Grand Rounds Recap 2.2.22
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MORBIDITY AND MORTALITY CONFERENCE WITH DR. COLLEEN LAURENCE
Recognizing Sepsis:
ACEP Task Force published sepsis guideline in Summer 2021
Define sepsis as confirmed or suspected infection with new or worsening organ dysfunction and dysregulated host response to infection, but is not defined by a single datum or finding
SEP-3 Guidelines define septic shock as hypotension requiring vasopressor therapy and an elevated blood lactate level (2 mmol/L or above) after initial resuscitation
Highly morbid condition with nearly 20% mortality
Sepsis Screening Tools
qSOFA
SEP-3 and SSC guidelines recommend use of qSOFA which evaluates BP, RR and mental status
qSOFA > 2 should trigger consideration of sepsis (17.3% sensitivity, 98.8% specificity)
No validated evidence-based tool or strategy reliably facilitates early sepsis recognition in the ED or the pre-hospital setting.
ACEP TaskForce recommend instead that such screening tools be used more so as an adjunct in addition to history and physical exam.
Sepsis Treatment
Much of current practice is dictated by CMS metrics which continue to be guided by principles initially proposed in Early Goal Directed Therapy (Rivers)
Resuscitation with 30cc/kg IBW crystalloid (weak recommendation, low-quality evidence)
At least 1 measured lactate (weak recommendation, low-quality evidence)
Barriers to initiation of treatment:
Delay or difficulty in obtaining blood cultures before you can start antibiotics
Nursing communication, nursing ratios
Waiting for urine or CXR due to desire to tailor antibiotic choices
COVID - lack of rapid viral testing leads to diagnostic uncertainty
Arrival/distraction of critical patients
Antibiotics
Surviving Sepsis Campaign Guideline recommends administration within 1 hour of sepsis recognition. CMS recommends antibiotics within 3 hours.
Adjusted in-hospital mortality ⬆ by 9% for each hour of delay in antibiotics (95% CI: 1.05-1.13).
Absolute mortality for those in septic shock ⬆by 1.8% with every 1 hour delay (95% CI 0.8-3.0).
Summary Points:
Sepsis is a highly morbid condition that requires prompt recognition to expedite appropriate diagnostics and care.
Sepsis recognition is challenging in the absence of a single finding or datum that defines it, and sepsis screening using qSOFA is limited by poor sensitivity.
The optimal time frame for antibiotics in sepsis remains undefined, but CMS sepsis core measures encourage antibiotic administration within 3-hours.
Early administration of antibiotics in sepsis is associated with a mortality benefit, especially for patients with evidence of septic shock.
De Novo or Decompensated Acute Heart Failure (AHF)
There are approximately 1 million ED visits annually for heart failure exacerbations of which 80% will require hospitalization. Patients with known heart failure average 2 hospital admissions per year.
Diagnosis of Acute Heart Failure
A systematic review and meta-analysis comprising 57 studies with a total of 17,893 patients who presented to the ED with dyspnea as their primary complaint compared ED evaluation characteristics to an eventual diagnosis of AHF.
Physical Examination
S3 Gallop ( +LR 4.0)
JVD (+LR 2.8)
Diagnostic Studies
Ischemic changes on EKG: +LR 2.9 overall
T Wave Inversions (+LR 2.4), Afib (+LR 2.2), ST Depressions (+LR 2.0)
CXR: Kerley B lines (+LR 6.5), interstitial edema (+LR 6.4), cephalization (+LR 5.6), alveolar edema (+LR 5.3)
Lung Ultrasound: B-lines +LR 7.4
An additional systematic review and metaanalysis published in 2019 showed the pooled sensitivity of lung ultrasound was 88% (95% CI: 0.75-0.95) and specificity was 90% (95% CI 0.88-0.92).
Comparatively, the sensitivity for chest x-ray was 73% (95% CI: 0.70-0.76) with a specificity of 90% (95% CI 0.75-0.97).
Overall Pros: better sensitivity, immediate results that are responsive to dynamic change if you diurese or give fluids, they are easy to interpret, and avoid ionizing radiation
POCUS Echo: Reduced EF (+LR 4.1)
BNP: In general, a BNP > 500 (+LR 9.1)
Varies based on cutoff point, specific lab assay used, and whether it was NTproBNP or BNP.
