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Civilian Aeromedical Evacuation Sustainment Training A Survey of

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Civilian Aeromedical Evacuation Sustainment Training A Survey of Powered By Docstoc
					  Prepared for the United States Department of Defense                                                       April 2011

Highlights of the Report                                  Robert W.Koch, RN, DNSc, Wayne J. Pitts, PhD, Marian Levy, PhD,
                                                    Daniel Kirkpatrick, RN, MSN., Tera M. Tongumpun, and Amanda L. Yacko
• The University of Memphis,
  Loewenberg School of Nursing
                                       Civilian Aeromedical Evacuation Sustainment Training:
  and the School of Public Health,     A Survey of Professionals Regarding Curriculum
  in partnership with Wright State     Content, Format, and Implementation
  University, are working to de-
  velop a curriculum for Civilian
  Aeromedical Evacuation Sus-           Introduction                                completing the survey than females
  tainment Training (CAEST).                The University of Memphis,              (47.8%). There were far more white
                                        Loewenberg School of Nursing and the        respondents (88.1%) than blacks
• In January 2011, 673 profession-      School of Public Health, in partnership     (9.0%), Native Americans (1.2%),
  als were invited to complete a        with Wright State University, through       Asians (0.5%), or others (1.2%).
  web-based survey designed to          a grant funded by the United States             Despite the convenience sampling
  measure opinions about the con-       Department of Defense are working to        strategy, the researchers were able to
  tent, format and implementation       create a program for civilian medical       reach a wide-variety of respondents
  of the proposed CAEST curricu-        and emergency personnel who may             according to the distribution of or-
  lum.                                  interact with military personnel in         ganizational types. Approximately
                                        emergency disaster situations. In Janu-     one-third of respondents came from
• Almost half (49.0%) of respon-        ary 2011, the Midsouth Survey Re-           non-profit organizations (32.1%)
  dents had personally responded        search Center at the University of          followed by local government em-
  to some sort of disaster.             Memphis launched a web-based survey         ployees (28.3%), for profit organiza-
                                        designed to measure attitudes and           tions (17.5%), state government
• Respondents felt most well-           opinions to inform civilian practitio-      (9.0%), federal government (3.9%),
  prepared to respond to medical        ners engaged in disaster recovery ac-       and military (2.8%). The remaining
  and emergency triage situations,      tivities to help them become more ef-       6.3% included individuals who
  natural disasters, and mass casu-     fective when working with military          marked some other employer type
  alty events.                          personnel during aeromedical evacua-        (i.e., self-employed, retired, city gov-
                                        tion. The major goals of the survey         ernment, academics). See Chart 1.
• Respondents believe they are          were to learn what information and          Nurses (35.2%) were the most repre-
  least well prepared for chemical,     data are collected and what informa-        sented profession in this sample of
  hazardous materials, radiologi-       tion and data are needed to support         respondents followed by emergency
  cal, and biological threats.          recovery activities. The survey also        medical technicians (32.8%), and
                                        gathered information on needs, gaps,        firefighters (10.7%).
• Military and civilian relations       challenges and opportunities related to         The convenience sample yielded
  will be complicated by commu-         training - especially in situations in-     a group of respondents with signifi-
  nication barriers, role confusion,    volving civilian and military collabora-    cant professional experience working
  and chain of command ambigu-          tion during disaster events.                with disasters. Almost half (49.0%)
  ity.                                                                                               (continued on page 3)
                                        Respondent Summary
• Respondents favor active, hands-
  on, simulation-based training             A total of 673 respondents com-
  activities.                           pleted the survey. Respondents
                                        ranged between 21 and 74 years of
• The most common barriers to           age with a mean age of 42 years old
  participating in training are the     (SD =11.0). The population was
  cost to participate and available     split fairly even according to gender
  time.                                 with slightly more males (52.2%)
Research Methodology
    All research protocols were reviewed and approved by the Institutional Re-
view Boards of the University of Memphis and Wright State University prior to
launching the survey. The potential risks of the research protocols were consid-
ered especially low because the questionnaire does not include any sensitive
questions and because respondents voluntarily and anonymously completed the
web-based survey. The respondents are all working professionals and the
bounds of survey were clearly within their everyday work responsibilities.
    The survey was conducted using Qualtrics software, an online data collection
tool widely used by academic and business professionals around the world.
Qualtrics offers superb on-screen graphics capabilities, a wide-range of question
design features, and useful reporting tools. After the data collection period was
completed, the records were exported to SPSS for analysis.
    This research used a convenience sampling strategy to recruit potential re-
spondents. The principal investigators received e-mail contacts for a variety of
professional contacts and the survey was distributed via electronic invitations to     Training Priorities
a variety of hospitals, list serves, military contacts, and individuals who had pre-   A list of possible training topics
viously attended trainings or meetings. The letter of introduction also invited        related to military and civilian
potential respondents to share the survey link with other relevant professionals at    aeromedical evacuation training
their discretion.                                                                      were provided and respondents
    All respondents were offered a $25 gift card incentive in return for their par-    were asked to check them if they
ticipation in the study. The gift card registration was facilitated through an         thought additional training was
anonymous link to a second survey where respondents could provide their name           needed in these areas. The list be-
and mailing address. Personal information cannot be matched to survey data.            low rank orders the selections with
Over 450 respondents claimed the incentive.                                            the most needed at the top.
    The mean time to complete the survey on-line was 1 hour and 14 minutes.
The outliers at the upper end were trimmed which made the mean far more rea-            1. Communication
sonable at 19 minutes.                                                                  2. Chain of command during a
                                                                                            disaster
                                                                                        3. Logistics of working with mili-
                                                                                            tary personnel
            Type of Employing Organization                                              4. Responder Safety
                                                                                        5. Expectations of the military
                                                                                        6. Patient tracking
                                 Other             Federal (non-                        7. Patient stabilization and needs
                                  6%                 m ilitary)                         8. Standards of care
             Military                                   4%         State                9. Military protocol and acro-
               3%                                                   9%                      nyms
                                                                                        10. Logistics of working with mili-
                                                                                            tary equipment
        Private (for                                                                    11. Data bases
           profit)
                                                                     Local              12. Other (i.e., expectations of ci-
            18%
                                                                      28%                   vilians, mutual respect, triage,
                                                                                            dealing with uninjured patients
                                                                                            with preexisting health condi-
                                                                                            tions including pregnancy,
                                                                                            public and environmental
               Non-profit                                                                   health issues)
                 32%




