Category Archives: Emergency Medical Services

Health Care Quality and Safety

Health care is a service devoted, by definition, to those who are vulnerable. People seek out health-related services during stressful times and may be easily swayed into trying less than effective methods, even ‘snake oil’ remedies, for treating their ails and pain. This being the case, the health care provider has a moral obligation to advocate for the patient. Advocacy entails considering only what is in the best interest of others, even to the detriment of one’s self. Patient advocacy helps to ensure both health care quality and safety. The Institute of Medicine defines health care as “[the] degree to which health services for individuals or populations increase the likelihood of desired health outcomes and are consistent with the current professional knowledge” (as cited in Savage & Williams, 2012, p. 26). Savage and Williams (2012) discuss the importance of effective and efficient delivery of health care, which means avoiding overuse (providing services to those who will least benefit) and underuse (failing to provide services to those that would benefit) stating, “quality is important in health care because there are limited resources to improve the health of both individuals and the population as a whole” (p. 72).

According to Savage and Williams (2012), all stakeholders are affected by the level of quality in health care. From a patient’s perspective, health care delivery should be aimed at addressing the patient’s problem with the least invasive, yet most effective, therapy possible. Delivering health care is a high-risk endeavor that focuses the risk towards the patient, potentially causing harm and great suffering. The provider, driven by the desire to help without harming, would benefit greatly by the development of ‘best practices’, or evidence-based practice, in order to help the most people with the available resources. Additionally, providers wish to be paid a fair rate in exchange for the services performed, and this can only occur in an efficient system with little waste to impact revenue. On the other hand, third-party payors, the most prolific purchasers of health care, demand the most effective and efficient services in return for their payment in order to control the costs of their own services. Third-party payors, like Medicare, Blue Cross, and others, have such a large client base that they are able to effectively negotiate health care services for lower rates.

As a health care manager, it is increasingly important to ensure quality and safety in the delivery of health services. Medical malpractice litigation, according to Savage and Williams (2012), is costly to practitioners and organizations, even though it does little to deter poor quality. Rather than relying on the courts to make forceful recommendations, an effective manager can use tools already available to promote best practice within their organization. For instance, continuous quality improvement (CQI) programs promote systematic, data-driven process improvements focused by the customer’s perceptions. CQI can uncover interferring processes and can make modest to significant improvements that can indirectly improve other, linear processes, thereby, making greater improvements, overall.


Savage, G. T. & Williams, E. S. (2012). Performance improvement in health care: The quest to achieve quality. In S. B. Buckbinder, N. H. Shanks, & C. R. McConnell (Eds.), Introduction to healthcare management (Custom ed.; pp. 25-79). Sudbury, MA: Jones & Bartlett.

Leadership: Determining the Best Approach

 The true value of leadership is empowerment, or the ability to promote those traits through the chain of command for subordinates to use to effectively make decisions that are in the spirit of the vision of the leader (Buchbinder, Shanks, & McConnell, 2012; Kirkpatrick & Locke, 1991; Wieck, Prydun, & Walsh, 2002). When leaders make decisions, the focus is not on the myopic view of the here and now but reflects the nature of ethics and vision promoting the endeavor (Kirkpatrick & Locke, 1991).

Buchbinder, Shanks, and McConnell (2012), discuss various strategies and attitudes employed to both lead and manage the health care workforce. Though each of the styles presented are effectively used in certain scenarios, many managers and ineffective leaders misuse these styles due to misplaced attitudes, trust, and motives. These styles are authoritarian, bureaucratic, participative, theory Z, laissez-faire, and situational. The authoritarian and bureaucratic styles are closely related as dictatorial and at risk for involving micromanagement; however, authoritarians tend to be motivated by their responsibilities, whereas bureaucrats tend to disregard their responsibilities. The participative and theory Z styles are more democratic and egalitarian describing the usefulness of a majority opinion or consensus before moving forward. Though these styles could result in indecision, they are best implemented when a leader has ultimate decision-making capabilities and relies on his or her subordinates for input. Laissez-faire leadership is typically characterized as the hands off approach. Laissez-faire leadership, when used correctly, relies on the specialized training or focused scope of the work of the subordinates and lends guidance only when necessary. Laissez-faire leadership, however, can provide refuge for a lazy manager. Situational leadership is the use of all or some of the styles described above depending on the specific circumstances of a given situation. For instance, providing guidance to a new employee might benefit from an authoritarian approach; however, deciding on the best approach to implementing a new process might benefit from a participative style of leadership.