Risk Stratification of Acute Heart Failure (AHF) in the ED
An episode of AHF portends an estimated 5-10% mortality in the next 30 days
Emergency Heart Failure Mortality Risk Grade Score (EHMRG)
Factors include: Age, Arrival by EMS, Systolic Blood Pressure at triage, oxygen saturation at triage, heart rate at triage, potassium level, creatinine, troponin, active cancer, metolazone use prior to ED arrival, ST Depression on EKG. Calculate it HERE
Has very good discriminative capacity with a c-statistic (equivalent to AUROC) between 0.74-0.81 for 7-day mortality.
Patients in the lowest risk category had 0.3% of 7-day mortality.
AHF Management: ED Observation
Pros: cost savings, decreased use of bed capacity, shorter LOS
Cons: risk of re-presentation, readmission, decompensation leading to increased mortality
A review by Rider et al in the American Journal of Emergency Medicine in 2021:
Uses EHMRG for stratification
Exclusion Criteria included known COVID-19 infection
New onset AHF patients should be admitted, as ED Obs is not appropriate for evaluation of etiology and initiation of treatment regimen
Some potential endpoints would be subjective improvement in dyspnea with exertion and blood pressure control as well as medical optimization for discharge
Summary
Despite its prevalence, diagnosis of de novo and decompensated AHF remains challenging
Bedside lung US and echocardiography are the most useful for affirming presence of AHF
EHMRG is an accurate, validated risk stratification score to help determine disposition for patients with AHF.
ED Observation protocols for AHF offer potential resource and cost savings with minimal adverse events, but more work is needed to evaluate appropriate endpoints.
Atypical Cardiac Ischemia
Wellens Syndrome Refresher
Wellens syndrome refers to the presence of T-wave changes in precordial leads V2-V3 (but can involve V1 and V4), indicating critical proximal LAD stenosis.
Pattern B is the more common variant accounting for 75% of cases
EKG changes typically develop when the patient is not experiencing active chest pain and cardiac serum markers are often normal or only minimally elevated
More of a preinfarction syndrome often caused by temporary occlusion from plaque rupture
Avoid provocative testing since it could precipitate AMI; treat as STEMI equivalent
Atypical Myocardial Infarctions (AMI)
~2% of AMI are missed each year
Some contributing factors:
Atypical symptoms like isolated shortness of breath
How providers assess risk factors, especially for atypical ones like Lupus or HIV
Age and sex can play a role as well
>40% pts over 85 yo with NSTEMI have a nondiagnostic EKG
Quality of EKG tracing and ability to compare to priors
How “negative” angiograms and stress testing are incorporated into risk assessment
Non-obstructive lesions can still suggest significant disease
stress testing is only 68-77% sensitive for single vessel disease (better for multi vessel)
Patients without chest pain are less likely to receive ASA, antiplatelet therapy, heparin, beta-blockers, and reperfusion therapy → ⬆mortality
The Value of Repeat EKGS
T wave inversions are most common change seen on serial EKGs
Persistent signs of ischemia on serial EKGs predicts significantly higher long-term risk of death
Could help identify patients who may benefit from more intensified therapy
Serial EKGs are markedly less sensitive than serial troponins or TIMI>2
AHA recommendation: if you have a non-diagnostic EKG–with either non-specific changes or otherwise limited by movement or arrhythmias–a repeat EKG should be obtained
Summary:
Wellens is a pre-infarction syndrome that remains a critical, yet challenging diagnosis given the typical absence of chest pain on presentation.
Acute cardiac ischemia is more likely to be missed in women < 55 years of age, those with SOB as presenting CC, non-white patients, and those with non-diagnostic EKGs.
While serial EKGs may not be sensitive for AMI in exclusion, they can be useful in patients with initial non-diagnostic EKGs or if clinical conditions change.
Care turnovers can lead to medical errors but also opportunities for rescue when reevaluation offers a fresh perspective.
Cardiac Arrest in Patients with CKD
Cardiovascular disease is the leading cause of death among ESRD patients, accounting for 40% of all deaths
Ischemic Cardiovascular Disease
Sudden cardiac death (SCD) related-mortality increases 14-fold in dialysis patients compared to those with a history of cardiovascular disease but normal normal kidney function
This risk carries to non-dialysis dependent CKD patients as well
Often present with more atypical ACS symptoms like nausea, shortness of breath and weakness rather than chest pain.