                                                              2
of those who completed the survey        aster training was also prominently
had personally responded to some         mentioned. More than two hundred
sort of disaster. Not surprising, the    other training programs were men-
most common type of disaster ex-         tioned by the respondents. In a later
periences were weather related (i.e.,    question in the survey, 77.8% of re-
tornadoes, hurricanes, floods, ice       spondents report that they have re-
storms) but there were several re-       ceived NIMS training and 62.7% say
spondents with hazardous materials       they have received FEMA training
spills, and there were a variety of      through the National Domestic Prepar-
transportation related disasters. Of     edness Consortium. A total of 38.0%        needed additional training.
these with disaster experience, most     have received Community Emergency          Almost one-fifth of respondents felt
had more than ten years of service       Response Training (CERT).                  that they needed more training in all
(69.5%). Only 10.2% had three                Respondents felt most well-            areas of disaster response. This was
years of experience or less. Thus,       prepared to respond to medical and         the most common response when
even though the sample was non-          emergency triage situations, natural       asked in what area the respondent
random, the survey reached a popu-       disasters, and mass casualty events. It    felt more training was needed. The
lation of people that have significant   is no coincidence that these are also      second most common answer was
disaster related experience.             areas with which respondents report        related to military involved disaster
    When asked to specify the types      having the most experience. When           responses with 17.1% mentioning
of disaster training they had received   asked what type of situations they felt    the need for more training in work-
in an open-ended question there were     least trained for, chemical, hazardous     ing with the military. Communica-
a broad range of types mentioned.        materials, radiological, and biological    tion issues, chain of command, and
Training provided by the Federal         threats were mentioned most often.         coordinating multiagency opera-
Emergency Management Agency              Respondents also mentioned a lack of       tions were also prominently men-
(FEMA) was the most common with          earthquake training. Some two hun-         tioned. When asked what they per-
National Incident Management Sys-        dred other training weaknesses were        ceived to be the greatest training
tem (NIMS) and Incident Command          also mentioned.                            needs among other organizations,
System (ICS) specifically mentioned          Less than one-third of respondents     the leading overall response was
the most often. Hazardous materials      (29.3%) had ever interacted with mili-     related to communications. Spe-
(HAZMAT) and hospital-based dis-         tary personnel during a disaster opera-    cific training on strategies for im-
                                         tion. This finding is not altogether un-   proving collaboration with military
                                         expected since the military is usually     personnel was also identified.
                                         only involved in the more severe disas-        The next question asked respon-
                                         ter situations. Given that fact, having    dents to consider how military and
                                         almost a third who had interacted with     civilian medical personnel interact
                                         the military during a disaster operation   during a disaster event. Next, re-
                                         make the results of this survey more       spondents were asked what they
                                         informative.                               thought the most important training
                                             There was considerable ambiva-         needs that should be addressed to
                                         lence about working with military per-     improve this working relationship
                                         sonnel. While 28.1% felt they were         were. Again, issues of communica-
                                         well-trained to work with military per-    tion were the most common prob-
                                         sonnel, most did not feel so confident.    lem and concerns about the use of
                                         Over one-third said they did not feel      common terminology was raised
                                         well-trained (36.8%) to work with the      several times. Other leading issues
                                         military during a disaster response, and   included: understanding the chain of
                                         another third were unsure (35.1%) as       command and awareness of capa-
                                         to whether they were well-trained for a    bilities, protocols, authority, and
                                         disaster response partnership or not.      responsibility of military and civil-
                                         Despite this apparent lack of clarity,     ian responders. There were con-
                                         nearly all respondents (87.4%) felt they   cerns raised about the different roles

