Category Archives: Emergency Medical Services

Critical Incident Leadership

The skills needed to lead and manage an incident within the command structure of an incident management team are broad and far-reaching. Though individual skills, traits, or attributes are not particular enough to manifest leadership (Zaccaro, Kemp, & Bader, 2004), two important skills that I have identified from my experience and from the text of Walsh et al. (2012), one of which I possess and the other could be enhanced or improved, are a wide breadth of acquired knowledge of the particular spheres of public safety, including operations of emergency and normalcy, and a particular political will that endeavors to ensure favor from most subordinates while carrying out the capacity of management (U.S. Department of Homeland Security, 2008).

Of the latter, I could certainly appreciate a need to remain favored and liked throughout the management of an emergent incident; however, the respect that is earned by the end of any successfully managed crisis is worth more to me than blind politicking, and I have no use for elected office unless that office has a use for me. I do understand how, if I managed to cultivate my political will, it might be easier to find resources and more willing accomplices to alleviate the tasks at hand, though I still wrestle with the notion of neighbors owing neighbors in times of emergent crisis.

To speak of the former is to identify acquired skill and knowledge that I can portray in solid foundation. Having been trained by some of the leaders in the field of disaster management as a member of their team, in both leadership and subordinate roles, I have the confidence to direct subordinates to the task at hand safely and efficiently while being directed or counseled (however my office might fall within a command structure). More important than being knowledgeable, though, is knowing when you require more knowledge. I am never afraid or apprehensive of my limitations, and I will always ask for assistance when needed.

It is interesting to discuss the traits and abilities needed by leaders in order to lead (U.S. Department of Homeland Security, 2008; Walsh et al., 2012); however, none of the literature can substantiate that any one particular trait or skill is particular to or required by a leader, or that it is found lacking in a follower (Zaccaro, Kemp, & Bader, 2004). So long as I am willing to take charge when needed and have the necessary knowledge to direct appropriate actions, I feel that I will continue to perform well in command positions, that is, until someone more adept avails themselves to the task.


U.S. Department of Homeland Security. (2008, January). National response framework. Retrieved from

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.

Zaccaro, S. J., Kemp, C., & Bader, P. (2004). Leader traits and attributes. In J. Antonakis, A. T. Cianciolo, & R. J. Sternberg (Eds.), The nature of leadership (pp. 101-124). Thousand Oaks, CA: Sage.

Critical Incident Response Plans

The possibility of a large-scale event threatening the health and safety of a large number of residents in Connecticut is sizable. Emergency response plans (ERPs) need to be in place to address concerns including epidemic/pandemic disease, the intentional or accidental release of a hazardous material, contamination of the food and/or water supply, and other incidents that might threaten the 3.4 million residents and could result in mass casualties. For this reason, the State of Connecticut Department of Public Health (DPH; 2005) has developed an ERP to guide the department in the event of a catastrophic threat the lives and safety of the residents of Connecticut. Additionally, the State of Connecticut has developed a State Response Framework, much like the National Response Framework, in order to allow for a modulation of an incident from a local level to a state or federal level (State of Connecticut, Department of Homeland Security, 2010; U.S. Department of Homeland Security, 2008). The ability of an incident response to grow and shrink as an incident dictates follows the natural progression of incidents starting and ending locally, whether involving state or local responses at any time during the response (Walsh et al., 2012).

The ERP (DPH, 2005) that guides the DPH allows for representation in the state EOC while forming a modular incident management team (IMT) to staff the DPH emergency command center. The DPH IMT is designed not only to support the state EOC when activated, but also supports the various local incident commands as a public health and medical service resource. In keeping with the modular aspects of the incident command philosophies and the state and national response framework, the DPS ERP becomes a valuable resource for both initiating a response to a significant threat to the public health and safety and allows for an expert resource when other incidents of magnitude, but not necessarily public health in nature, require or benefit from the availability of public health experts.

One criticism I do have, however, is that the plan (DPH, 2005) does not address the provision of emergency medical services (EMS). For some time, there has been much confusion as to where EMS falls in the realm of emergency service functions. EMS, for many jurisdictions, is a function of the fire department and may fall under the direction of ESF #4, firefighting, especially as many EMTs and paramedics are cross-trained to fight fire. However, ambulances are not firefighting apparatus. As ambulances do transport the ill and injured, perhaps EMS falls to ESF #1, transportation. This is unlikely, though, as the primary need is not the transportation provided but the care rendered. Public health and medical services, ESF #8, seems to me to be the logical category for EMS to fall under, but EMS has an expanded role that also fits ESFs #9, #10 & #13 (search & rescue, oil & hazmat response, and public safety & security, respectively), as well as the aforementioned ESFs #1 and 4. This lack of initial categorization may allow flexibility in the deployment of EMS personnel and equipment, but it could also lead to ineffective deployment strategies resulting in a shortage of EMS in one area and overutilization in another.


