Category Archives: Clinical

Clinical implications in EMS

101 Things We Should Teach Every New EMT

Originally posted at TheEMTSpot

I do not usually steal content or original writings, but this post is too important not to share (and keep for reference).  This was originally posted, with all credit due to the author of origin, at:

Though this list is focused towards emergency medical technicians, it has inferred and inherent application in many clinical and non-clinical professions.

1) You aren’t required to know everything.

2) You are required to know the foundational knowledge and skills of your job. No excuses.

3) Always be nice. It’s a force multiplier.

4) There is no greater act of trust than being handed a sick child.

5) Earn that trust.

6) Don’t ever lie to your patient. If something is awkward to say, learn to say it without lying.

7) Read Thom Dick’s, People Care. Then read it again.

8) You can fake competence with the public, but not with your coworkers.

9) Own your mistakes. We all make them, but only the best of us own them.

10) Only when you’ve learned to own your mistakes will you be able to learn from them.

11) Experience is relative.

12) Proper use of a BVM is hard and takes practice.

13) OPAs and NPAs make using a BVM less hard.

14) Master the physical assessment. Nobody in the field of medicine should be able to hold a candlestick to your physical assessment skills.

15) Keep your head about you. If you fail at that, you’ll likely fail at everything else.

16) There is a huge difference between not knowing and not caring. Care about the things you don’t yet know.

17) Train like someone’s life depends on it.

18) Drive like nobody’s life depends on it.

19) Pet the dog (even when you’re wearing gloves).

20) Have someone to talk to when the world crashes down.

21) Let human tragedy enhance your appreciation for all that you have.

22) Check the oil.

23) Protect your back. It will quite possibly be the sole determining factor in the length of your career.

24) Say please and thank you even when it’s a matter of life or death.

25) Wipe your feet at the door.

26) When you see someone who is really good at a particular skill say, “Teach me how you do that.”

27) Nobody can give you your happiness or job satisfaction; it is yours and yours alone, and you have to choose it.

28) We can’t be prepared for everything.

29) We can be prepared for almost everything.

30) Check out your rig. It’s more meaningful that just confirming that everything is still there.

31) Tell your patients that it was a pleasure to meet them and an honor to be of service.

32) Mean it.

33) Keep a journal.

34) Make it HIPAA compliant.

35) Thank the police officer that hangs out on your scene for no good reason.

36) Recognize that he or she probably wasn’t hanging out for no good reason.

37) Interview for a job at least once every year, even if you don’t want the job.

38) Iron your uniform.

39) Maintain the illusion of control. Nobody needs to know that you weren’t prepared for what just happened.

40) Apologize when you make a mistake. Do it immediately.

41) Your patient is not named honey, babe, sweetie, darling, bud, pal, man or hey. Use your patient’s name when speaking to them. Sir and Ma’am are acceptable alternatives.

42) Forgive yourself for your mistakes.

43) Forgive your coworkers for their quirks.

44) Exercise. Even when it isn’t convenient.

45) Sometimes it’s OK to eat the junk at the QuickyMart.

46) It’s not OK to always eat the junk at the QuickyMart.

47) Don’t take anything that a patient says in anger personally.

48) Don’t take anything that a patient says when they are drunk personally.

49) Don’t ever convince yourself that you can always tell the difference between a fake seizure and a real seizure.

50) Think about what you would do if this was your last shift working in EMS. Do that stuff.

51) Carry your weight.

52) Carry your patient.

53) If firefighters ever do #51 or # 52 for you, say thank you (and mean it).

54) Being punched, kicked, choked or spit on while on duty is no different than being punched, kicked, choked or spit on while you’re sitting in church or in a restaurant. Insist that law enforcement and your employer follow up with appropriate action.

55) Wave at little kids. Treat them like gold. They will remember you for a long time.

56) Hold the radio mike away from your mouth.

57) There is never any reason to yell on the radio….ever.

58) When a patient says, “I feel like I’m going to die,” believe them.

59) Very sick people rarely care which hospital you’re driving toward.

60) Very sick people rarely pack a bag before you arrive.

61) Sometimes, very sick people pack a bag and demand a specific hospital. Don’t be caught off guard.

62) Bring yourself to work. There is something that you were meant to contribute to this profession. You’ll never be able to do that if you behave like a cog.

63) Clean the pram.

64) Clean your stethoscope.

65) Your patient’s are going to lie to you. Assume they are telling you the truth until you have strong evidence of the contrary.

66) Disregard #65 if it has anything to do with your personal safety. Trust nobody in this regard.

67) If it feels like a stupid thing to do, it probably is.

68) You are always on camera.

69) If you need save-the-baby type “hero moments” to sustain you emotionally as a caregiver you will likely become frustrated and eventually leave.

