First Responders Triage Victims To Save Lives
NEAL CONAN, host:
This is TALK OF THE NATION. I'm Neal Conan, in Washington.
After a gunman opened fire at a shopping center in Tucson, first responders arrived on the scene within minutes. Some focused on the shooter and security, others on the 19 victims and on a critical series of decisions and procedures known as triage: who needed attention immediately, who could wait until more resources became available, who was beyond help.
Though nine-year-old Christina Taylor Green did not respond to CPR, she was assigned immediate attention and was among the first to arrive at University of Arizona Medical Center.
First responders, doctors, nurses, what do we need to understand about the decisions and rules of triage? How do you deal with the choices you make? 800-989-8255. Email us, firstname.lastname@example.org. You can also join the conversation at our website. That's at npr.org. Click on TALK OF THE NATION.
As we mentioned, the treatment of nine-year-old Christina Taylor Green was among the first that had to be made after the incident at the shopping center. At the University of Arizona Medical Center, Dr. Randall Friese led aggressive attempts to save her life, and he joins us now on the phone from Tucson, where he is associate medical director at the University of Medical Center Trauma Center, and nice to have you with us today.
Dr. RANDALL FRIESE (Trauma Surgeon, Associate Medical Director, University of Arizona Medical Center): Good afternoon.
CONAN: And can you take us through your decision and why you decided not to give up?
Dr. FRIESE: Well, it was a fairly - a very quick decision, and in effect, for me, a very easy decision. She was arriving to my care, receiving CPR after a traumatic, penetrating injury. And if you have any chance to try to reverse that physiologic process, the treatment is very aggressive and immediate surgery.
She was our first patient. So I felt that we were certainly not overwhelmed as far as resources go, and I felt very comfortable with that decision.
CONAN: And that last part, not overwhelmed as far as resources go, you had to know more patients, though, were on the way.
Dr. FRIESE: Exactly. And I knew that the procedure is very fast, and if she did not have immediate response, I knew that being able to wrap it up quickly would certainly be an outcome if you didn't have a fast response.
CONAN: And how long did it, in fact, take before you had to make your decision?
Dr. FRIESE: That procedure is very rapid. Within - I would say within three to four minutes, you've achieved the goals of that procedure, and then you can see if the patient is responding within the next several minutes after that. I think we spent about seven minutes or so in the process.
CONAN: And next you had to go to another patient, who turned out to be Congresswoman Giffords.
Dr. FRIESE: That's correct.
CONAN: And what was her situation like?
Dr. FRIESE: Well, her situation was certainly severe. However, her hemodynamics, her blood pressure and heart rate, were very stable. And that, you know, we had to deal with a severe brain injury, but luckily, her physiology was normal. And it allowed us to have a little bit of time to assess her completely, get some basic tests, get her on a breathing machine and get her airway protected and then get her evaluated.
CONAN: And all the news that we've heard about her condition, you must feel some measure of pride that you and your team contributed to that.
Dr. FRIESE: We're just doing our job.
CONAN: Just doing your job. And some people might say: How do you do that, after a nine-year-old girl dies on the table, and then you immediately have to turn and work on someone else?
Dr. FRIESE: It's just a measure of being focused. It's just a measure of compartmentalizing, knowing what's important and getting done. And I have to admit, you know, the emotion of it all comes a little bit later.
CONAN: A little bit later. It was obviously a very long day, though.
Dr. FRIESE: Certainly.
CONAN: As you think about it, were you and your team members, and it's important to remember this is not just you alone...
Dr. FRIESE: Exactly.
CONAN: Were you and your members of your team, do you think you were properly prepared? These can't come along every day, these decisions.
Dr. FRIESE: We - unfortunately, we do have situations where we have mass casualties or multiple trauma victims arriving at one time, usually not as many as 10, but certainly in the past we've had 10 and even higher.
Sometimes you'll have motor vehicle collisions where you have multiple injured patients. Usually, we're dealing with blunt mechanism. It's a little bit different, blunt mechanism evaluations than penetrating mechanism evaluations.
But we have certainly done multiple victims at one time, but this was certainly a stressful and challenging situation.
CONAN: And you mentioned 10, obviously 19 in all. Some never left the scene. Some went to other facilities.