State of Connecticut, Department of Homeland Security. (2010, October). State response framework. Retrieved from

State of Connecticut, Department of Public Health. (2005, September). Public health emergency response plan: Emergency Support Function #8 Public health and medical services. Retrieved from

U.S. Department of Homeland Security. (2008, January). National response framework. Retrieved from

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.

Emergency Operations Center Leadership

The emergency operations center (EOC) is a decentralized and secure place for senior management officials to maintain operational awareness when confronted with a large scale events or disasters (Walsh et al., 2012). Although these events or disasters may dictate the use of local incident commands at various emergencies throughout an area, the EOC allows an incident management team to direct the overall response effort while maintaining complete situational awareness. This allows for increased interoperability and the availability of resources and a centralized planning and intelligence effort (Walsh et al., 2012). During a multi-state event, a joint field office (JFO) might serve as the primary EOC to support other EOCs that have been activated.

Within the EOC, there are a number of leaders and managers responsible for ensuring an effective response strategy for the emergency that is being faced. One of these leaders is the Area Command Logistics Section Chief (or, “Log Chief”). The Log Chief is responsible for procuring and otherwise acquiring the facilities and personnel to support the response initiative. This includes “resources from off-incident locations […] providing facilities, transportation, supplies, equipment maintenance and fuel, food services, communications and information technology support, and emergency responder medical services, including innoculations” (Walsh et al., 2012, p. 60).

In response to an impending an ice storm in Austin, Texas, in 2003, the city’s EOC was activated 24 hours in advance of the storm. One of the crucial area command members activated was the Log Chief. The Log Chief ensured that redundant communications facilities were available as power outages were interferring with some established communications equipment. The Log Chief also ensured that there was food available for delivery to each small-scale incident as it developed. This was important as the available resources were deployed, there was a lack of available manpower during shift change, so feeding hungry crews was a priority. The Log Chief, on this incident, had many other important functions, but as a responder working in these adverse conditions, it was most important for me to be fed and have solid communications in the event I was to be one of the motorists sliding off the road.


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.

Unified Command and Cross-Agency Conflicts

Each and every day I am faced with incidents that involve a number of different agencies. A simple car crash, for example, can involve two police departments, two fire departments, three emergency medical basic life support services, and two emergency medical advanced life support services, yet we never use unified command, merely single command. Having been trained in ICS and incident management with a focus on unified command structures, it is disheartening to see my local responders attempt to manage incidents without this useful and effective facet. According to Walsh et al. (2012), responders frequently face incidents where multiple agencies and multiple jurisdictions are involved, and frequent use of unified command during incidents of smaller scale creates a familiarity which allows for seamless scalability when the need for a robust command structure presents itself.

A recent house fire brought this to the forefront of my mind. We had six fire departments, an emergency medical basic life support service, the state police, and two fire investigators onscene. We had one incident commander (the Chief of the jurisdictional department), no EMS command or law enforcement command, and no subordinate structure. The incident commander quickly found himself burdened with every detail of the incident and no one to help to alleviate the burden. Additionally, the incident commander (the only person who has detailed knowledge about the incident thus far) is finding himself walking in and around the fire building. If anything devastating happens, such as an explosion or toxic release, the entirety of command would be compromised and a whole command structure would have to be developed from scratch. More importantly, however, is the potential for conflict in determining who is ultimately in charge of each operational group (i.e. emergency medical services without an EMS command) or operational period, such as might occur in protracted incidents. Turf wars are notorious amongst public safety agencies, and planning the roles and responsibilities of each prior to responding to incidents can go a long way in preventing this conflict and confusion.