70) Emergency services was never about you.

71) The sooner you figure out #69 and #70, the sooner the rest of us can get on with our jobs.

72) People always remember how you made them feel.

73) People rarely sue individuals who made them feel safe, well cared for and respected.

74) You represent our profession and the internet has a long, long memory.

75) Don’t worry too much about whether or not people respect you.

76) Worry about being really good at what you do.

77) When you first meet a patient, come to their level, look them in the eyes and smile. Make it your habit.

78) Never lie about the vital signs. If the patients vital signs change dramatically from the back of the rig to the E.R. bed, you want everyone to believe you.

79) Calm down. It’s not your emergency.

80) Stand still. There is an enormous difference between dramatic but senseless action and correct action. Stop, think and then move with a purpose.

81) Knowing when to leave a scene is a vital skill that you must constantly hone.

82) The fastest way to leave a scene should always be in your field of awareness.

83) Scene safety is not a five second consideration as you enter the scene. It takes constant vigilance.

84) Punitive medicine is never acceptable. Choose the right needle size based on the patients clinical needs.

85) Know what’s happening in your partner’s life. Ask them about it after you return from your days off.

86) If your partner has a wife and kids, know their names.

87) No matter how hard you think you worked for them, your knowledge and skills are not yours. They were gifted to you. The best way to say thank you is to give them away.

88) Learn from the bad calls. Then let them go.

89) When you’re lifting a patient and they try to reach out and grab something, say, “We’ve got you.”

90) Request the right of way.

91) Let your days off be your days off. Fight for balance.

92) Have a hobby that has nothing to do with emergency services.

93) Have a mentor who knows nothing about emergency services.

94) Wait until the call is over. Once the patient is safe at the hospital and you’re back on the road, there will be plenty of time to laugh until you can’t breathe.

95) Tell the good stories.

96) You never know when you might be running your last call. Cherish the small things.

97) You can never truly know the full extent of your influence.

98) If you’re going to tell your friends and acquaintances what you do for a living, you’ll need to embrace the idea that you’re always on duty.

99) Be willing to bend the rules to take good care of people. Don’t be afraid to defend the decisions you make on the patients behalf.

100) Service is at the heart of everything we do. The farther away from that concept you drift, the more you are likely to become lost.

101) There is no shame in wanting to make the world a better place.

See more at:

EMS Research: Using t Tests

When considering the emergency medical services, there has been much discussion regarding the utility of advanced life support and its effectiveness within the emergency medical services (Stiell et al., 2005; Stiell et al., 2003; Stiell et al., 2002; Stiell et al., 1999). One of the most basic skills that paramedics use exclusively is intravenous cannulation and the subsequent delivery of isotonic intravenous fluid. Intravenous cannulation is one of the first advanced skills that paramedics utilize within the course of treatment as it allows to correct for shock, provides a means for administering parenteral medications, and provides a means for drawing blood for testing either in the field or upon arrival at the receiving emergency department. As the body’s stress increases when dehydration is present, it is imperative to correct dehydration during the course of treating most ailments; otherwise, the body’s own compensatory mechanisms can fail despite otherwise adequate treatment (Wakefield, Mentes, Holman, & Culp, 2008). Additionally, dehydration can mask some critical tests, such as other blood values and radiological findings (Hash, Stephens, Laurens, & Vogel, 2000).

Though the research is limited, it is also important to note that judicious use, or overuse, of intravenous fluids can be detrimental in some cases (Rotstein et al., 2008). In order to test the effectiveness of paramedic treatment of co-morbid dehydration, we can observe for fluid status before and after treatment as well as between those patients transported by paramedic ambulance as compared to patients who present to the emergency department by other means (e.g. basic life support ambulance, walk-in); however, it is first important to understand if those patients who present to the emergency department are, indeed, dehydrated.

In order to study if paramedics have an impact in treating co-morbid dehydration, there has to be an assumption that a) most people are not dehydrated and b) people who present to the emergency department (the dependent variable) are more dehydrated (independent variable) than most of the population. As we can never be sure of the hydration status of the entire population at any given time or the standard deviation of the entire population, we can use the normal mean blood urea nitrogen value of 10 mmol/L and assume a normal distribution (Hash et al., 2000).

H0:μ=10: Patients who present to the emergency department are not dehydrated (BUN = 10 mmol/L)
Ha:μ>10: Patients who present to the emergency department are dehydrated (BUN > 10 mmol/L)

Once the random sample of BUN values have been obtained, I can use the t-distribution to find the value of the t-test statistic:

t = (x̄ - μ) / (s / √n)

Next, I would compute the degrees of freedom (it is important to note that the sample size [n] must be greater than 30 as the standard deviation of the population is not known):

DOF = n - 1

As this test is one-tailed (specifically, right-tailed), and I am concerned with a 95% CI, I would compare the t-value with the t-table row indicated by the DOF. If the t-value is greater than the t-value corresponding with the DOF, then I will be able to reject the null hypothesis; otherwise, if the computed t-value is less than the table value, I will not be able to reject the null hypothesis.