In the emergency medical services, a move has been made over the last decade to separate from the authoritarian leadership of the fire service. In my opinion (due to the gross lack of research within both the fire and emergency medical services), the attitudes of the fire service leadership do not correspond well with the manner in which paramedics wish to be led. As paramedics are formally educated and expected to perform as skilled clinicians in the field, they tend to operate independently and view their supervisors more as a resource tool than as tactical or clinical decision-makers. Combination departments, or those that operate both fire and emergency medical services, would do well with developing situational leadership skills to guide both operations (Mujtaba & Sungkhawan, 2009). Though paramedics may utilize an authoritarian style of leadership during an emergency call (and, do well to follow such styles in these environments), during normal day-to-day operations, paramedics respond much better towards a laissez-faire, or indirect, style of leadership that allows for independent critical thinking (Buchbinder, Shanks, & McConnell, 2012; Freshman & Rubino, 2002). For example, during a call, I expect that when I direct my crew to perform a certain task that it is completed immediately; however, between calls when I might say that in a particular scenario a certain intervention is necessary, I expect some discussion to aid in the learning of my crews and to help develop and hone their critical thinking skills.

True leadership has its own rewards, primarily, empowering those who follow to synthesize the traits of their leaders and evolve into leaders, themselves. This, in addition to watching your own visions take root and flourish.


Buchbinder, S. B., Shanks, N. H., & McConnell, C. R. (2012). Introduction to healthcare management (Laureate Education, Inc., Custom ed.). Sudbury, MA: Jones and Bartlett.

Freshman, B. & Rubino, L. (2002). Emotional intelligence: a core competency for health care administrators. Health Care Manager, 20(4), 1-9. Retrieved from

Kirkpatrick, S. A. & Locke, E. A. (1991). Leadership: Do traits matter? Academy of Management Executive, 5(2), 48-60. doi:10.5465/AME.1991.4274679

Mujtaba, B. G. & Sungkhawan, J. (2009). Situational leadership and diversity management coaching skills. Journal of Diversity Management, 4(1), 1-55. Retrieved from

Wieck, K. L., Prydun, M., & Walsh, T. (2002). What the emerging workforce wants in its leaders. Journal of Nursing Scholarship, 34(3), 283-288. doi:10.1111/j.1547-5069.2002.00283.x

Leading the Way in Health Care

As the mantra states: when you have it, well, you just have it. As true as that may be in regards to political and social attributes, the statement does not preclude the ability of anyone to learn to ‘have it’, but what is ‘it’? Every enterprise is started by a singular idea, and many ideas may come together to form the basis of any enterprise, but it takes a visionary mind to manifest these ideas. The people with these ideas are leaders who, by their very nature, are agents of change. These leaders tend to seek each other out when they have a common purpose and create solutions and fill voids that address problems in need of answers. However, once the paradigm of the enterprise is expressed, manpower is needed to ensure its operation and success. Much of this manpower is entrusted to managers who may appreciate the vision and goals of the enterprise but lack the vision themselves to affect significant change, and although this statement sounds pessimistic towards the manager’s abilities, hope is not lost. Managers can, and do, learn to be leaders. Further, one does not require a management position to be a leader; leadership is both intuitive and learned (Buckbinder, Shanks, & McConnell, 2012).

Aside from being visionaries, leaders need to be socially adept in order to promote their views and constructs; therefore, in order to gain the trust and respect of subordinates, managers should strive to hone attitude and behavior to be more fit to lead (Freshman & Rubino, 2002). Mayer and Salovey describe four specific abilities that can improve one’s emotional skill set, also known as emotional intelligence (EI): “(1) the accurate perception, appraisal, and expression of emotions; (2) generating feelings on demand when they can facilitate understanding of yourself or another person; (3) understanding emotions and the knowledge that can be derived from them; and (4) the regulation of emotion to promote emotional and intellectual growth” (as cited in Freshman & Rubino, 2002, p. 3).