                                                           3
and functions within the same or-                                                    their personal preference. The op-
ganizations. Another frequently                                                      tions were: 1) Training as a group
raised concern was interoperability                                                  over a concentrated period (8 hours);
and compatibility of equipment.                                                      2) Training as a group in 1-2 hour
                                                                                     sessions spread out over time; and 3)
Training Format                                                                      Self-paced individual training - on
    One of the goals of this research                                                your own, as you have time. Re-
was to obtain feedback from profes-                                                  spondents were given the option of
sionals about preferred learning for-                                                writing in any other training option.
mats and styles of training. There                                                   The second option was the most
was clear consensus regarding the         ties that require trainees to be in-       popular. That is, respondents
utility of hands-on exercises and         volved actors. Multi-methods strate-       slightly favored 1-2 hour sessions
over 90% of respondents favored this      gies are also strongly favored. Simu-      spread out over time with 83.4%
approach to training. Listening and       lation exercises (mock disaster sce-       ranking this choice as either first or
participating in discussions and          narios) are seen as the most effective     second. Concentrated, all-day train-
watching films, seeing pictures and       training method and are strongly fa-       ings were slightly less favored with
diagrams were equally popular             vored by most respondents. Group           79.5% choosing this option as either
strategies with the vast majority find-   discussion and classroom training          their first or second choice. Self-
ing these somewhat effective or very      methods are also seen as effective         paced training was the least favored
effective. The least popular format       strategies for training. Methods em-       option. A number of training alter-
for training was taking notes or read-    phasizing self-paced training such as      natives were recommended. Many
ing. It is worth noting that only         assigned readings, online courses and      respondents favored didactic meth-
36.1% thought video games and             workbook exercises appear to be less       ods that were coupled with interac-
computer simulations would be a           favored. Computer based simulation         tive sessions, especially hands-on
very effective learning format.           methods fall somewhere in between.         motor skills and lab experiences.
Nearly all respondents favored a          Another question that appears later in     One person wrote, “learn one, do
combination of more than one format       the survey asks if respondents believe     one, teach one,” suggesting that
for training.                             that aeromedical evacuation training       trainees should perhaps learn first in
    In addition to format, the survey     should include human simulation            the classroom, practice their new
also included questions about train-      training. Essentially all of the respon-   skills, and then teach someone else.
ing methods. Table 1 show percent-        dents believe that training needs to be    Some favored augmenting lectures
ages for perceived effectiveness for      active and that participants should be     with multimedia options including
the various methods proposed.             able to engage in physical activity,       on-line work, podcasts, and videos.
Qualitative comments in several sec-      scenario-based training. See Table 1.          The survey also included ques-
tions of the survey emphasize a           Respondents were asked to order            tions regarding which method of re-
strong preference for applied activi-     three training options according to        tention would be most effective.
                                                                                     Most respondents favor having bian-