Dr. FRIESE: Most of them ended up here. We are the only level one trauma center for Tucson. So even though some of the outside hospitals saw some patients and initially evaluated them, most of them ended up here, those that had significant injuries.
I'm referencing the initial seven, and then we had a couple after that arrive from other hospitals.
CONAN: And were you, again, with that experience and I guess it's sad to rack up that amount of experience, but does it sound like you were ever overwhelmed?
Dr. FRIESE: No, I think we were very fortunate in the most - the two most - and I have to commend Northwest Fire and our pre-hospital personnel for getting the two most critically injured patients to us in a very rapid fashion.
They did outstanding jobs with their decisions getting the patients to us by ground because sometimes getting them to us by ground is faster than getting a helicopter on-scene, and getting those patients to us so that we can be the most aggressive we can to try to reverse the physiology that's going on.
CONAN: And are they also feeding you information?
Dr. FRIESE: We get some information over the radio network. It came to me on my pager. Usually, we get - we actually got a heads-up information, probably at least 10 to 15 minutes before the first patient arrived that this was occurring.
And that's - we were very fortunate that we had two full trauma teams in the hospital. We could assemble those teams downstairs. We were very fortunate we had several residents, surgical residents that were able to help, and as well as the emergency room physicians were also very important in providing manpower for this event.
CONAN: As I understand it, you've talked about the car accidents and other events that have put your - have tested you and your team. But Christina Taylor Green's funeral, I gather, was the first that you'd attended.
Dr. FRIESE: That's true, yes.
CONAN: As one of your patients.
Dr. FRIESE: Correct.
Dr. FRIESE: I felt, I just wanted to get to know her a little bit more. I felt that her sacrifice was so very great. We had a team of people going to the funeral from the hospital. They invited me to come along, and I just took the invitation.
CONAN: After a terrible event, but again, as you say, not your first, how are things at the hospital this week?
Dr. FRIESE: Still quite out of the ordinary a little bit, but things are settling down some.
CONAN: I hope they continue to settle down. I hope you fall way out of practice.
Dr. FRIESE: I appreciate that. Thank you.
CONAN: Dr. Friese, thanks very much for your time today.
Dr. FRIESE: OK, bye-bye.
CONAN: Randall Friese, associate trauma medical director at the University of Arizona Medical Center and associate professor of surgery at the University of Arizona, with us today from his office in Tucson.
Dr. Michael Millin joins us now on the phone from Baltimore. He's an emergency physician at Johns Hopkins Hospital there and the medical director for the Baltimore-Washington Airport Fire Department, a disaster medicine expert who went to Haiti last year to treat victims of the earthquake, and nice to have you back with us today.
Dr. MICHAEL MILLIN (Emergency Physician, Johns Hopkins Hospital): Thank you very much for having me.
CONAN: And as you listen to Dr. Friese describe the decision process that he went through, is this the standard process of triage?
Dr. MILLIN: I would say absolutely. Really, the idea of triage is to categorize patients into three different categories. There's patients for which no matter what we do for the patient, the patient's going to live. There's patients for which no matter what we do for the patient the patient's going to die. And there's patients for which we have the potential to be the deciding factor and be able to intervene and prevent death.
It sounds to me - of course, I was not there at the scene and wasn't at the hospital. It sounds to me that Dr. Friese had a patient in front of him for which he felt there was a potential that he'd be able to save the patient's life and did what he had to do.
And then also, in a very quick time period, when he realized that that was not going to be the case, made a decision to go on so he could take care of the next patient, and that is absolutely the appropriate thing to do in triage.
CONAN: Of course, and also the part that he said he didn't think his resources would be overwhelmed.
Dr. MILLIN: Yes. And that's one thing one always has to anticipate, where one is at right there at the moment, as well as where one's going to be in the future. And so at the time that the child came to him, obviously the resources weren't strained, but I think he also knew in the back of his mind that the resources would probably become strained in a short period of time, which is, I would say, probably what contributed to his decision to initiate a resuscitation and do what he could and then also make a pretty quick decision when he felt like it was not going to be a successful resuscitation.
CONAN: It's interesting, also there are different levels of triage. Obviously, the first responders at the scene, they have to make those decisions, too.
Dr. MILLIN: Absolutely. There are really multiple levels of triage. As soon as we do a triage, we then are starting the next phase of triage. Triaging is ongoing all the time. There'll be times when we will triage a patient on a high level and then be able to move them down or vice versa.
