Ground Team composition

[SARMedTech]

Yes, absolutely QuikClot and let the surgeous scream. However, here in Illinois, Oxygen, however delivered is a med which requires a scrip or EMS agency licensure to give it. Under CAP regs, we cannot use it in the field. By definition, when you administer any substance to a patient by any method you are giving a medication (other than water of course which should be given very sparingly in the field). Though its stupid, with CAPR's as they now stand, we cannot give oxygen in the field.

[SARMedTech]

Thanks for reminding me of the name of the Asherman. I know my medic friend in the Sandbox uses them all the time, I just couldnt remember the name and of course, Illinois EMS being what it is, alot of regional medical directors dont want to use them.  I also carry the broncho-dilator inhalers to be used in lieu of epi, but how do you personally recommend adjusting the does (to dose equivalent epi of .15mg 1:1000). I dont mind giving an adult a full blast, but at not sure how you would accurately adjust the dose for a child with a metered dose inhaler. Please advise. Also, here in IL except in extreme emergencies, epi is a "patient assisted"medication, meaning we technically dont administer it, we "help them" and also we dont "technically" carry it on the rigs. Same with activated charcoal, which has in fact been taken out of the protocol in IL since it was "messing up the rigs" when it came back up which it does about 90% of the time.

Thank you, sir, and I look forward to your reply.

Semper Vigilans!

[RogueLeader]

Though its stupid, with CAPR's as they now stand, we cannot give oxygen in the field.

I am not a medic/EMT, just have first aid; but if I had a patient that need 0₂ to live, Darn the regs, patient is getting 0₂.

[SARMedTech]

1. I agree with you totally.
2. If a licensed EMT or medic gives 02 in the field with no standing orders or medical direction or liabilty coverage from CAP, said EMT will likely lose his license and find himself on the business end of a law suit.
3. The necessary changes can be made so that EMT and Medics enrolled in CAP can actually do what they are trained to do. Its a matter of money. A SAR organization where I lived in NM is a tiny fraction of CAPS size and they have medical staff, liabillity and medical direction. Simply put, there is no reason for CAP not to follow suit except for not wanting to spend the money.
4. Who among us wants to make the knock on the door in the middle of the night to say "Ma'am, on behalf of the US Civil Air Patrol, it is my duty to inform you that your son/daughter, husband, wife has lost their life while serving their country because adequate medical resources were not provided to our medical officers in the field. Im sorry...our hands were tied by antiquated regulations. Lets also get a working definitation of emergency stabilizing first aide and we might find that airway adjuncts, etc fit the bill and that would be a giant leap forward as would CAP EMTs and Medics being able to carry glucose, glucagon and epi...but I dont want to get ahead of myself.

Quite simply, we cant wait anymore, wringing out hands and saying it will never happen. It must happen. That being said, if there are those of you who are first responders, EMTs or Medics who work with GTs and would like to see these regs changed, please contact me via PM and lets see what we can do to get CAP to live up to its responsibility to its members the people it may find during a SAR actual. The time for waiting is over. The time for action is now. Thank you for listening and Semper Vigilans!

[RogueLeader]

UH RAH!!

[Major Lord]

Thanks for reminding me of the name of the Asherman. I know my medic friend in the Sandbox uses them all the time, I just couldnt remember the name and of course, Illinois EMS being what it is, alot of regional medical directors dont want to use them.  I also carry the broncho-dilator inhalers to be used in lieu of epi, but how do you personally recommend adjusting the does (to dose equivalent epi of .15mg 1:1000). I dont mind giving an adult a full blast, but at not sure how you would accurately adjust the dose for a child with a metered dose inhaler. Please advise. Also, here in IL except in extreme emergencies, epi is a "patient assisted"medication, meaning we technically dont administer it, we "help them" and also we dont "technically" carry it on the rigs. Same with activated charcoal, which has in fact been taken out of the protocol in IL since it was "messing up the rigs" when it came back up which it does about 90% of the time.

Thank you, sir, and I look forward to your reply.

Semper Vigilans!