                              Table 1: Perceived effectiveness of Training Methods
                                                                              Perceived Effectiveness
                                                                           Not       Somewhat         Very
                               Proposed Training Method                 Effective     Effective    Effective
                               Scenario Simulation Exercises          1.9           15.7          82.4
                               Group Discussions                      3.0           40.3          56.7
                               Classroom Settings                     1.5           46.4          52.1
                               Computer Simulation Games              10.9          48.0          41.1
                               Workbooks/Training Manuals             16.1          61.7          22.2
                               Online Courses                         18.6          63.7          17.7
                               Text-based Reading                     26.8          61.4          11.8

                                                           4
nual refresher course designed to keep
                                                 Table 2: Barriers to Training
information up to date. On-line tutorials
were a distant second choice and was               Barriers Making Training Inconvenient
only slightly preferred over receiving a                                                                      %
printed reference text containing up-              Costs - too expensive                                     71.0
dated information. Throughout the sur-             Ineffective, boring training methods                      62.2
vey, respondents consistently favor face
-to-face training methods over self-
                                                   Amount of time needed                                     49.7
paced training methods. Video gaming               Travel to training locations                              47.8
formats designed to review and update              Redundancy of information                                 25.7
training information was the least fa-
vored option. Although not accounted               Other                                                      4.9
for directly in the survey results, it may
be that some respondents are less famil-     issue affecting training participation is
iar with more recent video gaming            the amount of time required to partici-     self-paced methods are not fa-
simulation technology. These findings        pate in training. The first and third       vored. Respondents want to see
could evolve as these choices become         factors are possibly related since train-   more lively and energetic ses-
more widespread.                             ing time is essentially downtime for        sions with significant opportuni-
    Next, respondents were asked to          that employee. Ordinarily an extra          ties to practice their new skills.
identify the main factors that make any      person has to be brought in to replace      Some of the other barriers men-
type of training inconvenient for them.      the individual who is out for training.     tioned include: too few options
The most common barrier to participat-       The second issue of ineffective and         for attendance, the inconsistency
ing in training are the costs to partici-    boring methods should be considered         of training content, poorly
pate. There also seemed to be signifi-       carefully as future training strategies     planned simulation exercises,
cant concern about ineffective and bor-      develop. Respondents are weary of           and too much required reading.
ing training methods. The third leading      ineffective and boring trainings and        See Table 2.

Other Training Programs for Civilian Responders and Military Personnel

Thirty-six respondents (7.4%) said they were aware of some structured disaster related training to help civilian re-
sponders work with military personnel. They identified the following training programs:

   •   Basic Disaster Life Support and Advanced Disaster Life Support – see www.ndlsf.org
   •   Centers for Disease Control, Environmental Health Training in Emergency Response (EHTER) – See
       www.cdc.gov/nceh/ehs/workforce_development/EHTER.htm
   •   Military Emergency Management Specialist (MEMS). This is provided through the State Guard Association
       of the United States (SGAUS). http://www.sgaus.org/training/mems.html
   •   Metropoltian Medical Response System (MMRS) Especially useful for patient tracking. See http://
       www.bt.cdc.gov/
   •   National Disaster Life Support Classes (CDLS, BDLS, ADLS, NDLS-Decon) are approved through the
       AMA. www.ndlsf.org
   •   Prehospital Trauma Life Support, Counter Terrorism and Narcotics Operations Management (CONTOMS )
       – See http://www.acep.org/
   •   Tennessee, Indiana, Kentucky, Illinois, and Missouri – Military Assistance, Safety, Traffic (TIKI-MAST) –
       See http://tikimast.org
   •   World Health Organization (Violence & Injury Prevention Program and Essential Surgery Program), USAID/
       OFDA (PEER & HOPE courses), Especially for emergencies & disasters that meet the criteria of the new
       International Health Regulations. See violence_injury_prevention/services/traumacare/traumaguidelines/en/
       index.html