The importance of EI is evident in the highly ethically charged environment of health care. Many recommendations have been made to cultivate EI within health care, both with clinicians and administrators, yet it is not evident that this has been taking place, according to Freshman and Rubino (2002). Perhaps, at least philosophically, one must know themselves before attempting to truly know others, but being comfortable with one’s self and possessing the ability to relate and empathize with others, especially in the health fields where patients are vulnerable and providers are, themselves, empaths, will offer a manager leadership capabilities that will create trust and mutual respect in the workforce. Applied to health care adminstration, EI can be divided into five components (e.g. self-awareness, self-regulation, self-motivation, social awareness, social skills) that can be programmatically improved using training and career development opportunities with the organization.

Self-awareness goes back to the previous philosophical statement about knowing one’s self. We must take inventory of ourselves constantly in order to ensure that we understand our own strengths, weaknesses, as well as our motivations. Self-regulation, an important ethical descriptor, allows us to improve our own personal ethics in order to make difficult decisions more easily and without troubling remorse. Tough choices are made daily in the health care setting, and a leader should be able to make these decisions ethically with compassion and understanding. Self-motivation involves challenging one’s self daily to preserve the desire and passion personally and professionally. Social awareness is borne of the former components that allow one to consider the effect decisions have on others. Finally, social skills are necessary for effective communication, especially when considering the need to promote ideas and negotiate with others. These skills, inherent in great leaders, are beneficial to the health care administrator and beneficial, over all, to the health care organization.


Buchbinder, S. B., Shanks, N. H., & McConnell, C. R. (2012). Introduction to healthcare management. Sudbury, MA: Jones and Bartlett.

Buchbinder, S. B. & Thompson, J. M. (2010). Career opportunities in health care management: Perspectives in the field. Sudbury, MA: Jones and Bartlett.

Freshman, B. & Rubino, L. (2002). Emotional intelligence: a core competency for health care administrators. Health Care Manager, 20(4), 1-9.

Profile of a Health Care Manager

According to Buchbinder and Thompson (2010), formal training in hospital administration did not exist until 1934 when Michael M. Davis, along with the University of Chicago, developed the first Health Administration program, combining both business and social education to meet the dynamic and unique needs of health care. In today’s economy of almost 10% unemployment nationwide, the health care field continues to grow, even in the face of uncertain regulation and remuneration (Fiscella, 2011; Sanburn, 2011; Scangos, 2009). However, as the economy continues to stagnate, health care providers still require to paid for their services. This is where the health care manager comes in.

A good health care manager is expected to make decisions that benefit both the organization and the client. Although health care is a business, one might say that it is expected to be the most ethical of all businesses as people’s lives are dependent upon its efficacy and continuity. As such, health care managers are expected, according to Buchbinder and Thompson (2010), to have a high ethical standard along with a requisite savvy business sense. Health care managers are also expected to have refined interpersonal skills, leadership, and integrity. Katz (as cited in Buchbinder & Thompson, 2010) defines the characteristics of an effective manager as possessing critical thinking and complex problem solving skills, expertise in their field, and the ability to effectively communicate with others.

Health care managers can work in a variety of settings and operate under many titles; however, these settings can be defined by two descriptors: direct care and nondirect care. Direct care settings, as described by Buchbinder and Thompson (2010), are those settings in which services are provided directly to the patient. Managers within direct care settings should be customer-focused with great interpersonal skills and dedication. These managers should also be excellent problem solvers, as direct consumers tend to require more expedient solutions than ubiquitous deadlines permit. A person may be better suited for this role if he or she enjoys dealing with the general public and solving complex problems with limited information. Nondirect care settings, on the other hand, can be described as health care support organizations as they might provide supplies, logistics, and expertise to those in direct care settings. Managers within nondirect care settings need to be more business savvy as they will typically interact with clients and associates on that level than, per se, a patient-provider level. Nondirect care managers must also be skilled in marketing and finance. Those with an affinity to these roles might possess more professional or technical skills, focusing more on business than personal relationships.