Compare the above with how we would approach almost every incident when I worked for the city of Austin, Texas. In Austin, we relied heavily on the unified command approach to incident management. For any motor vehicle accident, house fire, technical rescue, or any other multi-agency response, we would establish fire command, EMS command, and law enforcement command (depending on the involvement of each agency). At the least, law enforcement would plug in to the command structure as an operational branch. We would always establish a command, and if the incident warranted, we would build the command structure in top-down fashion starting with operations. Many incidents in Austin did, in fact, have pre-plans established that each agency was well versed in and trained on often. This allowed for rapid mitigation of any unforeseen circumstances that might occur. Additionally, the command post was always removed from the scene enough to prevent the command structure from succumbing to the effects (whether physical hazards or emotional) of the incident scene. In this paradigm, there is always a superior to represent the interests of each agency and guide their members safely and effectively through the incident.

There are many methods of effectively responding to and managing incidents, and many of these methods work most of the time; however, best practices, as described in Walsh et al. (2012), are designed to ensure effective and efficient incident management as well as maintain operational security and safety.


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.

National Incident Management System

The National Incident Management System [NIMS] is a dynamic continuum of interrelated processes designed to allow for the systematic response to any incident, large or small, using standardized practices that transcend political and geographical boundaries and can be adopted easily without regard to specialty or professional focus (U.S. Department of Homeland Security, Federal Emergency Management Agency [FEMA], n.d.; Walsh et al., 2012). The five component philosophies of NIMS are:

  1. preparedness,
  2. communications and information management,
  3. resource management,
  4. command and management, and
  5. ongoing management and maintenance.

I have not included ‘supporting technologies’ as a component of NIMS merely because it is supportive in both description and function.

Supporting technologies are used to further enhance the efficiency and effectiveness of NIMS by providing tools that help to streamline processes (Walsh et al., 2012). Supporting technologies has to be the least important on the list as it can be used to facilitate each of the others, but the effectiveness of NIMS is not contingent on this component.

The strongest, or most important component, is arguably preparedness. Kirkwood (2008) outlines the importance of training when dealing with large and small events across multiple jurisdictions and demonstrates how preparing for the eventuality of an emergency allows for a greater degree of critical thinking without the burden of the emergency, itself. However, as NIMS is a continuum of systems and processes, each of the five components is strikingly important to the others and can be either complimentary or detrimental in the end.


Kirkwood, S. (2008). NIMS and ICS: from compliance to competence. EMS Magazine, 37(2), 51-2, 54-7. Retrieved from

U.S. Department of Homeland Security, Federal Emergency Management Agency. (n.d.). NIMS FAQ. Retrieved from

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.

The National Incident Management System

The National Response Framework (NRF) is an evolution of a series of national readiness plans that have been adapted to handle various emergencies at the national level (Walsh et al., 2012). According to Walsh et al. (2012), the federal government developed a response plan to guide the efforts and deployable assets in the event of any emergency that overwhelmed local and state capabilities. The first of these plans was developed in 1992, called the Federal Response Plan (FRP), and proved ineffective when implemented during a hurricane response in Miami, Florida, primarily due to a lack of familiarity and a focus on federal efforts instead of local scalability.

At the time the FRP was in effect, many fire departments across the country were adopting a modular system of incident management referred to as the incident command system (ICS). Early in its inception, ICS was not standard between the various departments, but as the federal government began to improve upon the FRP, developing the National Response Plan (NRP) with a focus towards incorporating and standardizing ICS, the various fire departments began to refer to the federal government implementation of ICS which promoted its standardization. The NRP was created in 2004 to answer concerns that were outlined in Presidential directives HSPD-5, HSPD-8, and discussions regarding the recent terror attacks on September 11, 2001, and the federal response to Hurricane Katrina. The NRP, in addition to standardizing ICS, addressed the roles of each level of government (local, state, and federal), non-governmental disaster aid organizations, and private business (U.S. Department of Homeland Security, 2004; Walsh et al., 2012). This growth, evolution, and adaptation of ICS within the NRP grew into a further adaptation of a comprehensive incident management system, now known as the national incident management system (NIMS) which allows for implementation at each level of government, within business, and with each private citizen (U.S. Department of Homeland Security, 2008a, 2008b; Walsh et al., 2012). This scalability also allows for increased modulation by either increasing the scope of a response or decreasing it as needed. In 2008, the U.S. Department of Homeland Security (2008a), understanding the shortcomings of the NRP and the promise of NIMS, further refined the response guidelines while using NIMS principles to develop the National Response Framework (NRF; U.S. Department of Homeland Security, 2008a, 2008b; Walsh et al., 2012). Both NIMS and the NRF share the foundation principle that most incidents start and end at the local level and are best managed by local interests (U.S. Department of Homeland Security, 2008a; Walsh et al., 2012).

