for minimal investment, resulting in more lives saved.

TacZen
TacZen

Well, here is the real scoop on "EMS Law' such as Scope of Practice etc... contrary to what you will hear over and over there is very little actual "Law", at least in such Black & White terms that will be presented to you in just about every EMS / rescue class you take. You will hear many stories and many "Facts", but you won't see any documentation to back anything up.

"Negligence" ("Liability") in terms of law requires a duty to act, but you will rarely see a true duty to act requirement in writing in law (that isn't to say a court won't determine you have a duty... just that it isn't generally in writing). Point is, when someone teaches duty as a fact, it usually isn't.

Scope of practice refers to what you are allowed to do (there are differences in what you are taught, certified to do, authorized to do etc...). But until you get into "practiceing medicine" and that requires an MD to sign off (such as medication administration and surgical procedures) most medical skills fall under "Basic life Support / First aid" and you are only limited to what you have been taught... "what would a person with similar training / experience do in a similar situation".

Also, understand that every organization has policies and procedures... but contrary to how they will present them to you... these are NOT law. I have worked for amulance companies that had policies that directly went against law and they were sued, but until that law suit, they enforced and preached these policies as law... polices can be great, but again, in a courtroom, they are not law. If you are sued, understand this, if you fail to follow a policy, they will ask you why and use it against you. If you follow a policy, they will point out that it is not law and that you had a duty to disregard it and use it against you. If you treat someone you can be sued, if you don't d treat someone, you can be sued. In court, it all comes down to what you can intelligently articulate... not what CERT or anyone says, but what a judge or jury thinks. If you blindly follow what someone tells you, you will not understand it and not be able to defend your actions, if you use your head, some common sense and do what you feel is best for the patients, then even a wrong decison is defensable.

so yes... follow your gut and do what you beleive is right, that is your best guard against a law suit or anything else. Good luck lifesaver, and be safe.

TacZen
TacZen

Well, here is the real scoop on "EMS Law' such as Scope of Practice etc... contrary to what you will hear over and over there is very little actual "Law", at least in such Black & White terms that will be presented to you in just about every EMS / rescue class you take. You will hear many stories and many "Facts", but you won't see any documentation to back anything up. "Negligence" ("Liability") in terms of law requires a duty to act, but you will rarely see a true duty to act requirement in writing in law (that isn't to say a court won't determine you have a duty... just that it isn't generally in writing). Point is, when someone teaches duty as a fact, it usually isn't. Scope of practice refers to what you are allowed to do (there are differences in what you are taught, certified to do, authorized to do etc...). But until you get into "practiceing medicine" and that requires an MD to sign off (such as medication administration and surgical procedures) most medical skills fall under "Basic life Support / First aid" and you are only limited to what you have been taught... "what would a person with similar training / experience do in a similar situation". Also, understand that every organization has policies and procedures... but contrary to how they will present them to you... these are NOT law. I have worked for amulance companies that had policies that directly went against law and they were sued, but until that law suit, they enforced and preached these policies as law... polices can be great, but again, in a courtroom, they are not law. If you are sued, understand this, if you fail to follow a policy, they will ask you why and use it against you. If you follow a policy, they will point out that it is not law and that you had a duty to disregard it and use it against you. If you treat someone you can be sued, if you don't d treat someone, you can be sued. In court, it all comes down to what you can intelligently articulate... not what CERT or anyone says, but what a judge or jury thinks. If you blindly follow what someone tells you, you will not understand it and not be able to defend your actions, if you use your head, some common sense and do what you feel is best for the patients, then even a wrong decison is defensable. so yes... follow your gut and do what you beleive is right, that is your best guard against a law suit or anything else. Good luck lifesaver, and be safe.

Erik Day
Erik Day

TacZen has a good point. You do have to know what you're doing, within the scope of your mission, and know it well enough to prepare to defend your actions if questioned. That's good policy, though, and beyond just legal defense but into personal accountability and confidence that you're mission ready. On the other hand… The legal aspects of "Scope of Practice" do count, even at the CERT level, and goes beyond Duty to Act and deep into issues of competence and Scope of Practice. It's enough that the CERT curriculum itself mentions liability protection, citing good samaritan laws as liability coverage. If you haven't gone over this portion yet, you will soon. Problem is: a lot of the coverage they talk about varies from state to state In California, the Good Samaritan protections just experienced a massive fail and allowed a good samaritan to be sued (see: Van Horn vs. Torti). This was exactly over Scope of Practice and who could do what, when and how. I won't go into details of the case (it was all kinds of wrong, from every angle), but it did have CERT programs on edge because of the reinterpretation of the language of the Good Sam law (in particular, the word "medical"). In some respects, I can see the semantic weakness of the previous view and how the recent judgment closed a gap that could be harmful to victims. OTOH, that decision assured Joe Average will keep driving when he sees you limply hanging out of a burning car. There is a happy ending, though; at least in California. The State Legislature passed a new law (Assembly Bill No. 83) that exactly covers where the original Good Samaritan law was supposed to (and failed). California was testing and setting legal precedent, but until your state follows similar suit, this may be a story that gets repeated.