Hash, R. B., Stephens, J. L., Laurens, M. B., & Vogel, R. L. (2000). The relationship between volume status, hydration, and radiographic findings in the diagnosis of community-acquired pneumonia. Journal of Family Practice, 49(9), 833-837.

Rotstein, C., Evans, G., Born, A., Grossman, R., Light, R. B., Magder, S., … & Zhanel, G. G. (2008). Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. Canadian Journal of Infectious Diseases & Medical Microbiology, 19(1), 19–53.

Stiell, I. G., Nesbitt, L., Pickett, W., Brisson, D., Banek, J., Field, B, … & Wells, G., for the OPALS Study Group. (2005). OPALS Major Trauma Study: impact of advanced life support on survival and morbidity. Academy of Emergency Medicine, 12(5), 7.

Stiell, I. G., Nesbitt, L., Wells, G. A., Beaudoin, T., Spaite, D. W., Brisson, D., … & Cousineau, D., for the OPALS Study Group. (2003). Multicenter controlled trial to evaluate the impact of ALS on out-of-hospital chest pain patients. Academy of Emergency Medicine, 10(5), 501.

Stiell, I. G., Wells, G. A., Spaite, D. W., Nichol, G., Nesbitt, L., De Maio, V. J., … & Cousineau, D., for the OPALS Study Group. (2002). Multicenter controlled clinical trial to evaluate the impact of advanced life support on out-of-hospital respiratory distress patients. Academy of Emergency Medicine, 9(5), 357.

Stiell, I. G., Wells, G. A., Spaite, D. W., Nichol, G., O’Brien, B., Munkley, D. P., … & Anderson, S., for the OPALS Study Group. (1999). The Ontario Prehospital Advanced Life Support (OPALS) Study Part II: Rationale and methodology for trauma and respiratory distress patients. Annals of Emergency Medicine, 34, 256-262.

Wakefield, B. J., Mentes, J., Holman, J. E., & Culp, K. (2008). Risk factors and outcomes associated with hospital admission for dehydration. Rehabilitation Nursing, 33(6), 233-241. doi:10.1002/j.2048-7940.2008.tb00234.x

Discussing Cost-Effective Analysis

This week I was directed to provide insight to the cost-effective analysis (CEA) provided by Penner (2004) in A Cost-Effective Analysis for Proposed Alternative Interventions to Post-Procedure Surgical Pain Reduction. Within the CEA, three alternative treatments (guided imagery, hypnosis, and biofeedback) are proposed to reduce post-operative pain. The CEA is used to determine the efficiency that each intervention offers comparably to each of the other two alternatives.

I developed a PowerPoint™ presentation [click here] to provide a summation of the CEA and visually present the information for a quick rationalization of the chosen intervention. I will explain each slide of the PowerPoint™ as it pertains to the CEA.

The Cost-Effective Analysis

The CEA provided by Penner (2004) describes the various costs and benefits of using guided imagery, hypnosis, and biofeedback therapies to reduce post-operative pain (as defined on slide #3), which improves the overall healing process. The objective, as noted on slide #2, is the importance of effective pain control. The author of the CEA concedes that all three interventions similarly meet the therapeutic objective of limiting post-operative pain in a safe and low-risk manner; however, the cost differences are significant.


As provided in the CEA, the most significant tangible benefits, as mentioned above, are providing effective pain management in a safe, low-risk manner. Additionally, and as a result of reducing pain effectively, increased patient satisfaction, better patient compliance, and overall better healing leads to reduced costs associated with post-operative recovery, such as reduced length of stay and reduced need for post-surgical care (e.g. nursing care, physician care, rehospitalization, medications). Slide #4 of the presentation outlines these similar benefits.


The costs of each intervention are significant factors in deciding which intervention to promote. Once the annual cost for each intervention if figured, each of the identified costs are distributed across the expected patient volume of 197 and further distributed over the likelihood of each of three surgical procedures (spinal fusion, total hip replacement, and auto hema stem cell transplant) being performed. Though this is largely unnecessary, it does provide perspective for how the costs will be distributed and raise the overall cost for each surgical procedure performed, as shown on slide #8. The total annual cost for each intervention, as well as the per-patient cost, is outlined on slide #5 and graphed on slides #6 and #7.

The fixed costs for guided imagery include a psychology consultant, a surgery PA coordinator, wages for clerical staff, and training for the surgery PA.