Both direct and nondirect care settings are important to the delivery of health care, today. Buchbinder and Thompson (2011) describe each as well-paying with opportunity, commensurate with education and experience, to advance within the field of health care management. Health care is both growing and changing, and it is a promising occupational arena.


Buchbinder, S. B. & Thompson, J. M. (2010). Career opportunities in health care management: Perspectives in the field. Sudbury, MA: Jones and Bartlett.

Fiscella, K. (2011). Health care reform and equity: promise, pitfalls, and prescriptions. Annals of Family Medicine, 9(1), 78–84. doi:10.1370/afm.1213

Sanburn, J. (2011, August 18). Health care industry growth beginning to slow. Time Moneyland. Retrieved from

Scangos, G. A. (2009). Proceeding in a receding economy. Nature Biotechnology, 27(5), 424-425. doi:10.1038/nbt0509-424

The Need for Multi-Agency Coordination

Terrorists, whether foreign or domestic, typically choose targets that have value in societies or philosophies that they oppose (LaFree, Yang, & Crenshaw, 2009). For instance, according to the Federal Bureau of Investigation (n.d.), al Qaeda, under the leadership of Usama bin Laden, had their sights on the World Trade Center, a symbol of global capitalism, for many years. Another example, involving domestic terrorism, is the bombing of the Alfred P. Murrah Federal Building in Oklahoma City by Timothy McVeigh, Terry Nichols, and Michael Fortier. This target was chosen as a representation of the federal government, which McVeigh and Nichols despised, citing the incident involving federal agents in Waco, Texas, two years earlier.

Considering local community events that might be of significant interest to terrorists as potential targets, the Bristol Fourth of July Parade comes to mind. The parade is a major component of the oldest celebration of our nation’s independence and is attended by over 200,000 people each year (Fox Providence, 2011). The parade is symbolic and casualties could number in the thousands, depending on the tactics and strategies used.

There is limited egress from the Town of Bristol (see figure 1). Hope Street and Metacom Avenue are the only two roads that provide a route in and out of the town. Both lead to the Town of Warren to the north, and Hope Street converges with Metacom Avenue just before exiting the town by way of the two-lane Mount Hope Bridge to the south. Both roads are heavily trafficked during the parade inhibiting both evacuation and emergency response.

In the event that a significant terrorist act was to occur at this parade, the initial law enforcement response would be limited to those officers already on site. These officers, operating under the auspices of the Bristol Police Department would be primarily Bristol police officers with a small contingent of off-duty officers from neighboring jurisdictions. There is usually a small contingent of Rhode Island State Police troopers present. These officers would be on their own for a length of time, some of them probably affected by the attack.

Secondary responders would include both Rhode Island and Massachusetts State Police, along with mutual aid officers from approximately 10 to 15 neighboring communities; however, as people flee the initial attack, a secondary attack could create further confusion and increase the likelihood of severe traffic jams at all three evacuation points further inhibiting a timely response. Once the degree and scope of the incident is ascertained and the access difficulties are identified, it would make sense for a contingent of law enforcement to board helicopters and boats out of Providence and cross Narragansett Bay. Once on land, these officers (most likely consisting of U.S. Coast Guard, Providence Police, U.S. Border Patrol, and other federal law enforcement entities housed in Providence, RI) would rely on alternative means (walking, bicycles, ATVs, et al.) to reach the scene.

Colt State Park, to the southwest, would make a viable forward area command, allowing access for all types of vehicles, including single-engine fixed-wing aircraft. There is also an added benefit of a strong sea breeze to help direct any plume away from this forward area command post.

I have to consider that the law enforcement entities, along with the local emergency management authorities, have a working disaster plan in place for the Bristol Fourth of July parade; however, the plan must detail the fact that all resources would be overcome due to the scope and severity of such an incident; therefore, contingencies, such as stand-by assets, must be established and ready to respond by alternative means in the event that a catastrophic event were to occur, whether criminal or accidental in nature.