This was evident during the 2008 hurricane season. As a contractor under Emergency Support Function #8 – Public Health and Medical Services Annex – I was part of the largest single mobilization of emergency medical services in history. Although we could have taken over jurisdiction from the clearly overwhelmed local government (as might have occurred under the FRP), we continually offered our assistance and only responded when requested. This allowed for a more focused response with rapid demobilization and remobilization when confronted with a second and third hurricane that threatened another region. This effort was appreciated by the local emergency managers who not only learned from the event but also adapted their local response plans to include variations of significant mobilizations of each of the emergency support functions.
The continued development of the response plans, incident management systems, and command structures and systems is a testament of the government’s ability and readiness to assist in the event of an emergency, but it is also a testament to the understanding of self-reliance.


U.S. Department of Homeland Security. (2004, December). National response plan. Washington, DC: Author.

U.S. Department of Homeland Security. (2008a, January). National response framework. Washington, DC: Author.

U.S. Department of Homeland Security. (2008b, December). National incident management system. Washington, DC: Author.

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.

Motivation: A Career that I Enjoy

I am lucky to work in a career that I absolutely enjoy. As a paramedic in the emergency medical services (EMS), I am called upon to help those in my community in the worst of circumstances to help them when they feel helpless. There are drawbacks, however. Many people rely on EMS for problems that even they do not view as emergent, and others just plainly abuse the system. Still, I enjoy being the one called upon to help. My primary motivations are my sense of community, my ability to reduce suffering, and my ability to raise the standard of care within the system. Maslow (1943) includes some of the earliest accepted work on motivational theory, and more contemporary work is based on the acceptance, rejection or modification of his theories, so I will focus on Maslow to begin. My needs, according to Maslow, are not as important to motivation. Need fulfillment will not motivate me to perform; however, a lack of fulfillment may prevent me from performing. This is especially true for Maslow’s lower-order needs. Maslow discusses how emergency situations can “obscure the ‘higher’ motivations [and create] a lopsided view of human capacities and human nature” (p. 375), and while my career is focused on responding to emergencies, this may hold true for me. While Maslow’s theory is not wholly accepted motivational schema (Robbins & Judge, 2010), EMS managers, and other public safety managers, would do well to understand this exception to motivational theory.

Many EMS managers, it seems, subscribe to McGregor’s (1957/2000) theory X without understanding the ramifications or the competing theory Y. There is a deep-seated belief that the workforce is lazy and will do anything possible to undermine the operation. This results in micromanagement tactics that seem to promote an unwillingness to promote the goals of the employer. McGregor highlights this and cautions that it a result of poor management technique, not a cause that is easily rectified by the chosen technique.

Other theories, such as goal-setting, equity theory, and expectancy theory, as described in Robbins and Judge (2010), are all lacking in one particular constant: there is no constant in human behavior. There are a number of ways that a single motivational factor might influence a particular person on any particular day. For any theory to always be true in every situation, it would cease to be a theory and become a law. This being said, as managers, we need to measure the importance of certain tasks and focus our efforts on communicating this importance to the workforce. It is the manner of this communication that will tend to fail or succeed, based on both the needs of the manager and the needs of the employee at the moment the message is passed.


Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370-396. doi:10.1037/h0054346

McGregor, D. (2000). The Human Side of Enterprise (Reprinted from Adventure in thought and action: Proceedings of the fifth anniversary convocation of the School of Industrial Management, Massachusetts Institute of Technology, Cambridge, 1957, April 9. Cambridge, MA: MIT School of Industrial Management). Reflections, 2(1), 6-14. doi:10.1162/152417300569962

Robbins, S. P. & Judge, T. A. (2010). Motivation concepts. Essentials of organizational behavior (pp. 62-79). Upper Saddle River, NJ: Pearson Prentice Hall.

Long-term care versus acute care

This discussion, again, allows me to ponder some musings of my colleagues and consider them in scholarly reflection. As a paramedic, I frequently respond to skilled nursing facilities (SNFs) to care for patients with minimal medical complaints or exacerbations of chronic conditions. The comments are always the same: What is the point of having nurses here if they cannot care for their patients? As I have never had an acceptable answer to this quandary, I will use this opportunity to explore the usefulness of SNFs based on measured outcomes. I will also compare the abilities of acute care facilities (ACFs) with those of SNFs to weigh the appropriateness of relying on ACFs to care for SNF patients.