The fixed costs for hypnosis includes a psychologist skilled in hypnotherapy and wages for clerical staff. The amount of resources for hypnosis are significantly less than for guided imagery; however, the intervention is more substantial requiring significantly more hours per week paid (12 for hypnosis vs. 2 for guided imagery).

The fixed costs for biofeedback are more equivalent to, though slightly more than, those of guided imagery. Biofeedback requires a psychology consultant, a surgery PA coordinator, wages for clerical staff, and training for the surgery PA, but the fixed costs for biofeedback also include specific equipment, including skin sensors, two video monitors, VCRs, and carts.

The total identified costs for guided imagery is 32.18% less than biofeedback and 64.56% less than hypnosis.


Based on the CEA, the most cost-effective intervention for impacting and controlling post-operative pain on patients undergoing one of the three surgical procedures outlined is guided imagery. This result is stated on slide #10.


The appropriate management of pain is crucial to patient care. Assuming that the three interventions investigated are equally effective towards the objective of reducing and controlling pain, the cost of each intervention is the deciding factor when considering which of the three interventions to employ. In this case, guided imagery is the most cost-effective intervention and is the recommended intervention, per the CEA.

It is important to understand that these costs will be borne by not one but three different departments – the pain clinic, the orthopedic surgery department, and the patient education department. This cost-sharing removes the burden of providing the intervention from a single department and disperses the burden over the budgets of three different departments.


Penner, S. J. (2004). Introduction to health care economics & financial management: fundamental concepts with practical applications. Philadelphia, PA: Lippincott Williams & Wilkins.

Measuring EMS: Patient Satisfaction

As a paramedic, I become discouraged when so-called academic literature, like that of McLean, Maio, Spaite, and Garrison (2002), Spaite (1993), and Stiell et al. (2008), turns up describing what little impact the emergency medical services, especially advanced life support procedures, have on patients. Instead of dismissing these writings, I tend to focus within the view of my own practice and experience on how I feel that I impact the patients that I see. This exercise allows me to confront the literature in a specific and meaningful manner that might be used in the future to publish a dissenting view. This discussion gives me a lens through which to dissect the import I feel that the emergency medical services has as a public safety entity.

Public safety is typically viewed as the amalgamation of police, fire, and emergency medical services. In all three, the public seems to have the idea that we stop threats before they take hold; however, we typically respond to the aftermath, the police to investigate crimes that have already occurred, the fire department to conflagrations that have already caused damage, and emergency medical services to traumatic incidents or medical conditions that have already caused distress. There are exceptions. The police have learned to integrate crime prevention techniques, the fire department has learned to adopt a fire prevention model of service, and the emergency medical services in many areas support preventative health clinics, such as community immunization, blood pressure checks, and CPR and first aid classes. The public, I feel, has a skewed perception of each one of these departments (e.g. the police should stop crime in progress, the fire department should save their house, and emergency medical systems should save their loved one whenever called upon to do so). Any deviation from the public perception is, in their minds, a failure of the system.

I ask myself, “What is that we, as the emergency medical services, do that really matters?” For the public, it seems that the answer can be given two-fold: “save me” and “make me feel better.” El Sayed (2012) describes the manner in which both aspects, outcomes and patient satisfaction, can be measured, as both are essential. Unfortunately, El Sayed does not go into much detail regarding patient satisfaction scores, except as a means of measure. In contrast, I feel that the most benefit that we offer patients is that we alleviate suffering. From a confident, yet compassionate, bed-side manner to effective and efficient treatment modalities, emergency medical personnel can prove to be the mediator between illness or injury and definitive hospital-based care. Emergency medical providers should be knowledgeable enough about the hospital to calm and educate patients as to what to expect. Further, medical knowledge allows the provider to restore a choking person’s breathing, to stop an epileptic seizure, and to minimize a crash victim’s pain. In my opinion, these measures are just as important, if not more, to quality management as mortality and morbidity. Again, El Sayed mentions the generality of patient satisfaction; however, with the abundance of competing literature questioning the effectiveness of the emergency medical services, patient satisfaction should be expounded upon as a legitimate and important aspect of quality patient care.


El Sayed, M. J. (2012). Measuring quality in emergency medical services: a review of clinical performance indicators. Emergency Medicine International, 2012, 1-7, doi:10.1155/2012/161630

McLean, S. A., Maio, R. F., Spaite, D. W., & Garrison, H. G. (2002). Emergency medical services outcomes research: evaluating the effectiveness of prehospital care. Prehospital Emergency Care, 6(2), S52–S56. doi:10.3109/10903120209102683

Spaite, D. W. (1993). Outcome analysis in EMS systems. Annals of Emergency Medicine, 22(8), 1310–1311. doi:10.1016/S0196-0644(05)80113-1

Stiell, I. G., Nesbitt, L. P., Pickett, W., Munkley, D., Spaite, D. W., Banek, J., Field, B., … Wells, G. A., for the OPALS Study Group. (2008). The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity. Canadian Medical Association Journal, 178(9), 1141-1152. doi:10.1503/cmaj.071154

Quality and Safety Measurement

In regards to the incident surrounding the death of Josie King (Josie King Foundation, 2002), there have been many great improvements in the delivery of care at Johns Hopkins (Niedowski, 2003; Zimmerman, 2004). Those aside, and if I was faced with having to develop performance measures of quality and safety in the context of such a tragedy, I would strive to ensure that my measures were accurate and valid to identify areas of grave concern where Johns Hopkins would do good to improve.