Revascularization still offers the best chance for treatment
Should still receive ASA and standard ACS medications
Post-revascularization survival is poor (52% 2yr mortality after PCI), likely due to arrhythmias
Arrhythmias may be responsible for >50% of cardiac deaths in both PD and iHD patients
Occurs more commonly occurs at 60+ hours from last dialysis
Sepsis
Up to 300% increase in mortality from sepsis in ESRD patients
Accounts for 12% deaths in ESRD patients
Leading sources are CLAVI followed by atypical pneumonia
~5.5 episodes for every 1000 catheter days
Risk of MRSA infection is 100x greater in ESRD patients on HDS with a catheter compared to a fistula.
Hemorrhage
Much higher rates in ESRD patients than general population
Contributing factors include platelet dysfunction from uremic toxins, impaired interaction between platelets and the vessel wall, and regular use of anticoagulation to facilitate dialysis
Pericarditis and Pericardial Effusion
EKGs often does not demonstrate classic changes of pericarditis
Commonly uremic vs. dialysis-associated in etiology
Uremic pericarditis = before or within 8 weeks of initiation of dialysis
Dialysis-associated pericarditis = been on dialysis for more than 8 weeks
Dialysis-associated pericarditis is less responsive to dialysis for resolution and are more likely to have tamponade and hemodynamic instability on presentation
Summary:
Risk of sudden cardiac death progressively increases with decline in eGFR
Etiologies for SCD in patients with CKD are numerous, but most often related to ischemic heart disease, arrhythmia, and electrolyte shifts.
ESRD patients are at increased risk for SCD within 12 hours of initiating first HD treatment and at 60+ hours since last treatment.
Pericarditis may present differently in ESRD patients, but ultrasound is useful for determining need for emergent pericardiocentesis v. dialysis
Goals of Care Communication
In the ED, we have two kinds of goals of care conversations:
Crises Communication - used when a patient is acutely decompensated and decisions need to be rapidly made between multiple treatment strategies
Serious Illness Communication - occurs at an inflection point in an illness trajectory
Though challenging for many reasons, goals of care conversations offer many benefits, among them a greater likelihood of having wishes known and followed.
Different scripts for GOC conversations in the ED are available and offer the chance to learn more about patient values that may suggest preferences in care.
Goals of care conversations in the ED require training, personal reflection, practice, diligence and courage on the part of clinicians.
R2 CPC WITH DR. LAUREN GILLESPIE VS. DR. SARA CONTINENZA
The Case:
A young male presents with his mother to the ED with complaints of vision changes and rash. He states he was seen at an eye doctor in Dec 2019 and was told there is “nothing they can do for him,” and that his vision has been declining ever since. It is gradual, painless, steadily progressive, R>L, and most pronounced at night. No field cuts, floaters, flashers. No preceding trauma. His sister has similar vision difficulties but no family history of similar otherwise. Regarding his rash, he notes development of a prominent scaling of bilateral palms and soles for several months with subsequent development of anterior tibial rash in lower extremities. It is not painful or pruritic. No new topical agents or detergents, no recent travel. Social history is remarkable for no history of IVDU, drinks alcohol socially.
Vitals: BP 102/70, HR 117, RR 18, SpO2 99% on RA, T 99.0F
Ocular exam notable for bilateral hazy corneal opacifications, complete on the right and ~30% of the left and resultant visual acuities of hand motion and 20/100, respectively. Fluorescein, slit lamp and tonometry normal. Skin exam shows diffuse xerosis, lichenification with exfoliative scaling on bilateral palms, soles; coalescing erythematous to purple irregular plaques of varying sizes in anterior shins bilaterally with decreasing gradient of lesions distal to proximal. Chest, abdomen, trunk, head, neck, proximal arms unaffected. Remainder of physical examination shows a very thin male with a scaphoid abdomen but is otherwise unremarkable.
CBC with normocytic anemia and Rouleaux formation but no leukocytosis or thrombocytopenia. UA shows hematuria and proteinuria but no evidence of infectious process. LFTs with elevated alk phos to 222, AST 53, albumin 2.7 but otherwise normal, INR 1.5 BMP within normal limits apart frm Na+ 126 and calculated Osms 262. COVID positive. HIV reactive; absolute leukocyte count 1950. Hepatitis panel negative. CXR unremarkable, EKG sinus tachycardia. Vitamin A level and urine electrolyes are pending.