The general thinking is that you need to administer 10-12 or so full oral doses with an OTC inhaler to reach (adult) EPI pen dose levels. The problem is, in actual anaphalaxis, the patient does not want to breath at all, so the question in acute anaphalaxis is moot. You need IV or Sub Q Epi at that point. For initial onset stages, when the patient has uticaria, dyspnea, and looks bad, start the patient on as many OTC inhalations as they can manage. (within reason)  If they can still swallow benedryl, use it before they arrest.
For kids, start with a single dose unless the attack is so severe that respiratory arrest is likely. Listen to their lungs and titrate the dose as required. Status Asthamaticus can be dealt with in the same way.

Epi pen makes an adult and a Jr size. The administration of a full size adult dose of EPI to a child would be bad. On the other hand, to start with a small dose of epi on an adult is not a bad thing. If an adult has a bad heart, EPI can double-dog  kill them ( stop me if I am getting too technical here) Starting with oral or IM benedryl is safe if you have EPI as a backup.

FYI, an EPI pen costs about $100.00 these days. You can buy EPI for horses, which is the same product in a brown bottle for about $3.00 an ounce....it would be wrong to use an unapproved product on a human, so try it with a Senior Member first. We have lots of Lt. Cols with shakey tickers...

On the O2 issue, those people who have not been trained in 02 therapy shoul dknow that O2 can diminish or eliminate the respiratory drive in certain patients ( COPD) and once you start o2 , you pretty much need to follow the case to the end.

There has been so much negativity about providing medical care of any kind in CAP, I  would suggest that you just let your CAP member die in an orderly and proficient Air Force manner rather than actually rendering aid. We can always send out one of our highly trained and experienced Critical Incident Stress Counselors to help you deal with your guilt....

Capt. Lord

Tags - MIKE

[sarmed1]

There are places out there that O2 is considered a by stander item, in a local mall here in PA we have a number of AED cabinets that also have small o2 tanks in them, the tank turns on as soon as its removed from the case (so I hear, havent actually seen it happen) and starts flowing at 8LPM, with a simple mask pre- attached.

The Kendrick traction device is a tent pole looking kind of assembly that is used as a traction splint.  It usues mechanical traction from tensioning up the foot strap to eaqual manual traction.  When dis-assembled it fits in a 5 x 7 ish pouch.  Packs nicely into your aid bag.  Its a standard thing in most of the AFSOC bags, along with the asherman's, quick clot, chitosen dressings, CAT tourniquest and a much better fluid for volume replacement.  Hextend...its a uber-cool hypertonic solution, that stays in the vcascular space much longer than saline or ringers (800 out of 1000ml after 2 hours vs 200 of 1000 LR in the same time frame if I remember correctly) Also we have switched to the Israli dressings over the battle dressings.
In the Spec Ops land we have these really cool BVM's that crunch down small and yet still pop back to normal size even after a long time in storage (just carry a pedi size mask and you're good to go)

Personal on the rest of the kit listing I would just carry 1 size tape, Duct for me peronally but in EMS land a roll of 2" would suffice (you can rip off 1" sections if you really need it) Also I woudl forgo the bandage scissors, EMT shears are good enough for all around use.  I would add something like saline bullets for wound irrigation, easier on weight and space than the large bottles and doesnt eat up your supply of IV fluids.

mk

[SARMedTech]

There are places out there that O2 is considered a by stander item, in a local mall here in PA we have a number of AED cabinets that also have small o2 tanks in them, the tank turns on as soon as its removed from the case (so I hear, havent actually seen it happen) and starts flowing at 8LPM, with a simple mask pre- attached.

The Kendrick traction device is a tent pole looking kind of assembly that is used as a traction splint.  It usues mechanical traction from tensioning up the foot strap to eaqual manual traction.  When dis-assembled it fits in a 5 x 7 ish pouch.  Packs nicely into your aid bag.  Its a standard thing in most of the AFSOC bags, along with the asherman's, quick clot, chitosen dressings, CAT tourniquest and a much better fluid for volume replacement.  Hextend...its a uber-cool hypertonic solution, that stays in the vcascular space much longer than saline or ringers (800 out of 1000ml after 2 hours vs 200 of 1000 LR in the same time frame if I remember correctly) Also we have switched to the Israli dressings over the battle dressings.
In the Spec Ops land we have these really cool BVM's that crunch down small and yet still pop back to normal size even after a long time in storage (just carry a pedi size mask and you're good to go)

Personal on the rest of the kit listing I would just carry 1 size tape, Duct for me peronally but in EMS land a roll of 2" would suffice (you can rip off 1" sections if you really need it) Also I woudl forgo the bandage scissors, EMT shears are good enough for all around use.  I would add something like saline bullets for wound irrigation, easier on weight and space than the large bottles and doesnt eat up your supply of IV fluids.

mk

The device you are talking about sounds like a Hair Traction Splint to me...maybe I am just misunderstanding.  I like the chitosan dressings, but you need to make sure to ask your patient if they are allergeic to shellfish, since chitosan is derived from the shells and rubbery connective tissue of crabs, lobsters, etc and I have read studies about it triggering anaphylaxis.