First, I would consider measuring the structure of the care delivered. In Josie’s case, a medical response team responded when it was identified that she was in the midst of a medical crisis. The first measurement would serve to identify the availability of such teams and the adequacy of the team’s staffing. The measure would indicate the response time of the team and the licensing and certification level of each team member.

Second, I would consider measuring processes that might have contributed to the death of Josie King. In this instance, Josie was administered a narcotic while suffering acute dehydration. The administration of this medication was contrary to the physician’s orders regarding pain medication for this patient. This measure would indicate the appropriate use of narcotic analgesia in patients faced with contraindications, such as acute dehydration or shock. This measure would be a cross tabulation of recent vital signs and laboratory results.

Third, I would consider measuring outcomes. In cases where pediatric patients are downgraded from the pediatric intensive care unit (PICU) to a general ward, any adverse condition should prompt an upgrade back to the PICU. This measure would identify the number of cases in each reporting period that any recently downgraded patient was upgraded back to the PICU. This measure should account for the time between a crisis and upgrade along with a statement indicating the cause of the crisis and resultant upgrade. This measure should be augmented by a mortality and morbidity subset involving any patients who were downgraded from PICU.

My considerations for these processes are to determine if general ward nurses should be administering any medications on standing order or if there should be a requirement to ensure that any medication administered to a general ward patient is explicitly written in the patient’s chart at the time of administration. Also, nurses should be acutely aware of the contraindications of any medications that they are administering. The process measure will, hopefully, identify misuse of narcotic analgesia and any failure to assess the patient for other possible causes of distress before assuming the distress is in response to pain. Ultimately, a more timely and efficient use of medical response teams should result, which would avail physicians and more experienced nurses to the original patient care team. This should lead to an open discussion of how to better manage the patient post crisis. Also, a greater understanding of medication administration concepts should result, benefiting all patients.


Josie King Foundation. (2002). About: What happened. Retrieved from

Niedowski, E. (2003, December 15). From tragedy, a quest for safer care; Cause: After medical mistakes led to her little girl’s death, Sorrel King joined with Johns Hopkins in a campaign to spare other families such anguish. The Sun, pp. 1A. Retrieved from

Zimmerman, R. (2004, May 18). Doctors’ new tool to fight lawsuits: Saying ‘I’m sorry’. Wall Street Journal, pp. A1. Retrieved from

Medical Error: The Josie King Story

Josie King’s story (Josie King Foundation, 2002; Niedowski, 2003; Zimmerman, 2004) is heartbreaking, but the events told herein empowered Sorrel King, Josie’s mother, to take on a mission responsible for numerous patient care recommendations that have enhanced the safety of pediatric patients throughout the country. Josie King was only 18 months old when she climbed into a hot bath and suffered 1st and 2nd degree burns which led to her being admitted to Johns Hopkins pediatric intensive care unit (PICU). Within 10 days, Josie was released from the PICU and brought to the intermediate floor with all assurances that she was making a remarkable recovery and would be released home in a few days. Josie did not continue her remarkable recovery, however.

According to Sorrel King (Josie King Foundation, 2002), Josie began acting strangely, exhibiting extreme thirst and lethargy, after her central intravenous line had been removed. After much demanding by Sorrel, a medication was administered to Josie to counteract the narcotic analgesia she had been administered. Josie was also allowed to drink, which she did fervently. Josie, again, began recovering quickly. Unfortunately, the next day, a nurse administered methadone, a narcotic, to Josie as Sorrel told her that Josie was not supposed to have any narcotics… that the order had been removed. Josie became limp and the medical team had to rush to her aid. Josie was moved back up to the PICU and placed on life support, but it was fruitless. Josie died two days later and was taken off life support.

The Institute of Medicine (2001) published six dimensions of health care: safety, effectiveness, patient-centered, timeliness, efficiency, and equality. In Josie’s case, the care was not delivered efficiently, effectively, safely, or in a patient- or family-centered fashion. The overuse of narcotics in Josie’s case was certainly not effective or safe. Additionally, withholding fluids and allowing her to become dehydrated was detrimental to her recovery, which was neither safe nor effective. As Josie exhibited extreme thirst, her symptoms were dismissed, which does not follow patient-centeredness. Moreso, when the nurse administered the narcotic to Josie despite the pleadings of her mother, it demonstrated a lack of family-centered care, safety (in that, the order should have been double checked), efficacy (further demonstrating overuse of narcotic analgesia), and efficiency, as medication orders were either unclearly written or removed.