It's a continuous event, not a one-time event. And it's really meant to be a very quick assessment and then a reassessment and a reassessment and ongoing reassessments. And a lot of that is because resources in an event are in fluid motion.
One has to be anticipating what resources are going to be yet also be realistic at what resources are at the moment.
CONAN: And realistic is - you've divided those three categories neatly. Obviously, there are big gray areas there, and that's where the problems ensue.
Dr. MILLIN: It is absolutely true. And those who are in the profession, as Dr. Friese and I are, as he said, at the moment, one becomes very focused. I absolutely agree with him, the emotions of an event usually take place after an event. During an event, we become very compartmentalized and very focused on to our job. But the reality is yes, it is very gray.
We try and keep it from being gray when we're actually in an event, but afterwards, as we start contemplating the decisions we make, we realize that they are absolutely very gray.
CONAN: The word itself, triage, it sounds French.
Dr. MILLIN: That is absolutely true. The word actually dates back to the French. The first studies of triage were in making decisions on the battleground during Bonaparte's time. So it really dates back many hundreds of years.
CONAN: And a principle that has been taught for many hundreds of years back.
Dr. MILLIN: That is correct, as well, and it's something we are ongoing teaching. And the science of triage really is also an evolution. There are many different methodologies to study triage and to use triage, and we are consistently trying to hone that down to make the best decisions we can.
So while we're always teaching triage, we're also continuously studying triage to try and get it better.
CONAN: And principles and rules, but every case is unique.
Dr. MILLIN: That is absolutely true that every case is unique. And as Dr. Friese said, there are definitely differences between blunt traumatic patients and patients who are injured from penetrating trauma. There's also differences between patients who are sick because of trauma versus because of medical issues.
The ideas of triage, though, the initial field triage is to be very quick, and we really make decisions based on physiologic findings: looking at someone's respiratory rate, their heart rate, what their mental status is and ability to walk. And all those things are things that are very quick and rapid and don't actually - they're affected by the physiology of what caused the injury, but they're, nevertheless, also more reflective of someone's baseline physiology and how well they're going to be able to respond to resuscitation.
CONAN: We're talking about triage this hour. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.
(Soundbite of music)
CONAN: This is TALK OF THE NATION. I'm Neal Conan in Washington.
Triage, from disaster relief to the battlefield to incidents like the one in Tucson 10 days ago, it's a process of making decisions, sometimes about life and death.
We're talking with Dr. Michael Millin, an emergency physician at Johns Hopkins Hospital in Baltimore and a disaster medicine expert who was on the scene in Haiti a year ago.
We want to hear from those of you who are first responders. Doctors, nurses, what do we need to understand about the decisions and the rules of triage? How do you deal with the choices you make? 800-989-8255. Email us, email@example.com. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.
Terry(ph) joins us on the line, calling from San Francisco.
TERRY (Caller): Hi, Neal. Thanks again for another great show.
CONAN: Oh, thanks.
TERRY: I wanted to emphasize the point of - first of all, I'm an emergency physician, and I've done a lot of work in the field doing triage and running a countywide ambulance system in the San Francisco area.
The importance of one's emotional reaction to the children that you're treating can't be underscored. I believe the kids are different. Most of us understand the physiology is different. And we tend to go the extra mile when there's a child involved.
I was particularly involved with a case (technical difficulties) the carotid artery by a gang member who was part of a gang initiation, and when he came to the emergency department, he was pulse-less and pale, looked dead, basically. But because he was such a young and healthy person, we decided to go with a resuscitation, open his chest, pinch off the arteries, pump blood into him, et cetera.
And although he had been basically dead for probably up to five minutes, five to seven minutes, we resuscitated him, and he had a completely normal mental status afterwards.
Kids can do that, but you and I, I'm afraid, are past the age where that's - where those resuscitations are possible. But with kids, you go the extra mile for just that reason.
CONAN: And it sounds like there may have been cases in your career, Terry, where, well, things did not work out so well, but every once in a while, you can warm yourselves with that memory.
TERRY: That's exactly right. And we always hang on to the good ones and use that to balance out some of the pain and suffering that's just part of the job.
CONAN: All right, Terry, thanks very much, appreciate it.
TERRY: Thank you, Neal.