Yes youre right about eliminating the bandage sheers. No real need for them if you are carrying trauma sheers. As a side note, I was given a pair of Big Shears (TM) as a gift. They are the super heavy duty buggers that will cut 1/2 leather, kevlar and have handles that are heavy and sturdy enough to break glass if need be. The only draw back is the cost: about $100 for 1 set. It sure seems worth it when you have to cut off a bikers full set of leathers though (you may also wish to carry a firearm as I have found that bikers do not wish to have their leathers cut...especially if they have their "club" colors on the back.

Obviously for EMTs in CAP, we arent carrying saline IVs. Do you know of a supplier for the saline bullets? My rig carries IVs, saline "bottles" for irrigation, and sterile water for irrigation. Any info you could give me on the "bullets" would be appreciated in a PM.

Is the Hextend available commercially?

I also carry Israeli dressings over battle dressings when i can get them.

Thanks for all of your suggestions. I would like to discuss them with your further in a PM if you dont mind.

[sardak]

The device you are talking about sounds like a Hair Traction Splint to me...maybe I am just misunderstanding. 

The only similarity between a Hare(R) Traction Splint and a Kendrick Traction Device (TM) is the traction function.  The third common type is a Sager(R) Traction Splint.  The design of all 3 is different, with the Sager and KTD being similar to one another, but the function is the same.

The non-CAP SAR team I'm on has all three.  The Hare doesn't leave the rescue trucks except for trainings where the truck is handy.  There is a KTD in each of our med packs, since as mentioned, they collapse into a small pouch, and the Sager goes in the field often.  We need traction devices several times a year.

Google each device to see the differences.

Mike

[SARPilotNY]

Mike...I say bring back the old half ring splint.  Cheap, nothing moves, all you need is the multi purpose triangular bandage.

[SARMedTech]

Just for clarity sake and (for once) not meaning to be a nit picker-

The idea that "nothing moves" in a splint, or in most field splints, is not really true. They certainly restrict motion, or unwanted motion of a broken bone, but they do not immobilize it entirely. This has also been noted in the names of our old friend the c-collar. The device and the technique of using it are no longer referred to as "spinal immobilization" but rather SMI or "spinal motion restriction" a name meant to reflect the best case scenario for use of the device. The reason for the change was that EMS agencies were getting sued as were manufacturers of various C-collars because they were making the claim of immobilization. Even the best collar, well applied and secured with either a head bed or towel rolls, etc allows for c-spine motion of fractions of an inch. The same is true of splints. As to what kind of splint, my favorite for SAR still has to be the time tested SAM. Lightweight, easy to carry, moldable and cuttable to a variety of circumstances and needs. I think I saw somewhere the recommendation for cadets was to carry the old wire splints, which in my experience, are just this side of useless. Fine in a pinch and certainly cheap, but you do get what you pay for, and I dont know that I would want to rely on them for more than one use, since what your essentially using is chicken wire. The SAM can also be fairly effectively cleaned for re-use with a solution of water and bleach in a ration of 13:1 respectively. Much more than that, while perhaps providing more cleaning power tends to degrade some of the padding materials on the SAM.

[sarmed1]

how about the v-notch board splint for traction purposes....thats really old school.


mk

[SARPilotNY]

When was the last time anyone in CAP carried out a survivor of a plane crash without activating and using 911/EMS?  My experience is that survivors won't live or die based on what CAP does in the next hour.  Either they are stable or in shock, the latter usually results in death sooner or later.  To carry someone out any distance usually requires more people than we have.

[SARMedTech]

When was the last time anyone in CAP carried out a survivor of a plane crash without activating and using 911/EMS?  My experience is that survivors won't live or die based on what CAP does in the next hour.  Either they are stable or in shock, the latter usually results in death sooner or later.  To carry someone out any distance usually requires more people than we have.