Federal Bureau of Investigation. (n.d.). Famous cases & criminals. Retrieved from

Fox Providence. (2011, July 5). Inbox: Fourth of July festivities. Retrieved from

LaFree, G., Yang, S., & Crenshaw, M. (2009). Trajectories of terrorism: Attack patterns of foreign groups that have targeted the United States, 1970-2004. Criminology & Public Policy, 8(3), 445-473. doi:10.1111/j.1745-9133.2009.00570.x

Rhode Island Emergency Management Agency. (2008). State of Rhode Island hurricane evacuation routes: Town of Bristol [Map]. Retrieved from

Figure 1.

Bristol RI Evacuation Route
“State of Rhode Island hurricane evacuation routes: Town of Bristol” (Rhode Island Emergency Management Agency, 2008).

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

The Patient Perspective: Patient Safety

The Speak Up materials provided by The Joint Commission (2011a, 2011b) do a great service in succinctly illustrating the need to be educated about health care issues. Patients and their families have a unique perspective to understanding their (or, their family member’s) health (Vincent & Coulter, 2002). Although physicians, nurses, and allied health providers are responsible for providing quality care, it remains the domain of the patient to express uncertainty or provide additional information to guide the provider. Ultimately, the patient or surrogate decision-maker must provide consent for treatment and must do so with full understanding. There are times, however, that the scope of treatment is so drastic, emergent, or specialized that the patient may not have the facilities to gain a full understanding of care needing to be rendered (Vincent & Coulter, 2002). This is the exception.

In the case of Josie King (Josie King Foundation, 2002; Niedowski, 2003; Zimmerman, 2004), which I elaborated on last week, Sorrel King, Josie’s mother, was educated about her daughter’s condition and spoke up as The Joint Commission recommends. Unfortunately, this case turned into tragedy not because Sorrel King did wrong but because the nurse disregarded her apprehension. This was tantamount to malpractice and no patient or family member could have prevented this, save for using force to physically prevent the administration of medicine. According to MacDonald (2009), there are nurses that believe “[patients] have no say and that medications are the domain of doctors, leaving the nurse and the patient to trust that the doctors would do the right thing” (p. 29).

Perhaps things were slightly different, however. As MacDonald (2009) explains, patient’s who are knowledgeable of their illness and take an active role in their health care decisions add another layer of safety, especially when considering medication action, reaction, and interaction. Medication prescription errors are numerous within health care, and as in the case of Josie King, improved communication between the physicians, nurses, and Sorrel King might have prevented Josie from being administered the narcotic and instead receiving the fluid she so desparately needed (Vincent & Coulter, 2002).

Health care should be patient-centric as it remains the responsibility of the patient to be educated about the care they receive and to provide consent for that care and treatment to be rendered. An uneducated patient does add risk, but sometimes this is unavoidable. It is in these instances that special care should be taken until a full medical history can be attained.


The Joint Commission. (2011a, March 7). Speak up: Prevent errors in your care [Video podcast]. Retrieved from

The Joint Commission. (2011b, April 5). Speak up: Prevent the spread of infection [Video podcast]. Retrieved from–prevent-the-spread-of-infection/

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

Macdonald, M. (2009). Pilot study: The role of the hospitalized patient in medication administration safety. Patient Safety & Quality Healthcare, 6(3), 28-31. 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

Vincent, C. A. & Coulter, A. (2002). Patient safety: what about the patient? Quality & Safety in Health Care, 11(1), 76–80. doi:10.1136/qhc.11.1.76

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

Ethics and Decision Making During Critical Incidents

As a paramedic, I am faced with ethical decisions fairly frequently. As an example, I am usually the sole responding paramedic to an incident that might involve a number of seriously ill or injured patients (e.g. car accidents, fires, carbon monoxide). These incidents are challenging in that I have to choose which patient(s) will be treated at the higher level of care that I can provide versus the lower level of care that the basic life support units can provide. Typically, I base my decision merely on which patient is more ill or injured; however, many times I am faced with a number of critical patients and must decide based on ethical criteria, such as who would benefit more from my care in the long run, including the fact that adolescent and adult patients tend to fair better than elderly and infant patients (Broos, D’Hoore, Vanderschot, Rommens, & Stappaerts, 1993; Kypri, Chalmers, Langley, & Wrigh, 2000; McGwin, Melton, May, & Rue, 2000).