CONAN: Here's, Dr. Millin, a tweet that we have: The four colors on the tags say it all and set the priority for care.
What does that refer to?
Dr. MILLIN: So the common methodology of triage, we actually divide patients, as I said, philosophically into three categories. But there's really four in the method that we often use.
And that's - they are green, red, yellow and black. Green patients are patients that we call the walking wounded, where typically on a scene, providers will ask all the patients who can walk to go to a certain area. That identifies patients who are minimally injured and don't need acute services.
Patients then are divided between red and yellow, who are the most critically ill patients, who need services emergently, with a red being a higher acuity, a more severe level than the yellow. And then black patients are patients in the field that we make a decision are highly likely to die or are dead.
CONAN: And those are - can somebody see that there's been a black tag put on them?
Dr. MILLIN: Typically, field providers will use a tag that will have a color strip on it of some method. Different states use different forms, but they're all basically the idea that there will be a color so that very quickly the field providers know which type of patient a patient is so that everyone can see the patients that are green patients, that don't need care. Everyone can see the black patients that are dead. So everyone is quickly able to focus on the red and yellow patients.
CONAN: How do you start with young medical students and begin to teach them the principles of triage?
Dr. MILLIN: Typically what I do is I will start in a lecture room, talking about the philosophy of triage and the methodologies we use triage. That gives people an opportunity to learn in a fairly comfortable setting, in a didactic setting and to be able to ask whatever questions they may have.
Then what I will do is I'll use simulated cases where I often will take little beanie baggies and write on the beanie bag, you know, little beanie babies, kind of physiology, different findings that might be found with that person. I'll have all those in a box, and then I'll throw them into the field and have the medical students or my paramedics working with me go and quickly triage those bean bags as to the acuity level they think.
I usually will do that with a stopwatch to time people, and then I'll come back to the classroom, and we'll discuss every single case so that everyone has an opportunity to discuss each thing.
There's often no right or wrong answer, and sometimes, as you said earlier, there is definitely a lot of gray. And one of the ways we learn is by talking about it amongst each other. The more we become comfortable with the concept and ability to do triage in a simulated situation, the easier it is to do it in the real-world situation.
CONAN: Is there any training for the emotional reaction that we've also heard about?
Dr. MILLIN: I would say that's a very difficult thing. There certainly are things we can talk about, ways we can help each other out as we talk about the emotional things.
One really knows how they're going to react to difficult situations until they're there. I would say most of us who choose these professions have a pretty good idea when we're going into it that we're going to be able to handle the difficult emotions. And I know I, for myself, have a lot of support in my family and my friends that I use to help me get through difficult times. And I think that's very important for those of us in these situations, that we have ways to relieve that stress on the emotions when they come on.
CONAN: Let's get Adam on the phone. Adam's with us from Marion Station in Pennsylvania.
ADAM (Caller): Hi, Neal.
CONAN: Hi, Adam, go ahead.
ADAM: I was recently in the emergency room. I had a severe case of bronchitis. And even though my primary care physician who sent me to the emergency room had called ahead, I was sent into the triage area, where they decided to give me an X-ray.
But in addition to the bronchitis, though I had been complaining I had severe, severe back pain, and they completely ignored the back pain because of the triage, assuming that the back pain was a result of this bronchitis.
Only later did I find out that that back pain was because of two herniated discs. And because of their ignoring of this back pain, they had set me up sitting up in a hospital bed, and it was excruciatingly painful.
I was really curious how often stuff like that happens or how often do those negative consequences come out when people make these snap decisions with triage patients.
CONAN: I hope you're feeling better, Adam, but Dr. Millin?
Dr. MILLIN: Yes, so first of all, I'm sorry for the caller's pain, though the world that we live in, it's very difficult sometimes for people to understand that when we're faced with a situation of having to take care of large numbers of patients in a very quick period of time, we have to make decisions that are very difficult, decisions that are difficult for us and very difficult for other to understand from the outside.
CONAN: Adam, you all right?
ADAM: Yeah, I'm all right. I'm wondering, though: How often do you find, in your practice, that these kinds of things happen, where things don't come to the surface because of the snap decisions associated with triage?
Dr. MILLIN: Yeah, I would say in the emergency department, you know, our role and our job, and especially in the field, our first thing is to make sure we don't lose life that we could've saved.