These are the kinds of discussions I truly enjoy, in large part because my (in progress) masters degree is in the field of disaster medicine. Lets look at your questions individually:

1. I dont know. Ive asked this question in a few different places but havent really .gotten any responses.

2. Addressing that 1 hour: As has been previously stated in can be some time before CAP gets to a crash site and gets to the pilot. Adding time for things like extrication, an assessment by a HSO with the ground team to determine whether or not the pilot should be moved or not and if you have a pilot in shock, you are looking at a significant period of time. That being said, I should think that the likelihood of a pilot who has survived a crash being in some type of shock would be relatively high, but...

3. We have to ask what type of shock? Given that shock is defined in general terms as inadequate perfusion at the cellular level, ie the exhange of co2 and oxygen, for our purposes we should think of the two biggest categories of shock: compensating and decompensating. In the first, a state of shock exists but the person's physiological functions are such that they are still strong enough to withstand the effects of this insufficient perfusion. In decompensating shock, this is not the case and a person's chances of living are decreasing over time. We could sort of think of it as a person who faints or passes out and recovers is in compensating shock. A person who is shot or otherwise otherwise severely injured and losing  blood, either internally or externally sufficient to cause unconsciousness with out recovery is not compensating and will almost certainly die over time if emergency interventions are not performed.

4. The pilot or other victim living or dying depending on what CAP does in the next hour: how long ago was the person injured and when does CAP encounter them, thus starting the above mentioned hour. The golden hour (the time between injury and corrective medical measures (generally, surgery) has almost certainly passed. Now the question becomes how soon is EMS activated, how soon do they reach the patient and how soon are they able to begin medical intervention. Here's where CAP comes in...

5. Lets say that our pilot has crashed his a/c in a heavily wooded area such that EMS cannot get to him directly, ie they cannot get to him directly by ambulance nor by helo. Now CAP is in a situation of having to "evacuate" that patient. Assuming that there is a HSO on the ground team with sufficient skills to stabilize the patient, given that per regs we cannot start IV fluids, give meds, etc, stabilization would essentially consist of getting that patient onto some form of stretcher, litter, backboard, etc, into a c-collar and evacuating them by carrying them out to such a point where EMS can access them. Lets say this distance is a mile. Given that an unencumbered adult male can cross 3 miles on foot in one hour, this evacuation would would take approximately 20 minutes. Of course we have to factor in how heavy the patient is, on what they are being carried, the terrain, how many GT members we have, etc.

The long and short of it is, CAP accessing that injured pilot could well mean the difference between life and death. There are so many factors that act as variables, but the one thing that is not variable is that if a patient is in decompensating shock, the WILL die. If CAP is able to carry that patient out, access EMS and emergency interventions including IV access are able to be achieved, that patient may well live.  If there is a HSO who is an EMT or medic on that GT, the odds of survival increase. If that EMT or medic is able to stabilize the patient even a little, the odds of survival increase again.  So yes, what CAP does can make the difference between life and death for the injured pilot. While it could be difficult depending on the abilities, strength and physical capabilities of the individual GT members, 4 people would be sufficient to carry an injured person. It is possible with three, and very difficult but possible with only 2 depending on type of litter or stretcher. We are almost certainly going to have more than two people on a GT. If we have an entire search line, and the patient can be transferred between GT members as they become tired, getting that pilot out over the above mentioned 1 mile is well within our capabilities. What CAP does after finding that injured pilot increases his chances of survival exponentially. If bleeding is stopped, chances go up. If respiratory assistance is necessary and can be  provided via bag valve  (which is why I carry one in my pack) or mouth to mask  methods chances go up.

Quite simply, the mere act of finding that downed pilot increases his likelihood of survival. Remember, if he is in shock and his body can still compensate, simple fluids given by mouth from a canteen can increase the chance of survival.