…and then a test was ordered…
Working Through the Differential:
This case is not really amenable to using a traditional differential diagnosis mnemonic. Instead, tried to narrow down to things that can cause rashes and vision loss. With the assumption that the gradual vision loss, corneal clouding and non-painful gradual onset rash involving the hands and soles are related to the same pathophysiologic process, we get to the top 3 possible diagnoses:
Secondary syphilis with ocular involvement
Vitamin A deficiency
Tuberculosis
Her bet: Syphilis
Syphilis:
Signs/Symptoms
Primary
2-3 weeks from exposure
Painless chancre at the inoculation site
Secondary
6-12 weeks from exposure
Rash
Visceral involvement (renal and hepatic most commonly)
Tertiary
>12 weeks after exposure
Gummatous lesions on skin
Aortitis
Coronary arteritis
Latent - asymptomatic
At any time, with any stage
Neurosyphilis
Ocular syphilis
Otic Syphilis
Epidemiology
Increasing rates of infection in past two decades
In men who are sexually active with men and have either primary or secondary syphilis, 42% have concommitant HIV infection
New syphilis infection⬆HIV viral load and ⬇CD4 counts in HIV+ patients
HIV+ patients more likely to have rapid progression to neurosyphilis
Typically have more prominent chancres during primary stage
Diagnosis
Direct - not widely performed: darkfield microscopy, PCR, direct tissue examination, or antigen detection with direct fluorescent antibody testing
Serologic
Treponemal = FTA-ABS
Typically remain positive for life
Non-treponemal = RPR or VDRL
Used to measure treatment response and for surveillance purposes
Treatment
Primary and Secondary - single dose of IM Penicillin G
Tertiary - IM Penicillin G x3, weekly
Latent
Early - IM Penicillin G x1
Late - IM Penicillin G x3, weekly
Otic, Ocular or Neurosyphilis - IV Penicillin G q4hrs x10-14d
R1 CLINICAL KNOWLEDGE: ESOPHAGEAL EMERGENCIES WITH DR. MEGAN WRIGHT
Upper GI Bleed:
6-week mortality ~15%; variceal bleeds account for ~40%
Key Interventions
Resuscitation with restrictive perfusion
Coagulopathy is notoriously difficult to correct, and FFP may(?) worsen outcomes
Somatostatin bolus ⬇ portal pressure by 17% and helps control bleeding, but no reduction in mortality
Octreotide doesn’t demonstrate the same pressure reduction
Antibiotics – fluoroquinolone or cephalosporin reduces mortality by 9%
Ceftriaxone reasonable for high fluoroquinolone-resistance and more severe disease, but data best for ciprofloxacin
22% of variceal bleeds develop SBP within 48 hours; associated w/ higher rates of rebleed
Definitive management with endoscopy
Early is (probably) better, generally means <12hr
Blakemore as a hail Mary
Esophageal Impaction:
Common occurrence; 13/100000 Incidence of food bolus impaction
Foreign body most common in children rather than food
Typically occurs at one of the 3 sites of narrowing; 75% at level of cricopharyngeus muscle
Site of impaction may not correlate with location of patient’s globus sensation
Fish and chicken bones may be lodged in oropharynx rather than esophagus
Presentation
Adults – retrosternal pain, odynophagia, dysphagia, n/v
Peds – choking/gagging, vomiting, dysphagia/odynophagia but up to 76% can have normal exam
Severe – hypersalivation, aspiration, inability to tolerate secretions
Diagnosis
Imaging often not required – and may not be as helpful as you think
59% of kids with confirmed foreign body ingestion had normal chest x-ray
47% of all adult cases and 87% of food bolus cases in adults have normal chest x-ray
CXR lacks sensitivity and can cause false positives. Lateral CXR more specific.
If concerned for complete impaction or complication, including perforation or development of RPA, get a CT with IV contrast
Ultrasound?
Visualize foreign body, persistent air-fluid levels after swallowing, esophageal dilation
Medical Management
Most obstructing foreign objects, especially food, pass spontaneously
Up to 25% of cases self-resolve; 40% resolve with some combination of medication management.