Voodoo
Voodoo

Erik,

I completely agree. It's wonderful that so many people are interested in the topic, and I do hope it leads to more people volunteering and eventually saving lives.

Good point on the litigation issue, and I'm hoping that is why it was brought up so often.

Thank you for the detailed explanation of the human impact, it's definitely what I'm having the hardest time with, but I don't think I'll ever be able to just walk past someone I have the ability of helping. Even in a MCI.

I really appreciate your perspective and thank you for sharing and commenting.

Bryan

Erik Day
Erik Day

Bryan,

First, it's fantastic that so many folk have come out of the woodwork to comment on this. Just by raising the issue, you're giving CERT training some much-needed promotion… and it's the exactly this kind of word-of-mouth that gets people into classes -- and lives are saved down the road.

It's unfortunate that your instructor used the litigation issue, but I can see his point. From an instructor's perspective, the average class (as officially taught) is 17.5 hours. You're on a timetable to get folk in, get them aware and get them out -- especially if your instructors are firemen on the clock. In fact, the legality of Scope of Practice is a valid argument (even for CERT) and for most folk, the threat of a suit can end an issue right there. Boom, class back on schedule. Is that the best solution? Not at all, but start into the philosophy and now you're taking time away from teaching another part of the class.

As for START as a triage method? IMO, yes: it's definitely the best method. The problem you're having, it seems, isn't really with the method, it's with the human impact of the circumstance. Here, we have to back up just a bit. CERT is taught as a disaster response method, not an emergency response method. The critical difference is that in a disaster, professional emergency responders are overwhelmed. The fire engines, the RAs and the paramedics will be assigned to the "high value" targets.

Even First Responders can be overwhelmed, hence a situational condition called a Multi-Casualty Incident or "MCI". The idea is that the worst-off (but savable) patients get the highest priority care… but you still have to sort *all* the patients before you can definitely say who is the worst. In the process of sorting *all* those patients is where CERT members (or firefighters, etc) make their initial intervention if it's called for. That's the :30 to treat for the killers.

This might make you feel better: we get doctors and nurses occasionally coming through CERT class and many of them have the same issue you do. The critical aspect to remember is that START is applied in a suspected MCI. If there are more victims than rescuers, or there are an unknown number of victims (i.e.: CERT search and rescue in an unknown building), the rules are different than if the responders outnumber the victims. A guy suffering cardiac arrest because he just saw the bar tab doesn't need START, he needs CPR. A damaged building with victims strewn through it will save more lives with START than giving rescue breathing to the first guy you see that isn't breathing (but has a pulse).

This comes back to the human impact of the circumstance: making that decision to walk away can haunt you. In this type of scenario, though, by slipping prematurely out of triage mode and into treatment mode will likely doom somebody that could've been saved with a simple intervention. These are the lessons that come from the WWI era, every bus and train accident and every densely-occupied structure that just endured a natural disaster since then.

Bryan: you're right to be patient's advocate. Just remember that once you announce you're a CERT team and you're there to help (your voice triage), you own that building. You've just taken responsibility for *all* the potential patients within, not just that one guy with the airway issues. That's where START is definitely your friend.

TacZen
TacZen

Great response by Eric day... i'll add my 2 cents.

First, don't disagree with you, just some things to consider.

First; anyone who quotes "Legality" probably doesn't know what their talking about. I've been a FF/Paramedic for 10 years, and I'm a cop and deal with Law all the time... and dispite the numberous "stories" you will be told, people just don't get sued for this stuff. The few law suits that exist revolve around those NOT treating when they should have and GROSS negligence like a Paramedic leaving a patient to die etc... As for scope of practice, you can and should perform to YOUR scope of practice. As a Paramedic, just becacause I take a CERT class doesn't mean I have to only do what that 1 day class taught me and forget the 3 year full time Paramedic training. You do what you have been trained to do (with certain "Authorization" restictions that mostly apply to Medical Practice at an ALS/Paramedic level...).