                                                             5
Conclusions

    The survey respondents have identified a number of       also less desirable Videos are fine as supplemental
challenges and opportunities for those who are develop-      training tools.
ing the curriculum Civilian Aeromedical Evacuation               There were numerous helpful comments and rec-
Sustainment Training. First, there is widespread agree-      ommendations that should be carefully considered
ment that additional training is needed. This is sup-        during the curriculum design process. The appendix
ported by the respondents’ self-reflection on their train-   section on the next two pages includes paraphrased
ing needs and their perceptions of others’ training needs.   suggestions from the qualitative data collected. Each
Most people feel most comfortable with their levels of       one of those included poses questions and unique
training for more common disaster scenarios (i.e.,           observations from these professionals.
weather related, mass casualty traffic events) and least         Extra expenses and the amount of time required to
comfortable with terrorism related events, earthquakes,      attend trainings are pressing concerns. Many respon-
and biological threats.                                      dents favor allowing training to be included as part of
    The most common concerns in dealing with civilian        their continuing education requirements. Some re-
medical personnel and military transport and evacuation      spondents are also interested in developing more
activities are communication and chain of command.           grant resources to help support training efforts. An-
How can the differences in goals, roles, and expectations    other challenge for curriculum designers will be in-
be bridged? How will differences in jargon, equipment,       formation retention and ensuring that training reflects
and standard operating procedures affect patient care?       the most recent threat information.
There are many unanswered questions and there is con-            Several promising training programs already ex-
siderable anxiety amongst civilian and military profes-      ist. A sampling of these are included in the report
sionals.                                                     and should be systematically reviewed. Several re-
    Respondents in this convenience sample favor hands       spondents mentioned there are often conflicts be-
-on mock event training, and mixed presentation formats      tween the various training materials. Every effort
are preferred. Self-paced training, especially workbook      should be made to ensure best practices are being
formats and other strategies that require significant        followed.
amounts of reading were criticized. On-line options are




                    For more information about the Midsouth Survey Research
                               Center or about this survey, contact:

                                         Wayne J. Pitts, Ph.D.
                              Director, Midsouth Survey Research Center
                               School of Urban Affairs and Public Policy
                                          University of Memphis
                                             1-901-678-5662
                                          wpitts@memphis.edu
                                                         6
Appendix A: Recommendations for Training Content
                                                     • Military medics are great when treating 18-30 year old, fit soldiers
    Is there anything else that you                     that are injured - pediatric patients and older adults with co-morbidity
                                                        concerns are another matter.
    think we should consider regard-
                                                        • We all need to be trained in the same Incident Command System.
    ing the content of any proposed
                                                        • Utilize an “All-Hazards” approach.
    training curriculum?                                • Because the possibility of chemical and biological weapons of
                                                        mass destruction are a real threat, all participating should be well
                                                        trained in dealing with this type of attack.
•    Both the civilian and military personnel should receive this standard national training and be licensed the same.
•    We need to understand the care, food and shelter of those who are not ill or injured and the evacuation of them.
•    Civilians must be trained on the medical equipment and techniques used by the military.
•    Cohesive planning and logistics are needed for all groups involved.
•    Utilize common datasets, standards, and terminology.
•    Communication of orders (Who gives the orders and what are their practical qualifications? Do they really have the
     experience to be giving the orders?)
•    Content needs to cover more than the 'standard' things we get as part of alphabet
     soup (ITLS, PALS, ACLS, BLS, etc).
•    Training should include issues of dealing with nonmilitary personnel at nonmilitary
     facilities.
•    Dealing with psychological trauma is important—sometimes the emotional aspects
     are over-looked.
•    Describe proper patient movement and give examples of military litters.
•    Describe what a Flight Surgeon does in an Air Evacuation capacity.
•    Plan for different resources and staffing levels at night and on the weekends.
•    During an emergency, first responders must make rapid decisions to protect their community’s safety as well as
     their own. Should they evacuate the area? How many blocks should they evacuate? Should they don protective
     equipment?
•    It is imperative to understand equipment hand receipt procedures and chain-of-custody procedures.
•    Everyone has to understand how significant and important dysentery is in a shelter.
•    One of the worst things I have seen at disaster scenes is the overabundance of people. That usually leads to
     some type of freelancing and then you have the problem of accountability.
•    What are the expectations related to communication with family members of responders?
•    FEMA IC classes (the 100/200/300/400) preach the importance of plain language and no jargon/codes. The mili-
     tary is still very reliant on this and it should be addressed.
•    Fire and rescue need to work/train side by side for training.
•    Fire is a paramilitary structured organization, yet the military does not recognize our ICS system. Bridging this gap
     would be beneficial.
•    First responders need to understand that all credible threats, even if they test negative, need to be sent to a labo-
     ratory for confirmation to avoid false negatives.
•    Are there any financial resources or grants available to obtain additional training?
•    Great focus should be placed on symbiotic relationships between civilian health care professionals and military
     personnel.
•    HIPPA is always an issue, but it helps to know what was done, what worked and what didn't.
•    How are we covered for malpractice in disaster settings?
•    How can we forecast the needs of the next 48 hrs not just the current crisis?
•    How can we use all agencies involved and their resources to their full extent? There is no need to call for 100 and
     actually on use 25 of them.