One of the problems with attempting to remain ethical while decisions during an emergency response is that the situational picture is almost never as clear as you need it. This is especially true as the scope and scale of the incident increases. As the magnitude of an incident grows, the incident command team become inundated with information, and it is common to be overwhelmed. We do, though, try our best to be just and fair in our determinations. We need to make our decisions based on the current information and not dwell on if they were right or wrong (Walsh et al., 2012), only if we could have approached the problem more effectively and efficiently, and this should be done only in the debriefing.


Broos, P. L. O., D’Hoore, A., Vanderschot, P., Rommens, P. M., & Stappaerts, K. H. (1993). Multiple trauma in elderly patients. Factors influencing outcome: importance of aggressive care. Injury, 24(6), 365-368. doi:10.1016/0020-1383(93)90096-O

Kypri, K., Chalmers, D. J., Langley, J. D., & Wrigh, C. S. (2000). Child injury mortality in New Zealand 1986–95. Journal of Paediatrics and Child Health, 36(5), 431–439. doi:10.1046/j.1440-1754.2000.00559.x

McGwin, G., Melton, S. M., May, A. K., & Rue, L. W. (2000). Long-term survival in the elderly after trauma. Journal of Trauma, Injury, Infection, & Critical Care, 49(3), 470-476.

Walsh, D. W., Christen, H. T., Callsen, C. E., Miller, G. T., Maniscalco, P. M., Lord, G. C., & Dolan, N. J. (2012). National Incident Management System: principles and practice (2nd ed.). Sudbury, MA: Jones & Bartlett.

A Failure of Best Practices – A Critique

The incident that occurred on April 23rd at 0753 involving an explosion at a soda bottling plant was handled poorly by officials and the incident management team; however, this evaluation does not reflect the efforts of the rescue workers, themselves. Though the management of the incident was poorly thought out and implemented, the incident was brought under control within just a few hours.

The biggest problem to impact the response to this large incident was the failure of local, county, and state officials to prepare a plan to deal with incidents of this type and scope. Once rescue officials were informed of the incident, a plan had to be constructed and implemented. This delayed rescue, firefighting, evacuation, and containment efforts. Also, logistics were negatively impacted by not having predesignated resources identified to respond on a contingency basis (Walsh et al., 2012). All supplies and specialized resources needed to be sought during the active incident response. This took valuable time and delayed efforts. Further, evacuations were not planned for and resulted in public confusion and unwarranted distress that complicated the overall evacuation effort (Walsh et al., 2012).

In addition, planning was negatively impacted by a number of other failures, including the loss of cellular communications which was detrimental to the situational picture. A further planning failure allowed the weather to change dramatically without forewarning to the rest of the incident management team. This drastic misstep resulted in a loss of incident control and was detrimental to firefighting efforts (Walsh et al., 2012).

However, the most telling feature of this incident is the incident management team member who left his post in dereliction to attend to his family. This action only served to cause alarm amongst the other team members and required staffing augmentations that took time away from actual management of the incident (Walsh et al., 2012).

These failures, among others, manifest themselves as added difficulty to an already complex incident. Lives may have been jeopardized, as well as the health of the public as evidenced by the surge in emergency room visits in the months following the incident (Walsh et al., 2012).

Though there were mistakes made, some features of this incident are to be lauded. First, mutual aid agreements allowed for a multi-jurisdictional response across five counties, including state resources. Though these resources were hampered in large part by the failures in preplanning and mitigation, they did succeed in controlling the incident in just a few hours, facing poor weather conditions and prolonged extrication of trapped victims.

According to Walsh et al. (2012), responders at every level and in every capacity need to be involved in preparation, mitigation, training, exercising, evaluation, and improvement of response efforts. By having an updated plan in place that all responders are familiar with and integrating a unified incident management effort, most large scale incidents can be resolved systematically without any further threat to lives or property. Responders need to be prepared and capable to handle all emergencies, large and small.


Walsh, D. W., Christen, H. T., Callsen, C. E., Miller, G. T., Maniscalco, P. M., Lord, G. C., & Dolan, N. J. (2012). National Incident Management System: principles and practice (2nd ed.). Sudbury, MA: Jones & Bartlett.