And so our greatest priorities are always to focus on saving lives and not missing things that we could have corrected in terms of lives saved. That's always our greatest priority.
And then we go from there, as we're able to.
CONAN: Adam, thanks very much for the call.
ADAM: Thank you.
CONAN: Appreciate it. And Dr. Millin, we know you've got an appointment, and you need to run.
Dr. MILLIN: Yes, thank you, and thank you so much for having me on the radio again. It's been a pleasure.
CONAN: Michael Millin, an emergency physician at Johns Hopkins Hospital in Baltimore, medical director for the Baltimore-Washington Airport Fire Department and a disaster medicine expert who was in Haiti last year treating victims of the earthquake, with us on the line from Baltimore.
The first 911 call after the shooting in Tucson came in at 10:11 a.m. Mountain Standard Time. Fire Station 30 was the first on the scene. First responders rolled out of the station at 10:14, arrived five minutes later and entered the scene at 10:22.
Adam Goldberg was on call that day, arrived 25 minutes after that. He is the captain paramedic for the Northwest Fire and Rescue District in Tucson and joins us now from member station KUAZ in Tucson.
Nice to have you with us today.
Mr. ADAM GOLDBERG (Captain Paramedic, Northwest Fire/Rescue District): Thanks, nice to be here.
CONAN: Captain paramedic, that's your title?
Mr. GOLDBERG: Yeah, captain is pretty short and works very well.
CONAN: OK. What was the scene like 20 minutes after the shooting, when you arrived?
Mr. GOLDBERG: Well, upon - I was on call essentially as the public information officer and the spokesperson. However, there's a time period until that role really needs to be activated and fulfilled. So initially, if there's any assistance - also being an engine company paramedic for 10 shifts a month, if they needed some assistance, needed some additional patient care, I'm available for that.
When I got there, they were just loading into the ambulance as the last of the non-critical patients. So that scene had gone very fast. It's very dynamic. The critical patients were already in route and had arrived at the trauma center, and they were just working on getting the less critical or the serious injured and those that were walking wounded into transport units and on their way to hospitals for their care, as well.
CONAN: And I'm sure you've talked to your colleagues, among them Tony Compagno, also at First Station 30, among the first people on the scene. What has he told you that they did to assess the condition of the victims?
Mr. GOLDBERG: Well, their first-arriving operations were, of course, triage. They got out of the truck, brought their triage kit up to the scene. As Tony had said - and I could feel and appreciate where he was at based on other mass casualty instances that we've arrived at - you just got to stop. You got to take a deep breath. You got to look around you and absorb so much in a very short amount of time, and it was truly overwhelming.
His mind took a little bit of a hiatus. It said: Gather my thoughts. He came back to it. And then, as Dr. Millin was saying, we went into autopilot. We followed our training. We followed our protocols for triage, looking at respirations, pulse, mentation, the ability for anybody to walk away from the critically injured and be treated at another location, and that operation just went like clockwork. So he had that second of awe. He had that second of overwhelming-ness...
Mr. GOLDBERG: ...and then went into his program, went into his operation, and, of course, the emotional factor came afterwards.
CONAN: Sure. The triage kit. What's in a triage kit?
Mr. GOLDBERG: We carry, essentially, fanny packs that are designed specifically for triage, and that we have the triage tags, exactly like Dr. Millin was talking about. They're color-coded. The exact same colors that are used in his fire department are used here in Arizona as a whole standard - some scissors to be able to expose and check for breathing, the tags themselves, some pens to utilize for the tags and airway devices called OPAs, or oropharyngeal airway.
As we are assessing for breathing and respirations, one of the things we need to do for any victim that's non-responsive is open the airway. We look for spontaneous return of respirations. If they don't have them, they're usually marked the black dead, or soon to be dead and dying.
CONAN: Do civilians play any role in this?
Mr. GOLDBERG: Well, of course, one of the factors in the original arriving triage group and the first six firefighters on the scene were trying to decipher who was hurt, who was a patient, who was a bystander that was assisting the patients, who were witnesses, and there were several dozen witnesses. Some of the bystanders had blood on them. So it was trying to decipher who was actually hurt and who was there assisting. So that took a little bit of a process.