This story is clearly a demonstration that mistakes can happen at even the best of hospitals.


Institute of Medicine. (2001, July). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

Josie King Foundation. (2002). About: What happened. Retrieved from

Niedowski, E. (2003, December 15). From tragedy, a quest for safer care; Cause: After medical mistakes led to her little girl’s death, Sorrel King joined with Johns Hopkins in a campaign to spare other families such anguish. The Sun, pp. 1A. Retrieved from

Zimmerman, R. (2004, May 18). Doctors’ New Tool To Fight Lawsuits: Saying ‘I’m Sorry’. Wall Street Journal, pp. A1. Retrieved from

Scrutinizing the Literature of EMR

 As I scrutinize Dimitropoulos and Rizk (2009) for possible inclusion in a literature review for my research, I find it both promising and troubling. The article appears to be pertinent to my research question of how various laws and practices might adversely affect shared access of electronic health records; however, it is important to understand if this article is a documentation of primary research or a review of existing research, and as I describe below, this is unclear. This lack of clarity obscures other facets of the article that important to a researcher. These are also described below.

Initially, the work of Dimitropoulos and Rizk appears to be pertinent to my research based on the title and the publication in which it appears. Health Affairs is a respected journal within the realm of public health research, practice, and instruction, and it is ranked seventh of all health policy and service journals by Journal Ranking ( Publication within Health Affairs does not degrade the reputation of the authors and serves only to promote their work to their peers. As my research is within the realm of public health, Health Affairs is an obvious avenue to pursue for relevant work, and as this article by Dimitropoulos and Rizk appears to reflect a specific focus on the relationship between privacy laws and the ability, or lack thereof, to share health information, it appears to have relevance.

According to the abstract, Dimitropoulos and Rizk (2009) examine how variations is state (and, territorial) privacy laws might inhibit sharing health information via an central exchange, or repository. Though it would seem plausible for Dimitropoulos and Rizk to conduct their own research, the abstract seems to imply that they are merely reporting on the findings of a committee charged with examining such irregularities in privacy laws amongst the states and territories, presumably, of Canada. After reading the report, though, I find a disconnect between the abstract and the article. In the abstract, it appears more as if the authors are detached reporters, but within the body of the article, it seems as though they appear to take ownership of the primary research. This is confusing as it was plainly stated that the research was conducted by a large consortium of state officials: “the project initially engaged organizations in thirty-four … and later … forty-two jurisdictions. This collaborative work is commonly referred to as the Health Information Security and Privacy Collaboration (HISPC)” (p. 429).

This report is confusing to read as the perspective shifts frequently between first- and third-person. Additionally, the authors describe opinions formed and emotions felt during the primary research (opinions and emotions that only the primary researchers could know), yet it is unclear if these were transmitted through other writing or if the authors formed and felt these themselves. It is unclear whether the authors, Dimitropoulos and Rizk (2009), were participating researchers or merely reporters.

Both authors are noted to work for RTI International’s Survey Research Division, yet this corporation is not credited with any of the original research (Dimitropoulos & Rizk, 2009). I would have to conduct further research into the authors, their employer, and the project, itself, in order to make a final determination of the credibility of this article. This research would, hopefully, give the authors’ words better context, also. Complicating this is the absence of clearly delineated references, although a few appear within the Notes section that appear to be worth investigating.

Dimitropoulos and Rizk (2009) describe an effort to create a cohesive environment that will enhance the ability to share health information throughout a number of jurisdictions. As such, there is no scientific inquiry and it follows that adherence to the scientific method would be inappropriate. Again, however, it is unclear if this research is original or not.

In closing, it appears that Dimitropoulos and Rizk (2009) are credible in their writing; however, as each article must be able to stand on its own, and the article is lacking in form and perspective, I question the origination, application, and utility of this article, at least as it pertains to my original research question. Privacy in computing has been a major concern in the past two decades (Johnson, 2004). I feel that I could find more pertinent literature by expanding my search beyond this article.


Dimitropoulos, L. & Rizk, S. (2009).A state-based approach to privacy and security for interoperable health information exchange.Health Affairs, 28(2), 428-434. doi:10.1377/hlthaff.28.2.428

Johnson, D. G. (2004). Computer ethics. In L. Floridi (Ed.), The Blackwell guide to the philosophy of computing and information (pp. 65-75). Malden, MA: Blackwell.