                                                               7
•   How will Public Health be protected during the first response and clean up of the site?
•   I feel a curriculum should include a variety of exercise involving a multi agency response.
•   Identify treatment options that require electricity or other electronic resources.
•   If not injured, we have to know their BIG problems that will become problems without meds.
•   If we are working a natural disaster, what do we do with the children who are not hurt, but
    who may have lost parents?
•   Include a copy of the paperwork that a Flight Surgeon would use to move a patient.
•   Include the Global Patient Movement Resource Center (GPMRC) requirements for move-
    ment including a list of approved and unapproved devices for flying.
•   Training should emphasize infection prevention in temporary conditions.
•   Interface with bioenvironmental/HAZMAT teams and decontamination is a critical component.
•   Training should involve all hospital staff - not just emergency dept staff.
•   Knowing the other's method of care would broaden my own knowledge base with the cross training.
•   Landing and loading procedures are important. Lock down procedures should be covered.
•   Most state plans do not include anything under ESF regarding the pediatric patient. We cover pets, but not kids.
•   Needs to cover the 'fringe' items that those courses won't cover such as management of a tent hospital, care for pedi-
    atric patients, mental health needs secondary to a disaster, recognition of disaster related 'emergent' conditions
•   Patient tracking is super important.
•   It is important to consider principles and practice of public health surveillance in complex emergencies (where civil
    strife is present or possible).
•   Review the procedures for casualties. What are the nurse specific duties in mass casualty situations?
•   Include issues of prolonged care in disaster area alternative care sites.
•   What are the responsibilities of the Treatment Group Supervisor? When should there be an actual treatment area vs.
    just using the area where the patients are as the treatment area?
•   What would the role be for quasi-military agencies, (e.g., local agencies)?
•   Search and rescue response on how to locate victims in a disaster should be included.
•   Standards for manufacturers to assure that instruments detect analytes at the level required to assess potential human
    impact should be considered.
•   The simple things like contaminated water are important. We can't use that water to clean a wound. For elderly people
    with ulcerated feet in a shelter, this isn't the time or the place to unwrap those. This isn't the emergency.
•   The training (and maintaining it) will save lives that maybe lost due only to poor training efforts. We work on the earth
    quake fault line, and we do not have any earth quake drills of any kind. Furniture is not stabilized through out the hos-
    pital—these issue need to be addressed.
•   The training should be conducted with civilian and military personnel together to know what is expected of both
•   There should be disaster scenarios in various locations, even in high-rise buildings.
•   Too many times, we all focus on the large scale incident when many communities struggle with handling the simple,
    small scale incident. And in many cases, this is exactly where large scale disasters occur, in smaller communities.
•   Train the responders to use options not requiring electricity or other electronic resources.
•   Training needs to be simple enough that it can be remembered because it will not be used frequently.
•   Cover issues related to validation under variable field conditions (vs. pristine, highly-controlled laboratory conditions).
•   What I learned on 9/11 is that the FDA regulates blood donations. NO one who hasn't been through that 2 week train-
    ing can do anything to help with blood donors. There is no point in nurses or physicians going to help at these local
    blood donation centers. Clarify this point in the curriculum.
•   Without training, sample material may be depleted resulting in loss of criminal evidence and the ability to conduct ap-
    propriate laboratory testing.
•   Consider issues where WMD considerations/terrorism may be involved, or where martial law could be imposed.
•   I would like to see trainings at different times of the day and some a night; very seldom are there drills at night.
•   Write out a training curriculum that is as brief as possible and covers everything in easy-to-read and understandable
    English. Any responder should be able to pick it up, read it, and know the basics of what to do in each situation.
                                                                   8

				
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