[SARPilotNY]

Bravo...good answers but my experience with a Stokes litter or equivalent over rough, rocky, brush covered terrain would be different.  My dream team:  (remember, even the FAA has upped the weight of a pilot to 200 pounds)  8 persons on the litter, 8 for relief and 8 extras for lifting over rocks, getting through heavy brush, carrying hand over hand up slope , carring the kits and supplies.  One mile, at least one hour.  The only way to get 24 folks is find a fire department hand crew or two, good luck in the winter.  Our "first alarm" rescue response is 2 engines, (medic) 1 truck, 1 rescue (transport capable box) one ambulance and a chief.  17 people than minus the chief...too old to be doing this.  If we had that type of a hike w/o any helo, go for a second...now that is luxury!  My greatest fear in SAR is finding a survivor, it changes everyone's plans and makes everything go sour.  As a rescuer what  is a bad plane crash is?? ? one with a survivor a mile or two from the road.
In my CAP experience with survivors is that the ones that did survive, survived in spite of what little we did (blankets, reassurance, comfort) once we made contact with them.  Those that died were so far gone that   there was no chance for their survival.  Airway management was useless since PPV was impractical, suction almost impossible, BP and core temp 86P86degrees...

[SARMedTech]

Bravo...good answers but my experience with a Stokes litter or equivalent over rough, rocky, brush covered terrain would be different.  My dream team:  (remember, even the FAA has upped the weight of a pilot to 200 pounds)  8 persons on the litter, 8 for relief and 8 extras for lifting over rocks, getting through heavy brush, carrying hand over hand up slope , carring the kits and supplies.  One mile, at least one hour.  The only way to get 24 folks is find a fire department hand crew or two, good luck in the winter.  Our "first alarm" rescue response is 2 engines, (medic) 1 truck, 1 rescue (transport capable box) one ambulance and a chief.  17 people than minus the chief...too old to be doing this.  If we had that type of a hike w/o any helo, go for a second...now that is luxury!  My greatest fear in SAR is finding a survivor, it changes everyone's plans and makes everything go sour.  As a rescuer what  is a bad plane crash is?? ? one with a survivor a mile or two from the road.
In my CAP experience with survivors is that the ones that did survive, survived in spite of what little we did (blankets, reassurance, comfort) once we made contact with them.  Those that died were so far gone that   there was no chance for their survival.  Airway management was useless since PPV was impractical, suction almost impossible, BP and core temp 86P86degrees...

I didnt realize you were also an EMT. BTW, the core temp considered unrecoverable is 80f. At 86, passive re-warming is key. Once the temp has reached 90, active rewarming should begin. Also, unless you are taking temps "the old fashioned way" you arent getting what are medically considered core temps. Why on gods earth are you involved with search and rescue. You should be involved with search and recovery because you apparently have neither the interest the knowledge or skills, nor grasp of reality do be of any good on a ground team. Do me a favor...stay away from any SAR team I am a part of.

[SARPilotNY]

Bravo...good answers but my experience with a Stokes litter or equivalent over rough, rocky, brush covered terrain would be different.  My dream team:  (remember, even the FAA has upped the weight of a pilot to 200 pounds)  8 persons on the litter, 8 for relief and 8 extras for lifting over rocks, getting through heavy brush, carrying hand over hand up slope , carring the kits and supplies.  One mile, at least one hour.  The only way to get 24 folks is find a fire department hand crew or two, good luck in the winter.  Our "first alarm" rescue response is 2 engines, (medic) 1 truck, 1 rescue (transport capable box) one ambulance and a chief.  17 people than minus the chief...too old to be doing this.  If we had that type of a hike w/o any helo, go for a second...now that is luxury!  My greatest fear in SAR is finding a survivor, it changes everyone's plans and makes everything go sour.  As a rescuer what  is a bad plane crash is?? ? one with a survivor a mile or two from the road.
In my CAP experience with survivors is that the ones that did survive, survived in spite of what little we did (blankets, reassurance, comfort) once we made contact with them.  Those that died were so far gone that   there was no chance for their survival.  Airway management was useless since PPV was impractical, suction almost impossible, BP and core temp 86P86degrees...

I didnt realize you were also an EMT. BTW, the core temp considered unrecoverable is 80f. At 86, passive re-warming is key. Once the temp has reached 90, active rewarming should begin. Also, unless you are taking temps "the old fashioned way" you arent getting what are medically considered core temps. Why on gods earth are you involved with search and rescue. You should be involved with search and recovery because you apparently have neither the interest the knowledge or skills, nor grasp of reality do be of any good on a ground team. Do me a favor...stay away from any SAR team I am a part of.