And once that took place, we did have assistance with the bystanders of giving us some information about the patients that they were trying to care for. But really, it comes down to a set criteria that we stick to, no matter who's telling us what information, how bad the injuries look, what the bystanders are doing, because if we don't follow the set protocols every time, we're going to miss something or we're going to be inaccurate. And we don't want to do that.
CONAN: We're talking with Adam Goldberg, a captain paramedic for the Northwest Fire/Rescue district in Tucson, among those who arrived soon on the scene there 10 days ago. You're listening to TALK OF THE NATION, from NPR News.
Let's go next to Larry, and Larry's on the line with us from Sheridan in Oregon.
LARRY (Caller): Yeah, Neal. Thanks for taking my call.
LARRY: For both Dr. Millin - I know he's gone - and Mr. Goldberg, but can you truly honestly separate human emotion if you were in a scenario where you knew the victim was laying right next to the perpetrator? And then, you know, is it truly possible to eliminate the fact that this is the bad guy and this is the good guy?
Mr. GOLDBERG: We're fortunate in Tucson that we have a process that any violent crime scene that we respond to - whether it's a shooting, a stabbing, an assault or potentially an overdoes where a patient is reported to be violent - we hold off. We remain clear of the scene until the law enforcement agency can arrive and secure or render that scene safe for us.
In this case, we were five minutes from the fire station to a staging area just outside of the parking lot of the Safeway. The sheriff's department and a neighboring police department just north of the incident - the Oro Valley Police Department - both had units arriving and secured - from what I understand - secured the suspect. Three minutes after that process, we were notified that the scene was secure.
CONAN: And, Adam Goldberg, I don't mean to interrupt, but he's talking -I don't think about this particular case, but a hypothetical case.
Mr. GOLDBERG: Oh.
CONAN: If you had an injured victim and, say, the person who had injured the victim was also injured and laying next to him, who do you treat first?
Mr. GOLDBERG: Again, we follow that exact protocol. It is difficult to separate that, because our job and our mission is really to help those who are in need and injured. So we are not going to separate or try to decipher who was at fault, who the bad guy is or the good guy. We will treat based on injury alone, as long as that scene is secure.
CONAN: And again, that may factor into your emotions afterwards. But, Larry, thanks very much for the call.
LARRY: Thank you. Good day. Bye.
CONAN: Let's see if we can go next to Phil, and Phil's with us from Boise.
PHIL (Caller): (technical difficulties) a 20-year full-time paramedic, and some of the things that are - that I think have been missed in the earlier conversations are that when you do triage people, different groups, there are people that you assign to reassess those groups. You can have a red patient turn to black. You can have a red patient that you reassess and find really they're yellow, and move them to a different area. You may find that someone you thought was green suddenly has a problem and now is a yellow or red. So you have to reassess.
And as far as the earlier comment, how do you separate between a person that (technical difficulties) that person that was at a law enforcement situation where a couple of officers had pulled over this guy and he had a package in the back of his truck that they were asking about, a small, cardboard box. And he said he didn't know anything about it at all. And so they were suspicious. And so they were opening up the package, and it exploded and knocked both the officers to the ground.
And I was about a mile away responding to the incident. So, obviously, there were about 35, literally, police cars responding to the scene, as well. And so getting there and finding that the supposed perpetrator gets injured, as well. Honestly, I had some - afterwards, I'm thinking: That SOB. He, you know, injured these two officers, blew one of their -one of the officers, you know, thumbs are - fingers off, rather, and seriously injured them both. After the fact, I mean, some time after the fact, it was discovered that, in fact, he didn't know anything about the package. It was the new boyfriend of his ex-wife who sent the package for him.
CONAN: So had he...
PHIL: And so had I gone with my earlier feelings - and, honestly, we treated him just as well as we had the officers. We didn't make him wait. But I had these feelings of anger and animosity towards him because he injured these guys I work with. And then that really taught me. Boy, you really can't choose. You really don't know the whole circumstance. When you walk into it, the guy holding the gun may have been defending himself.
PHIL: The guy with the knife may not have been holding the knife when the incident occurred. So you can't - I mean, if you've been in the street for a while, you realized you don't know all the stories. You don't know exactly what took place before you arrived.
CONAN: Phil, thanks very much. I'm afraid we have to run, and we need to thank Adam Goldberg of the Northwest Fire and Rescue district in Tucson. Thanks to you all.
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