The leading number of long-term care facilities are elderly SNFs, and as such, the elderly are the major demographic cared for in SNFs, yet there is a shortage, even within SNFs, of health care providers skilled in geriatric care (Cohen, 2002; Gaugler, Duval, Anderson, & Kane, 2007; Shi & Singh, 2011b). As Gaugler, Duval, Anderson, and Kane (2007) describe, the mere admission of an elderly patient into an SNF is associated with poor outcomes, “questionable quality of care, early mortality for many residents, and psychological or emotional upheaval for caregiving families” (p. 14). As long-term care also includes varying degrees of home care, family care, and limited residential care (e.g. assisted living centers), an international effort has been underway to help determine ways of identifying and limiting SNF admissions in order to limit potential negative outcomes and maintain patients’ self-efficacy and quality of life (Kennedy et al., 2007).

SNFs and ACFs are similar in that they both house patients, have nursing staff, are demographed by the number of beds housed, and, typically, have some sort of medical team responsible for the patients’ overall care. ACFs are numerous in type and offering. General hospitals, specialty hospitals, free-standing emergency clinics, and tertiary care centers are just some of the ACFs available to treat illness and injury (Shi & Singh, 2011a). ACFs tend to focus treatment on acute manifestations of illness and injury, while SNFs (and other long-term care facilities) focus on continuing care for chronic maladies (Shi & Singh, 2011a, 2011b; Singh, 2011). While ACFs rely on outcome measures to improve the care that is offered, such as that in stroke, it appears that SNFs and other long-term care facilities operate on a more traditional sense without regard to their effect on patient outcomes (Ahmed & Ekundayo, 2009; Díez-Tejedor & Fuentes, 2001; Kennedy et al., 2007; Martin & Ancoli-Isreal, 2008).

As I contemplate my original question in light of the available literature, I find that the elderly should only be institutionalized as a last resort (e.g. lay-led self-care, home health care, independant or assited living), training in geriatric care needs to be improved within SNFs, and outcome measures need to be further developed and assessed to fully understand the impact of long-term care on the elderly population (Ahmed & Ekundayo, 2009; Cohen, 2002, Gaugler et al., 2007; Kennedy et al., 2007, Martin & Ancoli-Israel, 2008). Until these three issues are rectified, SNFs will need to rely on ACFs to safely, effectively, and efficiently care for their patients.


Ahmed, A. & Ekundayo, O. J. (2009). Cardiovascular disease care in the nursing home: The need for better evidence for outcomes of care and better quality for processes of care. Journal of the American Medical Director’s Association, 10(1), 1-3. doi:10.1016/j.jamda.2008.08.019

Cohen, J. J., Gabriel, B. A., & Terrell, C. (2002). The case for diversity in the health care workforce. Health Affairs, 21(5), 90-102. doi:10.1377/hlthaff.21.5.90

Díez-Tejedor, E. & Fuentes, B. (2001). Acute care in stroke: Do stroke units make the difference? Cerebrovascular Diseases, 11(Suppl. 1), 31-39. doi:10.1159/000049123

Gaugler, J. E., Duval, S., Anderson, K. A., & Kane, R. L. (2007). Predicting nursing home admission in the U.S: a meta-analysis. BMC Geriatrics, 7(1), 13-26. doi:10.1186/1471-2318-7-13

Kennedy, A., Reeves, D., Bower, P., Lee, V., Middleton, E., Richardson, G., … Rogers, A. (2007). The effectiveness and cost effectiveness of a national lay‐led self care support programme for patients with long‐term conditions: a pragmatic randomised controlled trial. Journal of Epidemiology and Community Health, 61(3), 254–261. doi:10.1136/jech.2006.053538.

Martin, J. L. & Ancoli-Israel, S. (2008). Sleep disturbances in long-term care. Clinical Geriatric Medicine, 24(1), 39–vi. doi:10.1016/j.cger.2007.08.001.

Shi, L. & Singh, D. A. (2011a). Inpatient facilities and services. Current issues in healthcare policy and practice (pp. 1-44). Sudbury, MA: Jones & Bartlett.

Shi, L. & Singh, D. A. (2011b). The future of health services delivery. Current issues in healthcare policy and practice (pp. 123-156). Sudbury, MA: Jones & Bartlett.

Singh, D. A. (2011). Overview of long-term care. Current issues in healthcare policy and practice (pp. 123-156). Sudbury, MA: Jones & Bartlett.

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