Now, it has been my experience that every CERT seems to be pretty different depending on the resources of the area (I've been a guest instructor for CERTs in Sourthern CA and well as Middle East Coast)... the cirriculm is supposed to be the same, but i've seen CERTs that have a 40 hour first response (medical) course and CERTs with only a 6 hour introduction to first aid/triage... and the instructors will vary from an experienced Paramedics to the layperson who's only training was a CERT he went through and has reach a position of leadership and so teaches the class... keep that in mind, many instructors are those that have never done any of this stuff.

Now, I do have to address your friend's story... 10 years in EMS I've seen a lot of cardiac arrests and many a PAramedic stop CPR (or just not start) when I thought they should have continued... BUT, I have NEVER seen anyone stop CPR on a Child, least of all one who had "drowned" which has a much higher rate of survivial than does other causes of arrest (oh, and Eric, the rate of survival for Traumatic arrest is least that 1%, and if it weren't for isolated cardiac Tramponode which is a treatable reson for arrest it would be even less). Back to the girl, first, I found it almost (and i do so almost) unbeleivable to think a Parameid would just stop CPR on a child. Additionally, presuming that the EMS was in fact at a Paramedic level and not a BLS (EMT-Basic level) or had restictions on pediatric airway interventions, they would have surely intubated the girl leaving no reason for the use of the stethoscope, which while inovative, not sure on how the 3 way open would perform for that use. Finally, unless you friend is a paramedic, I find it VERY unlikely (like 1 in million) that putting a soft stethoscope tube down the airway would have majicly found it's way to the trachea and not the esophagus when a real harder/formed tube with a stylet shaped to find the trachea still had only a 1 in 100 chance without some other way to guide it such a direct visualiztion (trained experienced paramedics still miss with THAT) or at leaset a digital intubation... so are you telling me he just put it in and it was in the trachea? really, a drowning victim with a larygospasm that would have closed off the trachea and it just majiclly bent itself up and foward and past the protective epiglottis and down the trachea... hmmm... not saying it can't happen, but i hear these stories alot and they just tend not to be true.

that being said, i'm a big beleiver in doing all you can, and yes, even knowing the statistics i do CPR on arrest victims all the time, if it were my family, i would want the 1 in a million chance...

so keep the questions going, keep doing the best you can, and consider CPR if needed.

Oh, and to echo eric... that is the same START triage just about every system uses, EMS and the like... but it is also supposed to be a guide, not an absolute rule, if i have 20 people, 19 get up and walk away with bruised toes and 1 in cardiac arrest,then i'm doing CPR. but if i have a victim not breathing but does have a pulse and have 10 others crawl up with amputaions and bleeding out, i'm leaving the arrest victim and slapping on 10 tourniquets... (and yes, some hemastatic agents, though i only carry packs, designed for me and a fellow officer).

so, i agree and disagree with CERT, and agree and disagree with you... but you basicly said it, use your brains and common sense, the "rules" are just there for when you panic and common sense isn't so common. good luck and be safe!

(down the trachea... realy?)