Glucagon 0.5 – 1.0mg IV (repeat dosing at 5-10 min) → no benefit compared to placebo
Papain → high risk of transmural esophageal tissue digestion, fatal mediastinitis, hemorrhagic pulmonary edema
Benzodiazepines → weak evidence
Calcium channel blockers (Nifedipine 10-20mg) → reduction in LES and smooth muscle tone, but limited data on actual outcomes
Disposition
If improved and well-appearing, okay to discharge
Adults with esophageal impaction need a scope
Many have underlying esophageal pathology
27-53% of adults with food impaction diagnosed with eosinophilic esophagitis, especially <50 and male
Inpatient if object of impaction is sharp, if signs of perforation, if no improvement and not tolerating secretions, or if has been >24 hours due to ⬆risk of perforation
Risk of perforation in impaction <1% but increases after 24 hours of impaction
Esophageal Perforation:
Over 50% occur iatrogenically but this is not the typical ED presentation
15% spontaneous, no pre-existing esophageal pathology
Preceding vomiting or severe retching, anything that causes intra-abdominal pressure increase
Penetrating external injuries
Foreign body or caustic ingestion, especially alkaline agents
History of bulimia, heavy weightlifting
Overall incidence not well known, but overall uncommon; M>F.
Presentation
Acute and sudden onset chest pain (~70%)
Vomiting
Shortness of breath
Tachycardia
Abdominal pain
Crepitus in the neck or chest wall (~67%)
Mackler Triad: Vomiting, chest pain and subcutaneous emphysema (14.25%)
Diagnosis
>80% meet SIRS criteria at time of presentation, usually 24-48hrs after occurrence
Feel the chest of anyone with chest pain/dyspnea
Maintain clinical suspicion and know limitations of diagnostic tests
Management
Treat as sepsis; add anaerobic coverage as soon as suspicious
Vanc/cefepime/flagyl, vanc/zosyn, vanc/meropenem
Antiemetics to prevent vomiting
Adequate pain control
Consider these patients a difficult airway
Take care with positive pressure ventilation
R4 CAPSTONE: EMS PROVIDERS AND SYSTEMS WITH DR. KATE CONNELLY
Types of Providers
Emergency Medical Responder (EMR)
~50 hours of training
Scope of practice includes: BVM ventilation or other oxygen delivery application, CPR, AED Use, trauma care (tourniquet, C-Collar), intranasal Naloxone administration
Emergency Medical Technician (EMT)
~150 hours of training, do not need to have EMR certification beforehand
Additional scope of practice: CPAP, monitoring of vital signs and doing EKG, spine board and traction splint placement, administration of epinephrine auto injector, aspirin, oral glucose, and patient-supplied nitroglycerin administration
Advanced EMT (AEMT)
~200 hours of training, requires prior EMT certification
Additional scope of practice: Supraglottic airway placement, End-tidal capnography, IV/IO Access, administration of parenteral analgesia, IV antiemetic, IV dextrose, glucagon, SL nitroglycerin, and immunizations
Paramedic (NRP)
~1200 hours of training, EMT (not necessarily AEMT) is required prior
Additional scope of practice: Endotracheal intubation, Cricothyrotomy, NG or OG tube placement, 12-lead EKG interpretation, Cardioversion, Manual defibrillation, Transcutaneous pacing, Needle decompression, Administer IV/IM/IN/IO medications, Thrombolytic administration
Can get specialty certifications like flight, critical care, community or tactical paramedic → does not expand scope, does not require additional training, is voluntary
National certification is equivalent to passing board exams i.e. NREMT cert alone does not allow someone to practice. They need state certification to practice in a given state
EMS Systems and Logistics
Scope of Practice vs. Protocols
States define scope based on national guidelines
Protocols define what an EMS provider can do while working for a specific agency
Protocols are set by the medical director, who may elect to restrict acts allowed under state scope but cannot expand them (at least not without special dispensation from the state)
Protocols may be specific to a single agency or multiple agencies within a region may operate under common protocols (e.g. southwest Ohio protocols)
EMS Systems - vary in medical direction, staffing, funding, agency type, level of training
Private EMS
Often do a lot of non-emergent interfacility transfers
Third-Service EMS
Separate, third public service agency (i.e. police, fire, and EMS)
Typically municipal (city/town) or county based
Primarily-911 but may also do some interfacility transfers (especially emergent ones)
Fire-Based