Physician-assisted Suicide

I have always maintained that the best thing that I have ever done for a patient was to hold their hand as they died; however, there are few scenarios that I can posit where I would ever cause the death of another, and I would never do it in my capacity as a medical professional. In the State of Connecticut, assisting a patient in their suicide is illegal (Kasprak, 2003; Saunders & Smith, 2010). Saunders and Smith (2010) describe the use of “semantic ploys” (para. 3) in arguing for physician-assisted suicide and how the court deemed the “issue rests with the legislature, not with the court” (para 4).

Two states have laws permitting physician-assisted suicide, Oregon and Washington (Death with Dignity Act, 1997; Death with Dignity Act, 2008). The other 48 states either have laws forbidding assisted suicide, such as Connecticut, rely on common law, or have no laws permitting or forbidding the practice (Kasprak, 2003). Personally, my thoughts on the matter are clearly reflected in my opening statement. More compelling, however, is a recent discussion on the discontinuation of implanted cardiac devices in patients with a desire to “refuse continued life-sustaining therapy” (Kapa, Mueller, Hayes, & Asirvatham, 2010, p. 989). Many of the respondants to this study viewed the discontinuation of pacemakers akin to physician-assisted suicide, whereas less felt the termination of cardioverter-defibrillator therapy was an ethical issue. Oddly, lawyers indicated less problems discontinuing therapy than did physicians.

There are conditions that are so intractably painful and wrought with suffering that I would not even consider thinking less of a person suffering such a malady who took their own life. Death, for many people, is a fear beyond fear, and for a person (of considerable sound mind) to choose death as a viable alternative to such suffering, I commend their bravery and choose not to judge them negatively. No physician or other health care provider should cause the death of a person directly, but acknowledging the patient’s will to die is another matter. In lieu of providing a chemical means of ending life, a physician could, in my mind, counsel a patient on the means and methods that might be viewed as more effective and humane than other means which might result in unwanted suffering. I do believe that a person has the right to choose an alternative to a surely painful and agonizing death, regardless of the presence of depression. If a person is suffering from depression because of a terminal illness that is causing physical suffering, it is hard to imagine this person will resolve the depression before succumbing to the causal disease process. In these cases, the person has the right to choose a more dignified death. For those cases where the person is incapacitated and cannot make health care decisions, I feel that any friend or family member, or a consensus of available friends and family members, should be able to make the decision to continue or discontinue life-sustaining measures. Even if the decision is wrong for the patient, most of the time the decision is for the benefit of the family and friends and lacks medical relevance aside from resource management, though there are spiritual, emotional, and moral considerations that the next of kin may face which are no less relevant.

Personally, I grant any person permission to end my life if they see me engulfed in flame or if taken on the battlefield by an enemy known for public torture. Beyond these two circumstances, I will always choose to live so long as I have my thoughts. I have heard some people intimate that they would wish to die if they were conscious but perpetually paralyzed (i.e. locked-in syndrome); however, I am not so sure that I would want to die just for lacking the ability to communicate with others. I would want to view the world, though, perhaps by television or radio. I am too curious as to what comes next for the world. As we interfere with the dying process, it does make sense that we address the morality in which we do this. It does not seem right to have brain dead patients connected to ventilators and feeding tubes forever. It’s Orwellian.


Death with Dignity Act of 1997, O.R.S. 127.800 et seq. (1997).

Death with Dignity Act of 2009, R.C.W. 70.245 (2008).

Kapa, S., Mueller, P. S., Hayes, D. L., & Asirvatham, S. J. (2010). Perspectives on withdrawing pacemaker and implantable cardioverter-defibrillator therapies at end of life: Results of a survey of medical and legal professionals and patients. Mayo Clinic Proceedings, 85(11), 981-990. doi:10.4065/mcp.2010.0431

Kasprak, J. (2003, July 9). Assisted suicide (OLR Research Report No. 2003-R-0515). Retrieved from

Saunders, W. L. & Smith, M. R. (2010, June 21). Assisted-suicide advocates fail in Connecticut. National Review Online. Retrieved from

Flawed Conclusions in Literature Review

For this week’s discussion, I have chosen to analyze an article (Sakr et al., 2006) that attempts to outline the efficacy and potential dangers of certain drugs used to treat shock. As a critical care paramedic, the discussion surrounding this article can provide insight to choosing alternative therapies when caring for my patients, but it is important for me to understand the potential biases and limitations of such a study that could lead to flawed conclusions (Gluud, 2006).

Sakr et al. (2006) collected data on ICU admissions over a two week period to further understand how dopamine effects mortality and morbidity when administered in response to hemodynamic compromise. Also, other administered vasoactive drugs were included in the analysis whether administered concomitantly with dopamine or instead of dopamine. The researchers did not distinguish between etiologies except to delineate between septic shock and non-septic shock. Patients who presented with shock or suffered a shock state within the first 24 hours of admission were included in the analysis. Patients admitted to the ICU mainly for 24 hour surgical observation where not included.