TacZen
TacZen

Great response by Eric day... i'll add my 2 cents. First, don't disagree with you, just some things to consider. First; anyone who quotes "Legality" probably doesn't know what their talking about. I've been a FF/Paramedic for 10 years, and I'm a cop and deal with Law all the time... and dispite the numberous "stories" you will be told, people just don't get sued for this stuff. The few law suits that exist revolve around those NOT treating when they should have and GROSS negligence like a Paramedic leaving a patient to die etc... As for scope of practice, you can and should perform to YOUR scope of practice. As a Paramedic, just becacause I take a CERT class doesn't mean I have to only do what that 1 day class taught me and forget the 3 year full time Paramedic training. You do what you have been trained to do (with certain "Authorization" restictions that mostly apply to Medical Practice at an ALS/Paramedic level...). Now, it has been my experience that every CERT seems to be pretty different depending on the resources of the area (I've been a guest instructor for CERTs in Sourthern CA and well as Middle East Coast)... the cirriculm is supposed to be the same, but i've seen CERTs that have a 40 hour first response (medical) course and CERTs with only a 6 hour introduction to first aid/triage... and the instructors will vary from an experienced Paramedics to the layperson who's only training was a CERT he went through and has reach a position of leadership and so teaches the class... keep that in mind, many instructors are those that have never done any of this stuff. Now, I do have to address your friend's story... 10 years in EMS I've seen a lot of cardiac arrests and many a PAramedic stop CPR (or just not start) when I thought they should have continued... BUT, I have NEVER seen anyone stop CPR on a Child, least of all one who had "drowned" which has a much higher rate of survivial than does other causes of arrest (oh, and Eric, the rate of survival for Traumatic arrest is least that 1%, and if it weren't for isolated cardiac Tramponode which is a treatable reson for arrest it would be even less). Back to the girl, first, I found it almost (and i do so almost) unbeleivable to think a Parameid would just stop CPR on a child. Additionally, presuming that the EMS was in fact at a Paramedic level and not a BLS (EMT-Basic level) or had restictions on pediatric airway interventions, they would have surely intubated the girl leaving no reason for the use of the stethoscope, which while inovative, not sure on how the 3 way open would perform for that use. Finally, unless you friend is a paramedic, I find it VERY unlikely (like 1 in million) that putting a soft stethoscope tube down the airway would have majicly found it's way to the trachea and not the esophagus when a real harder/formed tube with a stylet shaped to find the trachea still had only a 1 in 100 chance without some other way to guide it such a direct visualiztion (trained experienced paramedics still miss with THAT) or at leaset a digital intubation... so are you telling me he just put it in and it was in the trachea? really, a drowning victim with a larygospasm that would have closed off the trachea and it just majiclly bent itself up and foward and past the protective epiglottis and down the trachea... hmmm... not saying it can't happen, but i hear these stories alot and they just tend not to be true. that being said, i'm a big beleiver in doing all you can, and yes, even knowing the statistics i do CPR on arrest victims all the time, if it were my family, i would want the 1 in a million chance... so keep the questions going, keep doing the best you can, and consider CPR if needed. Oh, and to echo eric... that is the same START triage just about every system uses, EMS and the like... but it is also supposed to be a guide, not an absolute rule, if i have 20 people, 19 get up and walk away with bruised toes and 1 in cardiac arrest,then i'm doing CPR. but if i have a victim not breathing but does have a pulse and have 10 others crawl up with amputaions and bleeding out, i'm leaving the arrest victim and slapping on 10 tourniquets... (and yes, some hemastatic agents, though i only carry packs, designed for me and a fellow officer). so, i agree and disagree with CERT, and agree and disagree with you... but you basicly said it, use your brains and common sense, the "rules" are just there for when you panic and common sense isn't so common. good luck and be safe! (down the trachea... realy?)

Voodoo
Voodoo

TacZen, Your "scope of practice" comments do run contrary to what I've been told by my specific CERT instructors, unless they just left our some important details, which I'm hoping. Honestly on my story from a friend, there's no telling if that was 100% exactly as it happened because I wasn't there when the incident happened, I'm just restating what I was told. I'm glad though that you've never experienced or heard about EMS ever stopping CPR on a child, but stopping or never starting on someone does concern me. It does seem to me that while CERT is a great organization, I might be presented with the situation where I have to follow my gut and do what I know is right. That's pretty much with anything in life though if you ask me. Thanks for the comment, Bryan

Mike
Mike

I was under the impression that as a CERT member you are able to use your highest level of care that you are certified in. Granted I understand the idea of triage and I have had to do it before. But since I am EMT certified ,amongst many other certifications, wouldn't this mean I would be able to use my experience and discretion based on the situation at hand? Every emergency situation is different, no matter what they teach you. I am not sure if CERT policy is different in different communities or states. I agree with your views and could not pass someone that I feel still has a chance with CPR. The sooner CPR is administered the chance of that person surviving dramatically increases. Unfortunately it will prob take a lawsuit for anything to change, just like most volunteer government programs. Hey if getting blacklisted saves a life isn't it worth it?

fastmover
fastmover

I truly meant resources, not training. If you have 10 injured and 10 rescuers you can do much more than if you have 10 down and you are alone but know how to do open chest massage.

and "pulse not breathing"...i agree; me i would open a air way place a adjunct (simple oral airway) before moving to another.

my point with "they are dead already" was to point out; as a responder you don't want to get into the mind set that you killed them/you didn't save them/you could have done more...by no means did i mean don't try, i mean don't take on the mental burden that; this situation is your fault, that the out come is your fault, or you will risking becoming a casualty yourself. i tell rescuers; they were dead when you got there, any save is a win any loss was meant to be. Not that this is the mind trap that anyone here will get into, but i have seen it.

great thread.

fastmover
fastmover

I truly meant resources, not training. If you have 10 injured and 10 rescuers you can do much more than if you have 10 down and you are alone but know how to do open chest massage. and "pulse not breathing"...i agree; me i would open a air way place a adjunct (simple oral airway) before moving to another. my point with "they are dead already" was to point out; as a responder you don't want to get into the mind set that you killed them/you didn't save them/you could have done more...by no means did i mean don't try, i mean don't take on the mental burden that; this situation is your fault, that the out come is your fault, or you will risking becoming a casualty yourself. i tell rescuers; they were dead when you got there, any save is a win any loss was meant to be. Not that this is the mind trap that anyone here will get into, but i have seen it. great thread.

gilligan0211
gilligan0211

heh, Andrew called him Bry.... I caught that article a little late. I do agree with Andrew though, Bryan. Check out the Red Cross. In the US here, they teach the whole first responder package, throw in some natural disaster response, and finish up with a little triage. When you get a little higher up there they'll give you a truck from what I understand. I think in TX it would be one of those white hummers with the red cross emblem on it. If that doesn't get you the ladies, I don't know what will. They require monthly volunteer hours, and training. CE credits are fun. Just take a skywarn course and you should be good.