Small depts may have 3-4 ppl at station, hop on ambulance if EMS call comes in, engine if fire call comes in (rely on mutual aid for 2nd call)
Larger depts have EMT/medics dedicated to ambulance, type of call determines which apparatus/crews get dispatched (medic units typically assigned to structure fires and MVCs in addition to medical calls)
EMT (and increasingly paramedic) certification often required for career fire positions → risk of skill dilution especially in large departments
ALS vs. BLS
BLS = EMT x2 (or EMR driver/EMT in states w/ EMR)
ALS = EMT/medic or medic x2
May be hybrid (e.g. BLS ambulance with paramedic fly car response)
Level of care determined by patient need and provider scope
e.g. CP patient needs ALS because cardiac monitoring is a paramedic skill; extremity fx could be BLS or ALS depending on need for analgesia
Volunteer vs. Paid
Paid agencies are essentially staffed; people are scheduled to work set shifts
Volunteer services may be all volunteer or hybrid (e.g. a paid paramedic on duty in a fly car)
Volunteers may sit at station or may be on call from home, may have to respond to the station in their POV to pick up the ambulance
More common in rural areas
Rural EMS
Often have extended transport times to specialty centers (45 min - 1 hour not uncommon)
Limited resources, limited coverage
Eg. only 1 ambulance, staffing challenges, etc. → taking that one ambulance out of district for 3-4 hours may not be reasonable
May not have medics, just EMR/EMT
May rely on mutual aid for paramedics, meaning it takes a medic 40 minutes to get on scene
Emergency Medical Direction & Tiered Response
Calls are coded by dispatchers as they come in.
They ask set questions based on chief complaints and give instructions as needed.
Code details complaint, priority
Each EMS system determines type of unit and lights/sirens that will respond to each EMD code
System Status Management
Dynamic
Ambulances are stationed at “posts” throughout response area
As calls are dispatched, crews reposition to optimize coverage
Staffing level is often variable (e.g. more cars on during day than at night)
Static
Ambulances are based at stations
may reposition if system status drops (e.g. if only one unit available, may reposition to city center)
GLOBAL HEALTH: INTERNATIONAL EDUCATION IN A PANDEMIC WITH VISITING PROFESSOR DR. MEGAN RYBARCYZK
How do you develop an emergency care system? Where do you start?
Develop the presence of emergency medicine which is not a specialty in many countries
ED providers can help not only with patient care but in system development and improvement (EMS, triage, etc)
Find people or educate yourself on politics, funding and expectations of time
EVERYTHING takes more time than you think
My Project: Development of Certification in Emergency Medicine Program in Pakistan
Initially started with constant in-person training and resources
1 year program, divided into 12 blocks, designed to be progressive
Designed for those who have not really completed any specialty training (maybe completed a intern year equivalent)
Build redundancy for spaced repetition and accommodation of different learners
Implementation
Simulation: High and low fidelity models, table top exercises, E-simulation via slide presentation, video conferencing, apps
Small Groups: Case-, problem- or team-based learning
Ideal group is 4-5 trainees per instructor or facilitator
Relatively easy to translate to virtual format in breakout rooms
Can overcome limited faculty members using:
Jigsaw Method = peer-to-peer teaching of a concept after an initial training session by a single faculty member
Training of Trainers
Asynchronous Learning, especially free online resources
Modifications due to COVID
Virtual Learning Strategies
Organization – dropbox, google classroom, google drive, microsoft teams
Interactions/Discussion – zoom, PollEV, Kahoot, WhatsApp
Feedback, Logs, Attendance – google forms, EDPuzzle
Evaluation – socrative (written exams), zoom rooms for oral examinations, REDCap
Thinking About a Career in Global Health?
Lessons I’ve Learned
Gain experience
Take leadership roles
Professionalize your niche – get those certifications and pieces of paper
Approach the field with humility and professionalism
Educate yourself
Lancet Global Health, Journal of Global Health, Annals of Global Health, BMJ Journal Health…https://naturemicrobiologycommunity.nature.com/posts/41300-if-you-had-to-read-one-book-on-global-health
Learn how to work abroad
Practitioner’s Guide to Global Health
UN BSAFE
If you are interested in humanitarian work:
Learn the alphabet soup
SPHERE
Building a Better Response Units 1-6
DisasterReady.org
HRIC/HELP