No...I  am worse than an EMT...You missed the point w/ VS, this victim needs immediate ALS to survive, not BLS.  Yes...I would be useless on a ground team because all my training reverts to BLS since I would otherwise be working outside  of my scope.  My problem must be that I know my limitations, know my teams limitations and now the laws and rules that govern our ability to render aid.  And yes with CAP, most of what we do is a.  search and silence, b. search and recover, run across the vehicle accident and treat/assist and d. search and rescue.  Do you get much of any of these?  Trust me, I will  be miles in front of you and the SAR team you are on.  By the time you get there you can pick up the biohazards if you want.  And if you do crash in an aircraft (do you fly or are you even on a team) and want somebody to find you, you will wish that me and our team are looking for you.  OK, I give up...how many distress finds and CAP saves do you have?  How many missions do you go on a years?  Ante up or fold.
BTW, I just think of myself as an underpaid doctor.

[pixelwonk]

[SARMedTech]

Bravo...good answers but my experience with a Stokes litter or equivalent over rough, rocky, brush covered terrain would be different.  My dream team:  (remember, even the FAA has upped the weight of a pilot to 200 pounds)  8 persons on the litter, 8 for relief and 8 extras for lifting over rocks, getting through heavy brush, carrying hand over hand up slope , carring the kits and supplies.  One mile, at least one hour.  The only way to get 24 folks is find a fire department hand crew or two, good luck in the winter.  Our "first alarm" rescue response is 2 engines, (medic) 1 truck, 1 rescue (transport capable box) one ambulance and a chief.  17 people than minus the chief...too old to be doing this.  If we had that type of a hike w/o any helo, go for a second...now that is luxury!  My greatest fear in SAR is finding a survivor, it changes everyone's plans and makes everything go sour.  As a rescuer what  is a bad plane crash is?? ? one with a survivor a mile or two from the road.
In my CAP experience with survivors is that the ones that did survive, survived in spite of what little we did (blankets, reassurance, comfort) once we made contact with them.  Those that died were so far gone that   there was no chance for their survival.  Airway management was useless since PPV was impractical, suction almost impossible, BP and core temp 86P86degrees...

I didnt realize you were also an EMT. BTW, the core temp considered unrecoverable is 80f. At 86, passive re-warming is key. Once the temp has reached 90, active rewarming should begin. Also, unless you are taking temps "the old fashioned way" you arent getting what are medically considered core temps. Why on gods earth are you involved with search and rescue. You should be involved with search and recovery because you apparently have neither the interest the knowledge or skills, nor grasp of reality do be of any good on a ground team. Do me a favor...stay away from any SAR team I am a part of.

No...I  am worse than an EMT...You missed the point w/ VS, this victim needs immediate ALS to survive, not BLS.  Yes...I would be useless on a ground team because all my training reverts to BLS since I would otherwise be working outside  of my scope.  My problem must be that I know my limitations, know my teams limitations and now the laws and rules that govern our ability to render aid.  And yes with CAP, most of what we do is a.  search and silence, b. search and recover, run across the vehicle accident and treat/assist and d. search and rescue.  Do you get much of any of these?  Trust me, I will  be miles in front of you and the SAR team you are on.  By the time you get there you can pick up the biohazards if you want.  And if you do crash in an aircraft (do you fly or are you even on a team) and want somebody to find you, you will wish that me and our team are looking for you.  OK, I give up...how many distress finds and CAP saves do you have?  How many missions do you go on a years?  Ante up or fold.
BTW, I just think of myself as an underpaid doctor.

The fact is "doctor" that BLS saves lives. Airway, Breathing, Circulation. Without these, all of the ALS in the world is useless. As the post just before mine says, this seems to have turned in a contest by you. You dont think CAP saves lives? You dont think what we do is important? Then turn in your letter of resignation and get out. Im sure no one will try to stop you. Before joining CAP, I served with a private SAR organization in New Mexico and have participated in approximately 50 full blown SAR operations so far, all lasting 3 days or more with all of that time being spent in the field. About 43 of them involved "saves" of one type or another. in desert condition/extreme weather conditions and I teach advanced field first aide designed specifically for SAR operators. But they arent MY saves because I function as part of a team. A concept which seems to be a little foreign to you and your plane.

[RogueLeader]

To SARPilotNY: Since when are we allowed search and recover?  As having been told numerous times, when it is KNOWN that the subjects are beyond rescue, we are pulled off, and others take over.