Andrew
Andrew

Bryan,

maybe you'd be better served by going to your local red cross group for first aid training.

If it works the same way as it does over here in the UK, you do a 10 week course covering all aspects of being a first responder and a lot of ways how to save a life through basic (ie not paramedic) levels of training.

We do some of the things covered in CERT as our basic training for being Scout leaders, but for more detailed stuff we have to go a much more specialised route.

Still loving your work though Bry, keep it up

Andrew
Andrew

Bryan, maybe you'd be better served by going to your local red cross group for first aid training. If it works the same way as it does over here in the UK, you do a 10 week course covering all aspects of being a first responder and a lot of ways how to save a life through basic (ie not paramedic) levels of training. We do some of the things covered in CERT as our basic training for being Scout leaders, but for more detailed stuff we have to go a much more specialised route. Still loving your work though Bry, keep it up

Voodoo
Voodoo

Andrew, I'm Red Cross certified in CPR already, and definitely looking into what else they provide too. My mother calls me Bry... LOL! Thanks for the comment, Bryan

Nick
Nick

Really excellent comment by Erik...I was going to comment on scop of practice, but you said it much more thoroughly than I'd have.

Erik Day
Erik Day

Let me lift that moratorium for you...

The method of triage CERT uses is "START", an acronym for "Simple Triage and Rapid Treatment." It's evolved a bit since WWI, created in its current form in 1983 by Hoag Hospital and the Newport Beach Fire Department specifically for Multi-Casualty Incidents. The theory is to use no more than :30 for assessment and no more than an additional :30 for treatment. LAFD picked up the technique not long after, then their CERT program incorporated it, then FEMA co-opted the curriculum, then... well, enough history.

At a buck a pop, the triage tags aren't usually issued to CERT graduates. YMMV, of course, and our program will issue them to CERT teams… but only as they're deployed.

Re: Airway Obstruction

Your instructor, while surely well intentioned, got off on a tangent regarding the litigation. Really, that's a non-factor for making life-and-death decisions. The whole point of sorting, as you've mentioned, is doing the most good. Consider this: one guy got hit hard enough to have trouble breathing on his own. If that's the case (and you're actually there quick enough that he hasn't already suffered irreparable brain damage), what are the odds that two or three more guys aren't bleeding out in the next room? While you're starting CPR (bad idea, more on this in a sec), hoping to save a guy (~5% chance of living [if you really know what you're doing *and* have an ambulance on the way to this disaster scene…]), you've just doomed the two other guys to 0% chance of living when quick action on your part could've pegged them at 100% chance of living. Bryan, your moral dilemma just got infinitely more complicated.

Second, check your notes on keeping someone with the victim (in your "Counter" section). In practice, if another victim is available to assist, fantastic. Otherwise, you're propping up the airway and continuing your search. Practical advice: forget the towel, use their shoes. Jam them just under the shoulders (toe pointed down) to lift and tilt the head back, with one shoe on each side of their head for uniform lift and stability.

Now, about that CPR…

This guy isn't breathing. We don't mention anything about the heart. CPR is for folk with no heartbeat. You're thinking rescue breathing. In that confusion, you've just illustrated why an NPA would also be a bad idea: because people aren't going to remember how to use it unless they've been trained in it. A 2 minute primer in a CERT class isn't going to stick with them when the air is choked with plaster dust and people are screaming. If this victim is unconscious (if they're not breathing, they definitely won't be conscious), how did they get that way? Possible trauma? Do they have raccoon eyes? Battle's sign? No NPA for them.

And that slides into hemostatic agents…

Three words: "Scope of Practice."

Depending on your location, it's unlikely anybody is going to check your trauma kit for unauthorized toys before you're deployed. On that note, though, if you're carrying it, and you attempt to use it, you'd better know what [..] you're doing. In medicine, it's all about "scope of practice"… and it's drilled into professional rescuers and clinicians alike: if you haven't been trained in it, you're probably going to do more harm than good attempting it. Therein *does* lie a legal morass. It's not that no good deed goes unpunished, it's that your intervention may have elicited potentially lethal complications. What if the bleeding guy is unconscious when you slap that HemCon on and walk away, then find out later that he was severely allergic. *Was*.