Shock is defined as “a state of inadequate cellular sustenance associated with inadequate or inappropriate tissue perfusion resulting in abnormal cellular metabolism” (Hillman & Bishop, 2004, p. 121). There are many etiologies of shock, including sepsis, anaphylactic, neurogenic, hypovolemic, cardiogenic, and others, which respond differently to various therapies. This confounder creates an information bias, as this variable is not identified in the data collection and cannot be scrutinized. Simply identifying the etiology of each shock state would limit this bias. The researchers, however, acknowledge this limitation and others.

Another confounding variables is the time constraint of the data. In regards to septic shock, this variable becomes evident. Many pathogens spread predictively during certain times of the year. The concomitant treatment of these infections could predispose patients to suffer a prolonged state of shock (in cases where the pathogen might not be immediately recognized) or provide for an ideal treatment pathway when the pathogen and the antibiotic regimen are fully understood and effective. This selection bias could be controlled by choosing patients who present throughout the year.

As Gluud (2006) points out:

When intervention effects are moderate or small, the human processing of data, unsystematic data collection, and the human capacity to overcome illnesses spontaneously limit the value of uncontrolled observations. Experimental models are essential for estimation of toxicity and pathophysiology.
(p. 494)


Gluud, L. L. (2006). Bias in Clinical Intervention Research. American Journal of Epidemiology, 163(6), 493–501. doi:10.1093/aje/kwj069

Hillman, K. & Bishop, G. (2004). Clinical Intensive Care and Acute Medicine. West Nyack, N.Y.: Cambridge University Press.

Sakr, Y., Reinhart, K., Vincent, J., Sprung, C. L., Moreno, R., Ranieri, V. M., De Backer, D., & Payen, D. (2006). Does Dopamine Administration in Shock Influence Outcome? Results of the Sepsis Occurrence in Acutely Ill Patients (SOAP) Study. Critical Care Medicine, 34(3), 589-597. doi:10.1097/01.CCM.0000201896.45809.E3

Patient Safety Considerations for EMS

 In the out-of-hospital emergency care setting, patient safety is paramount. Initially, victims of trauma or illness are already suffering in an uncontrolled environment. It is this same environment where first responders, emergency medical technicians, and paramedics must operate to stabilize and transport the victim to the hospital, a more controlled environment. Unfortunately, there is little research in the area of patient safety in this setting (Meisel, Hargarten, & Vernick, 2008; Paris & O’Conner, 2008).


Focusing on patient safety and developing processes to ensure optimal safety would allow the study of inherently dangerous, yet potentially beneficial therapies, such as rapid sequence intubation where the clinician uses a series of medications to rapidly sedate and paralyze a critical patient for ease of inserting a breathing tube. Focusing on safety, an EMS department in Maryland successfully instituted such a program (Sullivan, King, Rosenbaum, & Smith, 2010).

With more research in this area, the Emergency Medical Services (EMS) can improve the care they seek to deliver to their patients.


There are many challenges facing EMS as they seek to deliver safe and effective care to their patients. Motor vehicle accidents (including air transportation accidents), dropped patients, medication and dosage errors, other inappropriate care, and assessment errors all contribute to the number of adverse events in the EMS out-of-hospital care setting (Meisel et al., 2008). Unfortunately, it has proved difficult to identify both the existence and the cause of each event (Meisel et al., 2008; Paris et al., 2008). Additionally, there are adverse events that are impossible to track, such as the iatrogenic exposure to a pathogen. It would be very difficult to distinguish how and when a patient was first exposed to the infecting pathogen without considering community-acquired infections and hospital-acquired infections, which are both equally difficult to ascertain (Taigman, 2007).

Strategies for improvement

As EMS seeks to increase the professionalism among its ranks, the stakeholders must acknowledge responsibility for providing evidence-based processes to ensure patient safety.


Meisel, Z. F., Hargarten, S., & Vernick, J. (2008, October). Addressing prehospital patient safety using the science of injury prevention and control.Prehospital Emergency Care, 12(4), 4-14.

Paris, P. M. & O’Connor, R. E. (2008, January). A national center for EMS provider and patient safety: helping EMS providers help us. Prehospital Emergency Care, 12(1), 92-94.

Sullivan, R. J., King, B. D., Rosenbaum, R. A., & Shiuh, T. (2010, January). RSI: the first two years. One agency’s experience implementing an RSI protocol. EMS Magazine, 39(1), 34-51.

Taigman, M. (2007, July). We don’t mean to hurt patients. EMS Magazine, 52(4), 36-42.