The CERT training, like medical training, has its own "Scope of Practice" limits. Yes, more can be done by rescuers than prescribed in the CERT curriculum. In fact, people write Emergency Response/Emergency Management research papers about every Unit in the course. CERT is a rescue primer, and a good one, but for someone like yourself, it should be considered a beginning, not the final word.

If the class leaves you wanting more, check your area for more advanced Search and Rescue groups. I'd be surprised if there wasn't something nearby, something that might appeal to a person that actually knows what an NPA and hemostatic agents are...

Erik Day
Erik Day

Let me lift that moratorium for you... The method of triage CERT uses is "START", an acronym for "Simple Triage and Rapid Treatment." It's evolved a bit since WWI, created in its current form in 1983 by Hoag Hospital and the Newport Beach Fire Department specifically for Multi-Casualty Incidents. The theory is to use no more than :30 for assessment and no more than an additional :30 for treatment. LAFD picked up the technique not long after, then their CERT program incorporated it, then FEMA co-opted the curriculum, then... well, enough history. At a buck a pop, the triage tags aren't usually issued to CERT graduates. YMMV, of course, and our program will issue them to CERT teams… but only as they're deployed. Re: Airway Obstruction Your instructor, while surely well intentioned, got off on a tangent regarding the litigation. Really, that's a non-factor for making life-and-death decisions. The whole point of sorting, as you've mentioned, is doing the most good. Consider this: one guy got hit hard enough to have trouble breathing on his own. If that's the case (and you're actually there quick enough that he hasn't already suffered irreparable brain damage), what are the odds that two or three more guys aren't bleeding out in the next room? While you're starting CPR (bad idea, more on this in a sec), hoping to save a guy (~5% chance of living [if you really know what you're doing *and* have an ambulance on the way to this disaster scene…]), you've just doomed the two other guys to 0% chance of living when quick action on your part could've pegged them at 100% chance of living. Bryan, your moral dilemma just got infinitely more complicated. Second, check your notes on keeping someone with the victim (in your "Counter" section). In practice, if another victim is available to assist, fantastic. Otherwise, you're propping up the airway and continuing your search. Practical advice: forget the towel, use their shoes. Jam them just under the shoulders (toe pointed down) to lift and tilt the head back, with one shoe on each side of their head for uniform lift and stability. Now, about that CPR… This guy isn't breathing. We don't mention anything about the heart. CPR is for folk with no heartbeat. You're thinking rescue breathing. In that confusion, you've just illustrated why an NPA would also be a bad idea: because people aren't going to remember how to use it unless they've been trained in it. A 2 minute primer in a CERT class isn't going to stick with them when the air is choked with plaster dust and people are screaming. If this victim is unconscious (if they're not breathing, they definitely won't be conscious), how did they get that way? Possible trauma? Do they have raccoon eyes? Battle's sign? No NPA for them. And that slides into hemostatic agents… Three words: "Scope of Practice." Depending on your location, it's unlikely anybody is going to check your trauma kit for unauthorized toys before you're deployed. On that note, though, if you're carrying it, and you attempt to use it, you'd better know what [..] you're doing. In medicine, it's all about "scope of practice"… and it's drilled into professional rescuers and clinicians alike: if you haven't been trained in it, you're probably going to do more harm than good attempting it. Therein *does* lie a legal morass. It's not that no good deed goes unpunished, it's that your intervention may have elicited potentially lethal complications. What if the bleeding guy is unconscious when you slap that HemCon on and walk away, then find out later that he was severely allergic. *Was*. The CERT training, like medical training, has its own "Scope of Practice" limits. Yes, more can be done by rescuers than prescribed in the CERT curriculum. In fact, people write Emergency Response/Emergency Management research papers about every Unit in the course. CERT is a rescue primer, and a good one, but for someone like yourself, it should be considered a beginning, not the final word. If the class leaves you wanting more, check your area for more advanced Search and Rescue groups. I'd be surprised if there wasn't something nearby, something that might appeal to a person that actually knows what an NPA and hemostatic agents are...

Voodoo
Voodoo

Erik, Thank you for your comments, they're certainly appreciated and I value your perspective coming from someone with a CERT background. Do you agree with START and feel that's the best way to go about things? I'm not sure how your CERT program teaches triage, I'm under the impression that it should be the same in any CERT program, but whether we're issued the triage tags or not is irrelevant. During the triage phase we're taught to group the victims whether we have the tags or not. So the "mark them dead" would become just moving on and not spending any time trying to save that life. I completely agree with you on making a life-and-death decision not being decided by possible litigation, and I feel that saying what my instructor did, completely dissuaded everyone in my CERT class from thinking independently and using their best judgement. If you drill litigation into someone it makes them think too hard instead of just acting, and that's what's important... action. Your counter to trying to save that life in front of me while others have the potential to be bleeding out is spot on. I understand this, and it's definitely something that has to be considered. My initial dilemma comes from the fact that I don't know if I'd be able to move on from the person right in front of me dying when I knew I could help them. I would hope that in that situation there would be additional CERT members to keep moving to reach other victims, but that may not always be the case. Additionally, I also see where if everyone stopped to save that life in front of them, who's left to treat the others? It's a tough situation no matter how you look at it. The shoe idea is excellent, and I'll definitely remember that one. Thank you. Thank you also for the correction on rescue breathing, I tend to get that wrapped up in the broad terminology of CPR, when in fact I know better than that. I did in fact mean rescue breathing and will try to correct the article to reflect that. Either way, CERT doesn't teach or allow rescue breathing either. Are you saying that because in my article I wasn't clear on the difference between rescue breathing and CPR that's an example of why people will forget how to use a NPA? I don't buy that. There are so many things that are important in CERT class that are taught no longer than two minutes, I'm a strong believer that people remember more than they think they do (even in the confusion of an emergency). My NPA suggestion is merely a way to keep an obstructed airway open, and I'm also aware there are times when one should not be used. When you point out "scope of practice" are you suggesting that I disobey CERT protocol and default to my level of training because I'd be covered under my scope of practice? I see your reasoning behind not using something unless you're taught to, but there again lies the action vs. non-action because of the legality. I'm not advocating using things you don't know how to use, just that how long does it really take to teach someone NPA and hemostatic agent use? Not long at all. HemCon is flawed IMHO because of the shellfish it contains, that's one of the many reasons why we don't carry it in any of our medical kits. We advocate QuikClot (Combat Gauze specifically) because the potential for allergic reaction is minimal unlike HemCon. And there again, action vs. non-action, I'd rather take the ding for having acted and attempted to stop blood loss than to worry about a possible allergic reaction. Honestly though, how hard is learning how to pack a wound with QuikClot Combat Gauze and ensure direct pressure is still used on top of it? It's not a hard concept and your talk of "probably going to do more harm than good" is the wrong attitude in my opinion. From my understanding (as dictated by my three CERT instructors) you're not to go outside of the CERT scope of practice, even if you have other training that *should* supersede. I'm definitely looking more into it, and appreciate the mention of the research papers. CERT is by no means where I'll stop with my training and volunteering, just something I was interested in experiencing and sharing on ITS. There's actually a local S&R group I'm already talking to. Once again, thank you for your perspective and comments. Bryan

Erik Day
Erik Day

Bryan, First, it's fantastic that so many folk have come out of the woodwork to comment on this. Just by raising the issue, you're giving CERT training some much-needed promotion… and it's the exactly this kind of word-of-mouth that gets people into classes -- and lives are saved down the road. It's unfortunate that your instructor used the litigation issue, but I can see his point. From an instructor's perspective, the average class (as officially taught) is 17.5 hours. You're on a timetable to get folk in, get them aware and get them out -- especially if your instructors are firemen on the clock. In fact, the legality of Scope of Practice is a valid argument (even for CERT) and for most folk, the threat of a suit can end an issue right there. Boom, class back on schedule. Is that the best solution? Not at all, but start into the philosophy and now you're taking time away from teaching another part of the class. As for START as a triage method? IMO, yes: it's definitely the best method. The problem you're having, it seems, isn't really with the method, it's with the human impact of the circumstance. Here, we have to back up just a bit. CERT is taught as a disaster response method, not an emergency response method. The critical difference is that in a disaster, professional emergency responders are overwhelmed. The fire engines, the RAs and the paramedics will be assigned to the "high value" targets. Even First Responders can be overwhelmed, hence a situational condition called a Multi-Casualty Incident or "MCI". The idea is that the worst-off (but savable) patients get the highest priority care… but you still have to sort *all* the patients before you can definitely say who is the worst. In the process of sorting *all* those patients is where CERT members (or firefighters, etc) make their initial intervention if it's called for. That's the :30 to treat for the killers. This might make you feel better: we get doctors and nurses occasionally coming through CERT class and many of them have the same issue you do. The critical aspect to remember is that START is applied in a suspected MCI. If there are more victims than rescuers, or there are an unknown number of victims (i.e.: CERT search and rescue in an unknown building), the rules are different than if the responders outnumber the victims. A guy suffering cardiac arrest because he just saw the bar tab doesn't need START, he needs CPR. A damaged building with victims strewn through it will save more lives with START than giving rescue breathing to the first guy you see that isn't breathing (but has a pulse). This comes back to the human impact of the circumstance: making that decision to walk away can haunt you. In this type of scenario, though, by slipping prematurely out of triage mode and into treatment mode will likely doom somebody that could've been saved with a simple intervention. These are the lessons that come from the WWI era, every bus and train accident and every densely-occupied structure that just endured a natural disaster since then. Bryan: you're right to be patient's advocate. Just remember that once you announce you're a CERT team and you're there to help (your voice triage), you own that building. You've just taken responsibility for *all* the potential patients within, not just that one guy with the airway issues. That's where START is definitely your friend.

Voodoo
Voodoo

Erik, I completely agree. It's wonderful that so many people are interested in the topic, and I do hope it leads to more people volunteering and eventually saving lives. Good point on the litigation issue, and I'm hoping that is why it was brought up so often. Thank you for the detailed explanation of the human impact, it's definitely what I'm having the hardest time with, but I don't think I'll ever be able to just walk past someone I have the ability of helping. Even in a MCI. I really appreciate your perspective and thank you for sharing and commenting. Bryan

Alex
Alex

Bryan:

I completely agree with your views and I will share a short story to illustrate my experience with CPR:

About four years ago, my girlfriend and my best friend were hanging out at my house when she spontaneously went into a Grand Mal seizure (she had no history of epilepsy at 22 years old). After a few seconds of very violent contractions, her body went limp and she fell to the ground - clinically dead. While my friend struggled to find a phone and call 911, I started to perform CPR on her. It would be dumb of me to cite the exact elapsed time for we all know the tricks shock plays on our perception of time, but I can assure you that AT LEAST five to six minutes went by before my friend came back into the room to ask me what my address was! At that point I almost gave up hope since I knew that EMS was not even on their way ... but I didn't. I continued to talk to her (lifeless body) and give CPR. Little by little, she started to regain consciousness and take very shallow breaths. The paramedics eventually got there but by that time she was back to normal (except for her memory, which took a while to come back). The moral of the story is that CPR works and that perhaps what is more important is the WILLINGNESS of the respondent to keep the victim alive. You obviously have that last characteristic and we are all better off for it! Wish there were more people like you around.

Alex
Alex

Bryan: I completely agree with your views and I will share a short story to illustrate my experience with CPR: About four years ago, my girlfriend and my best friend were hanging out at my house when she spontaneously went into a Grand Mal seizure (she had no history of epilepsy at 22 years old). After a few seconds of very violent contractions, her body went limp and she fell to the ground - clinically dead. While my friend struggled to find a phone and call 911, I started to perform CPR on her. It would be dumb of me to cite the exact elapsed time for we all know the tricks shock plays on our perception of time, but I can assure you that AT LEAST five to six minutes went by before my friend came back into the room to ask me what my address was! At that point I almost gave up hope since I knew that EMS was not even on their way ... but I didn't. I continued to talk to her (lifeless body) and give CPR. Little by little, she started to regain consciousness and take very shallow breaths. The paramedics eventually got there but by that time she was back to normal (except for her memory, which took a while to come back). The moral of the story is that CPR works and that perhaps what is more important is the WILLINGNESS of the respondent to keep the victim alive. You obviously have that last characteristic and we are all better off for it! Wish there were more people like you around.

Voodoo
Voodoo

Alex, Thank you for sharing your story, It's good that you knew CPR and exactly why I believe that CERT should teach CPR regardless of their policy of using it or not. Why would they not take advantage of taking people willing to learn and providing them with that knowledge. I'm CPR certified, and to hear that I'd be blacklisted by CERT for performing CPR is disheartening to say the least. That goes beyond the argument of whether it's the right thing to do in that situation or not, just knowing it's not to be done is what I have a problem with. I feel that your point about having the willingness is what's getting lost in all the "greatest good for the greatest amount of people." It's almost like saying it's hopeless and why even try... I'm going to try and not get off on a tangent, but so many people have that philosophy on more things than just CPR which is just inexcusable to me. The simple action of one man can make all the difference in so many situations. Bryan

spenceman
spenceman

I new I was skeptical of CERT for a reason. Like many programs from the .gov, good idea, poor execution.

fastmover
fastmover

triage is tough, those rules are there to save lives. if you have the resources to do more do more. but in a situation where you are tagging; you have to save the ones you can. remember if they are not breathing and have no pulse...they are already dead. the statistics for a person in full arrest do to trauma ever regaining vitals even with ACLS is...well, real real low.

Ryan
Ryan

I'm still trying to get someone from my local CERT training group to return my calls and emails...

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